Algunas aplicaciones de la refracción

The organisational barriers which exist to changing paramedic practice in an area customarily viewed as the pinnacle of paramedic practice is unknown, even if the new skill is proven to be more efficient and effective. There is no doubt the ILMA has been shown to have advantages over laryngoscopic tracheal intubation in the in hospital situation and it is not known how is this viewed from the paramedic’s perspective and what barriers will they perceive to the introduction of the ILMA.

According to Rogers (Rogers 2003) Diffusion of Innovation theory, there are a number of critical factors which determine if or how long it may take for an innovation like the ILMA to be adopted. The evidence

supporting the ILMA did contribute to ensuring the paramedics involved in the PILMAT trial to see the advantage it may bring to their practice. This

advantage is onlyone of five criteria which Rogers proposes as important

when introducing a new device or procedure and the other four criteria will require examination to determine their influence during the PILMAT trial

To date most of the published information on training and use of the ILMA has been conducted by the medical community with only one study involving paramedics use of the device in the out of hospital environment (McCall, Reeves et al. 2008). With the introduction of the ILMA into the paramedics’ scope of practice it is unknown how the novice and

experienced practitioner will accept the change and its influences on their confidence and competence.

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The study by Reeves et al (Reeves, Skinner et al. 2004) demonstrated the AAM paramedics were as effective as the hospital doctor who

occasionally performed tracheal intubation. This observational in-theatre study of tracheal intubation using the ILMA involving ambulance

paramedics (AAM trained), medical officers (tracheal intubation trained) and emergency department residents (never performed tracheal

intubation). These three groups of participants used the ILMA to perform tracheal intubation on anaesthetised adults in the operating theatre where in-line manual stabilisation of the cervical spine was applied. Tracheal intubation success and time to successful tracheal intubation was measured. ILMA tracheal intubation failure was 7% for ambulance paramedics, 20% for the medical officers and 16% for the emergency department residents. The mean time (seconds) to intubate were 32 seconds for the ambulance paramedics, 32 seconds for the medical officers and 36 seconds for the medical residents. These results clearly demonstrate AAM trained ambulance paramedics’ have the ability to perform tracheal intubation using the ILMA. This study was seen as a pilot trial to evaluate the use of the ILMA by paramedics with the aim

supporting a further study with paramedics using the ILMA in the out of hospital setting, the resultant trial was the ‘Prehospital Intubating Laryngeal Mask Airway Trial (PILMAT)”.

A search of the literature found no studies where the ILMA and the laryngoscope were used in the out of hospital field by paramedics and a comparison made between their respective success rates. One study by Timmermann et al (Timmermann, Russo et al. 2007) compared final year medical students’ use of the ILMA and laryngoscope to perform tracheal intubation and found they were more successful when using the ILMA. The PILMAT trial (McCall, Reeves et al. 2008) results of ILMA tracheal intubation by ambulance paramedics indicated this technique was as successful and required fewer attempts than the traditional laryngoscopic tracheal intubation. When using the ILMA these paramedics were 1.74 times more likely to be successful on tracheal intubation first attempt when using the ILMA than when using the laryngoscope. This study involved

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both AAM trained and non-AAM trained paramedics over a 12 month period and their use of the ILMA as an intermediate airway and as a tracheal intubation. The novice non-AAM trained paramedics, although only attempting a small number of out of hospital tracheal intubations using the ILMA did have a 100% tracheal intubation success rate. This study (McCall, Reeves et al. 2008) exclusively trained the paramedics in ILMA tracheal intubation using manikins alone.

Most EMS services currently use the laryngoscope for tracheal

intubation and the LMA as an intermediate airway device, with both these devices providing the paramedic a single purpose in airway management. The ILMA can perform the function of the LMA whilst also providing a secondary tracheal intubation device in the situations where either the use of the laryngoscope fails for whatever reason or its use is inappropriate. This dual role in the management of a critical patient’s airway has another advantage to paramedics because of the reduction in the equipment required to be carried due to the mobile nature of paramedic practice. Currently most EMS services do not have a secondary tracheal intubation method to employ in the critical situation of a failed laryngoscopic tracheal intubation; the ILMA may be a suitable device which may replace the LMA whilst providing an alternative tracheal intubation method.

The ILMA is a new tool for the out of hospital setting which may change the tracheal intubation training requirements. It has been shown to be superior in ease of use and skill maintenance to other commonly used airway devices such as the Combitube (The Kendall Company)

(Vertongen, Ramsay et al. 2003; Barnes 2005). This device initially slow to be taken up, is now seen as such a success it is recommended in the anaesthetic community as a priority in managing the difficult airway (Agro, Brimacombe et al. 1998) and failed intubation (Martel, Reardon et al. 2001). The ILMA may provide advantages and the resolution of some current difficulties in out of hospital AAM, but we know very little of the learning curve for paramedics when using the ILMA in the out of hospital setting, especially for tracheal intubation. A number of studies have

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indicated a high initial tracheal intubation success rate when using the ILMA (Choyce, Avidan et al. 2000; Caponas 2002; Reeves, Skinner et al. 2004; Tentillier, Heydenreich et al. 2007; Timmermann, Russo et al. 2007; McCall, Reeves et al. 2008).

Figure 3: Published Laryngoscopic and ILMA learning curves.

This study will examine the paramedic’s perception of AAM, use of the ILMA and its addition into their scope of practice. Specifically I will

examine the training methods, barriers, and the opinions of ambulance paramedics to the inclusion of the ILMA into their scope of practice. This study will compare the influence of training methods and implementation of paramedic tracheal intubation in Tasmania using the traditional

laryngoscopic method and the tracheal intubation technique using the ILMA.

2.8 Summary

Internationally Paramedics are at risk of having tracheal intubation removed as a core skill because of concerns they are unable to achieve and maintain competence in the out of hospital environment. This is of concern because the literature does not reflect paramedics’ attitudes about tracheal intubation practice or training and without in-depth

50 60 90 80 92 92 0 20 40 60 80 100 1 10 30 percent successful Number of attempts laryngoscope ILMA

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understanding it will be difficult to develop effective clinical education programs.

Paramedic tracheal intubation has exclusively utilised the laryngoscope as the tool and technique to perform the skill which has been based on its use by anaesthetists and their historical influence on paramedic AAM. Paramedics have infrequent practice of laryngoscopic tracheal intubation and the effect this infrequent practice has on paramedic confidence and competence has been reported to lead to frequent errors and difficulties.

This research will identify the components of AAM training which contribute the most influence on paramedic confidence and competence and propose a framework for AAM education. The current unease and worries about the value of teaching AAM using manikin-based simulation and the value of in-theatre real patient experience will be detailed so decisions can be made on their suitability and appropriate implementation into paramedic AAM education.

Evaluating the introduction of ILMA tracheal intubation into paramedic practice will provide information regarding this device as a suitable

alternative to using the laryngoscope. The training methodologies used for AAM and the introduction of the ILMA during the PILMAT trial will be evaluated in light of Rogers (Rogers 2003) Diffusion of Innovation model. Having this understanding of the AAM training elements will provide paramedic educators and training program developers with valid

components which they can include into AAM training programs and the implementation of other innovations. Knowing the paramedic's attitude towards tracheal intubation and the mechanisms to maintain competency will provide information to facilitate future AAM training.

An evidence base to support paramedics’ AAM training needs to be developed and this study will provide information regarding the

paramedics view on their competence and confidence of AAM training and effective measures which increase these areas for future AAM

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Chapter 3 Research Design