“Paramedics and EMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organisation, oversight, retention, and professionalism.” (Thomas, Abo et al. 2007).
Confidence in tracheal intubation has been influenced by a number of training activities and the other factors which may have some degree of effect are whether or not the paramedic completed their AAM training in Tasmania, whether or not they work in a rural or urban location, their clinical skill level and their previous AAM experience.
In our sample more of the paramedics who completed their AAM training in Tasmania were confident with ILMA tracheal intubation although this was not statistically significant (p=0.106). Conversely more of those not AAM trained in Tasmania were confident with laryngoscopic tracheal intubation (p=0.056). More of the paramedics working in a rural location reported confidence in ILMA tracheal intubation and confidence in laryngoscopic tracheal intubation was higher in this group as well though in neither case did this difference reach statistical significance.
133
Table 15: Factors associated with confidence in the use of each device.
confidence in ILMA
confidence in Laryngoscopic tracheal intubation tracheal intubation
yes p-value yes p-value
Trained in Tasmania - yes 95.2% (20/21) 81.0% (17/21) - no 80.0% (4/5) 0.106 100.0% (5/5) 0.056 Work location - rural 100% (7/7) 85.7% (6/7) - urban 84% (21/25) 0.552 64.0% (16/25) 0.387 Skill level - Paramedic 50.0% (1/2) 0* - ICP 95.2% (20/21) 66.7% (14/21) - CSO 77.8% (7/9) 0.105 88.9% (8/9) 0.046
Influenced by AAM experience
yes 31.8% (7/24) 22.7% (5/22)
no 70.8% (17/24) 0.550 77.3% (17/22) 0.681
Considered ILMA easier to use
yes 50.0% (12/24) 45.5% (10/22)
no 50.0% (12/24) 1.000 54.5% (12/22) 0.648
* Paramedics were not authorised to perform laryngoscopic tracheal intubation
1. Some of the questionnaires had responses to specific items missing or incorrectly completed, for example only 26 of the responses had the location where they were trained in AAM correct, with 7/35 not AAM trained.
The paramedic skill level reflects a higher level of training and clinical experience, with the paramedic level being the base level practitioner, ICP a higher clinical level and CSO the same clinical level as ICP but with additional training and quality assurance responsibilities. These increasing levels of clinical practice could be expected to be associated with
increased confidence.
The ICPs more often reported confidence with ILMA tracheal intubation and the CSOs more often reported confidence in performing laryngoscopic tracheal intubation. Higher proportions of paramedics who reported they were not influenced by their AAM experience, than of paramedics who reported they were influenced, were confident in the use of each device. These large differences in proportions did not reach statistical
significance. There was no difference in the proportions confident in the use of the ILMA between those who considered the ILMA easier to use. Among those who considered the ILMA easier to use, less than half were confident in laryngoscopic tracheal intubation whereas more than half of
134
those who did not consider the ILMA to be easier to use were confident in laryngoscopic tracheal intubation.
Two criteria that have been distinctive in this study are the exclusive use of manikins for training ILMA tracheal intubation and the paramedics having a choice of which device they could use to perform tracheal intubation. These two criteria were examined as outcomes of the
confidence of the participants to undertake either ILMA or laryngoscopic tracheal intubation.
Association between confidence in performing tracheal intubation and whether or not the paramedics believed manikin training to be essential was examined. All respondents who were confident in ILMA tracheal intubation believed manikin training was essential for initial tracheal intubation training. Whereas only 75% (3/4) of those not confident believe manikin training to be essential (p=.125). There was little difference in the proportions of those confident or not confident in laryngoscopic tracheal intubation who believed manikin training to be essential.
Table 16: Associations between confidence and belief about the essential use of manikin training and belief about which device should be first choice.
Manikin training ILMA
essential p-value First choice p-value Confidence in ILMA tracheal intubation yes 100.0% (28/28) 53.8% (14/26) no 75.0% (3/4) 0.125 75.0% (3/4) 0.613 Confidence in laryngoscopic tracheal intubation yes 95.2% (20/21) 65.0% (13/20) no 100.0% (10/10) 0.677 40.0% (4/10) 0.255
Having confidence in the use of a device or technique to perform tracheal intubation could be associated with favouring that device when there is a choice. Just over one half of the paramedics who were confident in performing ILMA tracheal intubation indicated it should be used as first choice in specific clinical circumstances. Whereas 75% of those not
135
confident in performing ILMA tracheal intubation indicated it should be the first choice (p=.613). A higher proportion of those confident in
laryngoscopic tracheal intubation than those not confident in its use believed the ILMA should be first choice.
Paramedic confidence was reported to be influenced by their first patient experience. When their first use of the ILMA was a positive one this increases their self-assessed level of competence which must have a degree influence on confidence. If a difficult or challenging clinical
situation was their first ILMA encounter and/or they experienced difficulties this reduced their confidence level for future use, as a respondent
conveyed,
“I came across trismus10 and I guess that knocks your confidence”
The AAM qualified paramedics reported the acquisition of the new skill, ILMA tracheal intubation, was made easier and their confidence levels were higher by their past training and experience in laryngoscopic tracheal intubation. This has previously been mentioned in relation to their previous knowledge of the upper airway, but Morgan et al (Morgan and Cleave- Hogg 2002) found during stimulated anaesthetic scenarios medical students clinical experience had no prediction to level of performance. It must be remembered in this study the AAM qualified paramedics were senior clinicians with overall more general experience than the non-AAM qualified paramedics. In relation to the benefits provided by the general AAM training, one paramedic stated:
“I think that once you have that training and you have got that confidence you feel so much more confident about handling a lot of patients whether they be head injuries or cardiac arrest or just respiratory failures. ……. if you don't do the laryngoscope training at least on some real anatomy situations whether it is theatre or other if you don’t get that
10 Trismus is clenching of the teeth together normally making it impossible to place anything in
136
and you just go on the plastic models I think there is always some doubt in your mind”
One of the AAM qualified paramedics felt that their past training in
similar supra-glottic devices11 outside of Ambulance Tasmania also
increased their confidence in the use of the ILMA, as stated,
“I felt very confident on my first use of it I don’t know if that is because I have put lots of standard LMAs in as well, but yes I had no concerns at all about putting it in.”
The paramedics did report their level of confidence could have been substantially increased with additional practice in the short time after the ILMA training program. One respondent stated;
“I felt quite comfortable actually at the job at the first time when I had a problem I thought ok I have to think about this. So I guess in retrospect, the actual training was fine but me personally should have grabbed the ILMA a few more times and had a few more practices with it on a manikin. I did have a few goes after we did the training session but I think I don’t know that I did 20 or 30 or 40, I probably did 10 or a dozen.”
Another reported;
“the training I thought was very basic but I thought it was quite adequate for what it was, I would have liked to have done it a few more times just as a play myself but I didn't have a manikin so I was just looking at it thinking what you went through. Actually the first time I used it was easier than I thought it would have been and we tubed through it”.
During an interview one of the AAM qualified paramedics expressed their increased confidence in using the new ILMA skill in comparison to the “more invasive” laryngoscopic tracheal intubation method. One participant stated,
11 Supra-glottic devices are artificial airways which locate above the glottis (vocal cords) such as:
137
“I would say I felt more confident with the ILMA because it was not as invasive”
The use of the ILMA was reported to be easy to use and in the
literature less challenging to use in patients deemed as difficult to perform tracheal intubation. The questionnaire asked paramedics their view on the use of the ILMA in some common difficult tracheal intubation situations