How do paramedics learn to intubate?

March 18, 2015

September 2, 2015

Graham McClelland, Research Paramedic (North East Ambulance Service NHS Foundation Trust)

Dan Haworth, Paul Younger, North East Ambulance Service NHS Foundation Trust

For [paramedics], [what education and training are required] to [gain initial competence in endotracheal intubation]?

You attend a 60 year old male in cardiac arrest. A double crewed ambulance with a student observer and a rapid response vehicle are already on scene. The patient has ongoing CPR and with effective ALS you regain a pulse. At this point the decision is made to intubate the patient to secure their airway for transport. During the debrief intubation is discussed and the student asks about the training the paramedics at the scene received. There is considerable variation in the training received by the paramedics and the training the student paramedic is undergoing at present. This sets you thinking about how paramedics actually learn to intubate.

NICE Evidence Healthcare Database search using AMED (Ovid) 1985 to Nov 2014, BNI (Ovid) 1982 to Nov 2014, CINAHL (EBSCO) 1981 to Nov 2014, Embase (Ovid) 1980 to Nov 2014, HMIC: DH-Data and Kings Fund (Ovid) 1979 to Nov 2014, Medline (Ovid) 1946 to Nov 2014 and Psycinfo (Ovid) 1806 to Nov 2014.

The search terms used were ((endotracheal intubation OR eti OR intubation OR tracheal intubation OR entubation) AND (prehospital OR pre-hospital OR paramedic* OR ambulance* OR ems OR emt OR (emergency AND services) OR (emergency AND medical AND service*) OR (emergency AND technician*) OR (emergency AND practitioner)) AND (educat* OR learn* OR train* OR competenc* OR attain* OR practice OR capabil* OR capacity OR expert* OR skill* OR proficien* OR suitab*))

163 papers were considered of which 13 were included. 7 additional papers were identified in the references and through author knowledge.

It appears from the papers reviewed that Endotracheal Intubation (ETI) for paramedics should be included as part of the wider subject of airway management. Training specific to ETI needs to cover underpinning knowledge and supporting information, learning the basic skills with practice in a safe environment using simulation then advancing to exposure to patients. A logbook should be kept during the education program to promote reflection and prepare the paramedic for independent practice where keeping a log of all ETIs is best practice.
Simulation seems a viable, effective and cost efficient method of learning and practicing the necessary skills and eliminates the need for animal or cadaver practice which may be unethical, expensive and difficult to arrange. The use of multimedia, such as recording of real ETIs, should be used to enhance and support the learning experience. All training should aim towards preparing the practitioner for the pre-hospital environment. High fidelity simulation would aim to replicate the prehospital environment by varying scenarios and situations and incorporating distractors. Operating theatres have historically provided the safe learning environment for paramedics. However, due to the increasing numbers of paramedic students, the decreasing use of ETI in operating theatres and competition from other medical professions for the limited opportunities to undertake ETI this may not be a sustainable way of educating paramedics.
The total number of ETIs needed to achieve initial competence is difficult to quantify but appears to be above the 25 ETIs specified by the UK Institute of Health Care Development (IHCD) and its predecessors. This number will vary from individual to individual and depends on many factors including confidence, level of fidelity and methods of training, exposure to pre-hospital ETI and supervision. Supervision is very important, both during initial training and for support once working in the pre-hospital environment.

From the evidence reviewed paramedics learning ETI require education and a training program that covers the range of airway management techniques up to and including ETI. Initial competence requires underpinning knowledge and supporting information, practice on manikins/simulators and a minimum of 25 to 35 in hospital or pre-hospital ETIs, some of which may be gained using high fidelity simulators, with supervision by clinicians with pre-hospital ETI experience.

Level 2: Studies considered were neither 1 or 3

1. Pepe PE, Roppolo LP, Fowler RL.. Prehospital endotracheal intubation: elemental or detrimental?
2. Sergeev I, Lipsky AM, Ganor O, Lending G, Abebe-Campino G, Morose A, Katzenell U, Ash N, Glassberg E.. Training Modalities and Self-Confidence Building in Performance of Life-Saving Procedures
3. Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR.. Paramedic Training for Proficient Prehospital Endotracheal Intubation
4. Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, Ward M, Keeble C, Blancke W.. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal colleges Ambulance Liaison committee Airway Working Group, June 2008
5. Deakin CD, King P, Thompson F.. Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills?
6. McCall MJ, Reeves M, Skinner M, Ginifer C, Myles P, Dalwood N.. Paramedic Tracheal Intubation Using the Intubating Laryngeal Mask Airway
7. Thomas JB, Abo BN, Wang HE.. Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation
8. Wang HE and Katz S.. Cognitive Control and Prehospital Endotracheal Intubation
9. Johnston BD, Seitz SR, Wang HE.. Limited Opportunities for Paramedic Student Endotracheal Intubation Training in the Operating Room
10. Wang HE and Yealy DM.. Out-of-Hospital Endotracheal Intuabtion: Where Are We?
11. Hall RE, Plant JR, Bands CJ, Wall AR, Kang J, Hall CA.. Human Patient Simulation Is Effective for Teaching Paramedic Students Endotrachel Intubation
12. Wang HE, Seitz SR, Hostler D, Yealy DM.. Defining the "Learning Curve" for Paramedic Student Endotracheal Intubation
13. Pratt JC and Hirshberg AJ.. Endotracheal Tube Placement by EMT-Basics in a Rural EMS System
14. Mulcaster JT, Mills J, Hung OR, MacQuarrie K, Law SJ, Pytka S, Imrie D, Field C.. Laryngoscopic Intubation: Learning and Performance
15. Owen H and Plummer JL.. Improving learning of a clinical skill: the first year's experience of teaching endotracheal intubation in a clinical simulation facility
16. Levitan RM, Goldman TS, Bryan DA, Shofer F, Herlich A.. Training with video imaging improves the initial intubation success rates of paramedic trainees in an operating room setting
17. Plummer JL and Owen H.. Learning Endotracheal Intubation in a Clinical Skills Learning Centre: A Quantative Study
18. Stratton SJ, Kane G, Gunter CS, Wheeler NC, Abelson-Ward C, Reich E, Pratt FD, Ogata G, Gallagher C.. Prospective Study of Manikin-only Versus Manikin and Human Subject Endotracheal Intubation Training of Paramedics
19. Stewart RD, Paris PM, Winter PM, Pelton GH, Cannon GM.. Field Endotracheal Intubation by Paramedical Personnel: Success Rates and Complications
20. Toda J, Toda AA, Arakawa J.. Learning curve for paramedic endotracheal intubation and complications