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Paramedic Intubation: Does Practice Make Perfect?
EMERGENCY MEDICAL SERVICES/EDITORIAL
Paramedic Intubation: Does Practice Make Perfect? Jestin N. Carlson, MD, MS*; Henry E. Wang, MD, MS *Corresponding Author. E-mail: [email protected], Twitter: @JestinCarlson. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.03.024
SEE RELATED ARTICLE, P.
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[Ann Emerg Med. 2017;-:1-3.] Practice doesn’t make perfect. Perfect practice makes perfect. —Vince Lombardi Intubation has played a key role in paramedic out-ofhospital care for more than 30 years. Many studies highlight the challenges of out-of-hospital intubation, including misplaced endotracheal tubes and interruptions in chest compressions.1-3 Intubation is a difficult skill, and experts believe that procedural and patient outcomes are closely tied to operator skill and proficiency. However, the best methods for achieving and assessing paramedic intubation skill are unclear. In this edition of Annals, Dyson et al4 examine the relationship between paramedic experience with intubation success and survival from out-of-hospital cardiac arrest. Drawing on data from 14,857 paramedic intubations in Australia (including 9,751 in out-ofhospital cardiac arrest patients), the authors found that previous paramedic intubation experience was associated with increased odds of first-pass (adjusted odds ratio [AOR] 1.02; 95% confidence interval [CI] 1.01 to 1.03) and overall intubation success (AOR 1.04; 95% CI 1.03 to 1.05). Although intubation experience was not associated with out-of-hospital cardiac arrest outcomes, first-pass intubation success was associated with greater odds of return of spontaneous circulation (AOR 1.52; 95% CI 1.35 to 1.72) and survival to hospital discharge (AOR 1.26; 95% CI 1.06 to 1.50). These findings led the authors to suggest that these results “may be associated with the proficient performance of intubation” rather than years of experience or number of intubation attempts. The study by Dyson et al alludes to the enormous challenges of and gaps in paramedic intubation training. The current model of paramedic intubation training encompasses 4 major modalities: 1. Acquiring a fund of knowledge (eg, didactics) Volume
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2. Acquiring basic psychomotor skills (eg, practice on mannequins) 3. Controlled, closely supervised practice on live human beings (eg, operating room, emergency department) or cadavers 4. Application for clinical out-of-hospital patients This graded sequence allows students to learn specific intubation components while gradually progressing toward the overall goal of proficient intubation on live out-of-hospital patients. Although well established in paramedic education, each of these elements has important challenges. Didactic teaching helps to establish the core foundation knowledge of intubation (for example, relevant anatomy, physiology, and the basics of laryngoscopy) but does not teach the physical nuances of the procedure. Task-training mannequins and newer human simulators offer platforms for learning and reinforcing the physical basics of laryngoscopy and intubation techniques. However, many mannequins do not accurately reflect the feel of live airway structures or the heterogeneity of airway anatomies encountered in clinical practice. Mannequins also do not provide feedback, limiting students’ abilities to appraise their performance.5 The tradition of teaching intubation by using operating room patients offers a safe, realistic learning experience with ample opportunity for repetition, as well as mentorship by expert anesthesiologists.6 However, there are numerous barriers to paramedic student intubation, including competition from other health care students, medicolegal concerns, and the broadening use of supraglottic airways instead of endotracheal tubes.7 The maintenance of intubation proficiency also requires ongoing clinical application, but opportunities for paramedic intubation are surprisingly low. Rates of out-of-hospital intubation in the United States are 7 to 8 per 1,000 emergency medical services calls, with many providers performing less than 1 intubation per year.8-10 Rates in the study by Dyson et al are even lower, at 5 per 1,000. Ensuring proficiency with this limited clinical opportunity is extremely difficult. Annals of Emergency Medicine 1
Carlson & Wang
Paramedic Intubation
These multiple training barriers suggest the need for novel approaches to acquiring intubation skill. New technologies offer potential for enhancing intubation mannequin-based training. For example, motion-capture technology uses a series of cameras and markers to track movement through space (Figure 1, lower left panel). Specialized software can integrate these data to graphically characterize movement patterns (Figure 1, lower right panel). We have previously used motion-capture technology to characterize laryngoscopy and intubation, providing highly detailed insights into the movements involved in the procedure.11 This technology allows 3-dimensional rendering of movements during intubation; specifically, how the laryngoscope moves as the provider guides it into the mouth and obtains the glottic view. Motion capture has helped to identify that experienced providers have efficient movements with little variability in technique compared with novice providers.11 Another technology is the inertial measurement unit, which uses accelerometers and gyroscopes to track movement patterns (Figure 2).
These portable devices could help to augment learning in settings such as the operating room and allow providers to compare their movements with those of experienced providers. Preliminary work suggests they may also be able to help discriminate movements between novice and experienced providers.12 If matured, these technologies could significantly enhance student intubation learning, providing novel ways for students to learn from visualizations of their movements. These and other evolving technologies could be leveraged to provide real-time visual or tactile feedback to the student, greatly enhancing the learning value of intubation mannequin practice.13 The study by Dyson et al also underscores the need for novel approaches to characterizing intubation skill. Current US standards require paramedic students to perform at least 5 intubations before graduation, but this experience benchmark may have no connection with student intubation proficiency.14 For example, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine have
Figure 1. Motion-capture cameras (upper left) tracking the movements of the laryngoscope (upper right) with markers on the subject while he or she performs intubation (lower left), with the corresponding computer rendering (lower right). Republished with permission from Wolters Kluwer Health, Inc.
2 Annals of Emergency Medicine
Volume
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no.
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Carlson & Wang
Paramedic Intubation
Supervising editor: Donald M. Yealy, MD Author affiliations: From the Department of Emergency Medicine, Saint Vincent Health System, Erie, PA (Carlson); and the Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL (Wang). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES
Figure 2. Inertial measurement unit worn on the left hand.
proposed changing residency training from a fixed period to a milestones-driven approach; that is, a student may be declared “competent” if he or she can demonstrate procedural knowledge and skill that meets a defined threshold.15 The challenge with intubation is that no such assessment currently exists. Hence, it is impossible to ascertain whether a student with 5 recorded operating room intubations is committing key errors such as holding the laryngoscope in the wrong hand. Novel technologies such as motion capture and inertial detectors could provide important new tools to help identify traits associated with intubation proficiency. For example, using these modalities, we have observed that expert intubators tend to exhibit small, smooth motions that are rapid but focused.11,12 Continued development of these technologies could provide educators with new tools to enhance and accelerate the acquisition of intubation skill. The implementation of intubation in paramedic practice requires significant system-level investments in baseline and continuing training. To improve the current model of paramedic intubation training, we must embrace new teaching tools and technologies so that students can learn how to practice perfectly.
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1. Benoit JL, Gerecht RB, Steuerwald MT, et al. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: a meta-analysis. Resuscitation. 2015;93:20-26. 2. Wang HE, Simeone SJ, Weaver MD, et al. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009;54:645-652.e641. 3. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001;37:32-37. 4. Dyson K, Bray JE, Smith K, et al. Paramedic intubation experience is associated with successful tube placement but not cardiac arrest survival. Ann Emerg Med. 2017; http://dx.doi.org/10.1016/j. annemergmed.2017.02.002. 5. Sun Y, Pan C, Li T, et al. Airway management education: simulation based training versus non-simulation based training—a systematic review and meta-analyses. BMC Anesthesiol. 2017;17:17. 6. Wang HE, Seitz SR, Hostler D, et al. Defining the learning curve for paramedic student endotracheal intubation. Prehosp Emerg Care. 2005;9:156-162. 7. Johnston BD, Seitz SR, Wang HE. Limited opportunities for paramedic student endotracheal intubation training in the operating room. Acad Emerg Med. 2006;13:1051-1055. 8. Carlson JN, Karns C, Mann NC, et al. Procedures performed by emergency medical services in the United States. Prehosp Emerg Care. 2016;20:15-21. 9. Wang HE, Mann NC, Mears G, et al. Out-of-hospital airway management in the United States. Resuscitation. 2011;82:378-385. 10. Wang HE, Abo BN, Lave JR, et al. How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations? Ann Emerg Med. 2007;50:246-252. 11. Carlson JN, Das S, De la Torre F, et al. Motion capture measures variability in laryngoscopic movement during endotracheal intubation: a preliminary report. Simul Healthc. 2012;7:255-260. 12. Carlson JN, Das S, Spring S, et al. Assessment of movement patterns during intubation between novice and experienced providers using mobile sensors: a preliminary, proof of concept study. Biomed Res Int. 2015;2015:843078. 13. Carlson JN, Das S, De la Torre F, et al. A novel artificial intelligence system for endotracheal intubation. Prehosp Emerg Care. 2016;20:667-671. 14. National Highway Traffic Safety Administration. Emergency medical technician paramedic: national standard curriculum (EMT-P). Available at: http://www.nhtsa.dot.gov/people/injury/ems/emt-p/. Accessed February 18, 2017. 15. Accreditation Council for Graduate Medical Education; American Board of Emergency Medicine. The Emergency Medicine Milestone Project. 2015. Available at: http://www.acgme.org/Portals/0/PDFs/Milestones/ EmergencyMedicineMilestones.pdf. Accessed March 10, 2017.
Annals of Emergency Medicine 3
Paramedic Intubation: Does Practice Make Perfect? Jestin N. Carlson, MD, MS*; Henry E. Wang, MD, MS *Corresponding Author. E-mail: [email protected], Twitter: @JestinCarlson. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.03.024
SEE RELATED ARTICLE, P.
.
---
[Ann Emerg Med. 2017;-:1-3.] Practice doesn’t make perfect. Perfect practice makes perfect. —Vince Lombardi Intubation has played a key role in paramedic out-ofhospital care for more than 30 years. Many studies highlight the challenges of out-of-hospital intubation, including misplaced endotracheal tubes and interruptions in chest compressions.1-3 Intubation is a difficult skill, and experts believe that procedural and patient outcomes are closely tied to operator skill and proficiency. However, the best methods for achieving and assessing paramedic intubation skill are unclear. In this edition of Annals, Dyson et al4 examine the relationship between paramedic experience with intubation success and survival from out-of-hospital cardiac arrest. Drawing on data from 14,857 paramedic intubations in Australia (including 9,751 in out-ofhospital cardiac arrest patients), the authors found that previous paramedic intubation experience was associated with increased odds of first-pass (adjusted odds ratio [AOR] 1.02; 95% confidence interval [CI] 1.01 to 1.03) and overall intubation success (AOR 1.04; 95% CI 1.03 to 1.05). Although intubation experience was not associated with out-of-hospital cardiac arrest outcomes, first-pass intubation success was associated with greater odds of return of spontaneous circulation (AOR 1.52; 95% CI 1.35 to 1.72) and survival to hospital discharge (AOR 1.26; 95% CI 1.06 to 1.50). These findings led the authors to suggest that these results “may be associated with the proficient performance of intubation” rather than years of experience or number of intubation attempts. The study by Dyson et al alludes to the enormous challenges of and gaps in paramedic intubation training. The current model of paramedic intubation training encompasses 4 major modalities: 1. Acquiring a fund of knowledge (eg, didactics) Volume
-,
no.
-
:
-
2017
2. Acquiring basic psychomotor skills (eg, practice on mannequins) 3. Controlled, closely supervised practice on live human beings (eg, operating room, emergency department) or cadavers 4. Application for clinical out-of-hospital patients This graded sequence allows students to learn specific intubation components while gradually progressing toward the overall goal of proficient intubation on live out-of-hospital patients. Although well established in paramedic education, each of these elements has important challenges. Didactic teaching helps to establish the core foundation knowledge of intubation (for example, relevant anatomy, physiology, and the basics of laryngoscopy) but does not teach the physical nuances of the procedure. Task-training mannequins and newer human simulators offer platforms for learning and reinforcing the physical basics of laryngoscopy and intubation techniques. However, many mannequins do not accurately reflect the feel of live airway structures or the heterogeneity of airway anatomies encountered in clinical practice. Mannequins also do not provide feedback, limiting students’ abilities to appraise their performance.5 The tradition of teaching intubation by using operating room patients offers a safe, realistic learning experience with ample opportunity for repetition, as well as mentorship by expert anesthesiologists.6 However, there are numerous barriers to paramedic student intubation, including competition from other health care students, medicolegal concerns, and the broadening use of supraglottic airways instead of endotracheal tubes.7 The maintenance of intubation proficiency also requires ongoing clinical application, but opportunities for paramedic intubation are surprisingly low. Rates of out-of-hospital intubation in the United States are 7 to 8 per 1,000 emergency medical services calls, with many providers performing less than 1 intubation per year.8-10 Rates in the study by Dyson et al are even lower, at 5 per 1,000. Ensuring proficiency with this limited clinical opportunity is extremely difficult. Annals of Emergency Medicine 1
Carlson & Wang
Paramedic Intubation
These multiple training barriers suggest the need for novel approaches to acquiring intubation skill. New technologies offer potential for enhancing intubation mannequin-based training. For example, motion-capture technology uses a series of cameras and markers to track movement through space (Figure 1, lower left panel). Specialized software can integrate these data to graphically characterize movement patterns (Figure 1, lower right panel). We have previously used motion-capture technology to characterize laryngoscopy and intubation, providing highly detailed insights into the movements involved in the procedure.11 This technology allows 3-dimensional rendering of movements during intubation; specifically, how the laryngoscope moves as the provider guides it into the mouth and obtains the glottic view. Motion capture has helped to identify that experienced providers have efficient movements with little variability in technique compared with novice providers.11 Another technology is the inertial measurement unit, which uses accelerometers and gyroscopes to track movement patterns (Figure 2).
These portable devices could help to augment learning in settings such as the operating room and allow providers to compare their movements with those of experienced providers. Preliminary work suggests they may also be able to help discriminate movements between novice and experienced providers.12 If matured, these technologies could significantly enhance student intubation learning, providing novel ways for students to learn from visualizations of their movements. These and other evolving technologies could be leveraged to provide real-time visual or tactile feedback to the student, greatly enhancing the learning value of intubation mannequin practice.13 The study by Dyson et al also underscores the need for novel approaches to characterizing intubation skill. Current US standards require paramedic students to perform at least 5 intubations before graduation, but this experience benchmark may have no connection with student intubation proficiency.14 For example, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine have
Figure 1. Motion-capture cameras (upper left) tracking the movements of the laryngoscope (upper right) with markers on the subject while he or she performs intubation (lower left), with the corresponding computer rendering (lower right). Republished with permission from Wolters Kluwer Health, Inc.
2 Annals of Emergency Medicine
Volume
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no.
-
:
-
2017
Carlson & Wang
Paramedic Intubation
Supervising editor: Donald M. Yealy, MD Author affiliations: From the Department of Emergency Medicine, Saint Vincent Health System, Erie, PA (Carlson); and the Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL (Wang). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. REFERENCES
Figure 2. Inertial measurement unit worn on the left hand.
proposed changing residency training from a fixed period to a milestones-driven approach; that is, a student may be declared “competent” if he or she can demonstrate procedural knowledge and skill that meets a defined threshold.15 The challenge with intubation is that no such assessment currently exists. Hence, it is impossible to ascertain whether a student with 5 recorded operating room intubations is committing key errors such as holding the laryngoscope in the wrong hand. Novel technologies such as motion capture and inertial detectors could provide important new tools to help identify traits associated with intubation proficiency. For example, using these modalities, we have observed that expert intubators tend to exhibit small, smooth motions that are rapid but focused.11,12 Continued development of these technologies could provide educators with new tools to enhance and accelerate the acquisition of intubation skill. The implementation of intubation in paramedic practice requires significant system-level investments in baseline and continuing training. To improve the current model of paramedic intubation training, we must embrace new teaching tools and technologies so that students can learn how to practice perfectly.
Volume
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no.
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:
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2017
1. Benoit JL, Gerecht RB, Steuerwald MT, et al. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: a meta-analysis. Resuscitation. 2015;93:20-26. 2. Wang HE, Simeone SJ, Weaver MD, et al. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009;54:645-652.e641. 3. Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001;37:32-37. 4. Dyson K, Bray JE, Smith K, et al. Paramedic intubation experience is associated with successful tube placement but not cardiac arrest survival. Ann Emerg Med. 2017; http://dx.doi.org/10.1016/j. annemergmed.2017.02.002. 5. Sun Y, Pan C, Li T, et al. Airway management education: simulation based training versus non-simulation based training—a systematic review and meta-analyses. BMC Anesthesiol. 2017;17:17. 6. Wang HE, Seitz SR, Hostler D, et al. Defining the learning curve for paramedic student endotracheal intubation. Prehosp Emerg Care. 2005;9:156-162. 7. Johnston BD, Seitz SR, Wang HE. Limited opportunities for paramedic student endotracheal intubation training in the operating room. Acad Emerg Med. 2006;13:1051-1055. 8. Carlson JN, Karns C, Mann NC, et al. Procedures performed by emergency medical services in the United States. Prehosp Emerg Care. 2016;20:15-21. 9. Wang HE, Mann NC, Mears G, et al. Out-of-hospital airway management in the United States. Resuscitation. 2011;82:378-385. 10. Wang HE, Abo BN, Lave JR, et al. How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations? Ann Emerg Med. 2007;50:246-252. 11. Carlson JN, Das S, De la Torre F, et al. Motion capture measures variability in laryngoscopic movement during endotracheal intubation: a preliminary report. Simul Healthc. 2012;7:255-260. 12. Carlson JN, Das S, Spring S, et al. Assessment of movement patterns during intubation between novice and experienced providers using mobile sensors: a preliminary, proof of concept study. Biomed Res Int. 2015;2015:843078. 13. Carlson JN, Das S, De la Torre F, et al. A novel artificial intelligence system for endotracheal intubation. Prehosp Emerg Care. 2016;20:667-671. 14. National Highway Traffic Safety Administration. Emergency medical technician paramedic: national standard curriculum (EMT-P). Available at: http://www.nhtsa.dot.gov/people/injury/ems/emt-p/. Accessed February 18, 2017. 15. Accreditation Council for Graduate Medical Education; American Board of Emergency Medicine. The Emergency Medicine Milestone Project. 2015. Available at: http://www.acgme.org/Portals/0/PDFs/Milestones/ EmergencyMedicineMilestones.pdf. Accessed March 10, 2017.
Annals of Emergency Medicine 3