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Studies explore the challenges and complexities faced by paramedics performing out-of-hospital endotracheal intubation

Paramedics often perform out-of-hospital endotracheal intubation (ETI), insertion of a breathing tube, on critically ill patients who can't breathe on their own. Although paramedics have been performing out-of-hospital ETI for the past 25 years, recent studies have questioned the safety and effectiveness of paramedic ETI.

A new study reveals paramedic and physician perceptions regarding the challenges and pitfalls of out-of-hospital ETI. A second study describes some of the cognitive complexities of out-of-hospital ETI. Both studies were supported by the Agency for Healthcare Research and Quality (HS13628). They are described here.

Thomas, J.B., Abo, B.N., and Wang, H.E. (2007, June). "Paramedic perceptions of challenges in out-of-hospital endotracheal intubation." Prehospital Emergency Care 11, pp. 219-223.

This study analyzed focus group discussions among 14 paramedics and 6 emergency medical service (EMS) physicians about their perceptions of the challenges in performing out-of-hospital paramedic ETI. While both groups recognized problems with the practice, they all felt strongly that paramedics should continue to perform the procedure.

Doctors and paramedics disagreed about the ability of paramedics to perform neuromuscular blockade-assisted intubation. This practice uses medication to blunt the gag reflex of a conscious or struggling victim, which makes it difficult to insert the breathing tube. Both paramedics and EMS physicians attributed paramedic ETI performance to a myriad of factors. These included EMS education (including skills acquisition and maintenance); organizational structure, culture, and oversight (for example, the role of the medical director); and paramedic retention and professionalism. Efforts to improve paramedic performance of out-of-hospital ETI must include strategies to address multiple aspects of EMS operations and culture, conclude the researchers.

Wang, H.E. and Katz, S. (2007, April). "Cognitive control and prehospital endotracheal intubation." Prehospital Emergency Care 11, pp. 234-239.

The authors of this paper used Rasmussen's Skills-Rules-Knowledge (SRK) framework, a model typically used to describe performance in high-risk work areas like power plants, to highlight the cognitive complexities of prehospital ETI. They point out that paramedic textbooks often present ETI as a discrete task. Yet, it actually encompasses multiple decisions and actions, and occurs under the constraints of an uncontrolled field environment (for example, inside a crushed car). It also involves higher level knowledge and skills.

The paramedic has to assess the need for ETI and identify potential ETI difficulty (for example, due to patient obesity, short neck, or small mouth). There are no guidelines for how the findings should alter the approach. Thus, paramedics have to draw on their knowledge to identify airway barriers and take appropriate actions.

Based on the SRK model, skills-based processing in prehospital care is the delivery of cardiopulmonary resuscitation (CPR) chest compressions. Most rescuers receive extensive training in CPR and usually do not need to consciously think about each step of it. An example of rules-based processing (performing a series of tasks in reaction to a recognized situation or scenario) in prehospital care is the decision to initiate CPR. For example, the paramedic might decide to perform CPR if the patient has no pulse. However, this decision may be difficult if the rescuer cannot confirm the absence of a pulse. Rule-based processing may fail in unfamiliar situations.

In these cases, paramedics may need to draw on and integrate a broader range of knowledge to formulate appropriate decisions or actions. For example, an ambulance crew may encounter a person in cardiac arrest, a situation in which rule-based thinking would advise the crew to begin CPR. However, a bystander mentioning that the victim was last seen an hour ago would prompt some paramedics to terminate resuscitative efforts, while others might proceed.

The researchers suggest that the education of paramedics in prehospital ETI should include an understanding of the airway management process, emphasis on ETI process integration, and methods to simplify airway management.

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