Paramedic choice and ease of use

When there is a choice to perform a skill, in this case tracheal intubation, using two different tools or techniques it is unsure what influences that choice. In June 2008 the UK Joint Royal Colleges

Ambulance Liaison Committee recommended “Tracheal intubation should

be developed as a specialist skill for selected providers” (Committee

2008). This recommendation makes no mention of the technique or device used and as such lacks a degree of currency with the variety of devices now available for paramedics to use to accomplish tracheal intubation.

Paramedics recommend ILMA tracheal intubation is a skill which should be within their scope of practice. Most reported the attending paramedic should decide which method of tracheal intubation should be used first and we assume this would be based on the patient’s characteristics and their clinical circumstances, which is supported by their report that the ILMA should be used first in specific patient presentations.

The majority (19/35) believed the paramedic should choose the method of tracheal intubation when given the choice between the laryngoscope and the ILMA. Only two participants reported the ILMA should be the first method of paramedic tracheal intubation compared to 40% indicating the laryngoscope.

The majority of Paramedics did agree for the ILMA to be used for specific clinical presentations. As one respondent reported,

“I think they both have their place someone not trained in intubation with a laryngoscope yes I think it is something they should be able to do, but having laryngoscopic intubation you have a choice of either one and

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then in certain situations well, intubation is the way to go but just the ILMA has a place”

Paramedics have declared laryngoscopic tracheal intubation should primarily be performed by the higher clinical skill levels, for example Intensive Care Paramedic and Clinical Support Officers, which supports the statements that tracheal intubation is a relatively difficult skill to perform.

Five respondents in this study were not AAM qualified (Paramedic level). The higher clinical skill levels of ICP and CSO were the clinical skill levels judged as most appropriate to perform laryngoscopic tracheal intubation. The paramedic respondents believed ILMA tracheal intubation should be performed by all clinical skill levels, the respondents strongly reported “all three” skill levels should be able to perform tracheal

intubation using the ILMA along with the higher clinical levels of “ICP and CSO”.

Figure 11: Which skill level should perform tracheal intubation?

Key: Para = Paramedic, ICP = Intensive Care Paramedic, CSO = Clinical Support Officer.

The notion of paramedics having a choice of airway management device is a paradigm shift, as to date almost all of paramedic airway

n=5 n=8 n=11 n=11 n=0 n=9 n=19 n=7 0 10 20 30 40 50 60

Paramedic ICP ICP & CSO All Three (Para, ICP & CSO)

%

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practice has involved adherence to a strict protocols. These protocols detail a standardised one approach for all patients and all airway management situations, which can be viewed as restrictive practice. Emergency Physicians and Anaesthetics have guidelines but their prime decision on how to managing a patient’s airway is determined by the patient’s characteristics and the presenting clinical context, which they then choose the best airway tool and technique to use.

Notably the paramedics did report the lower skill level of Paramedic could perform tracheal intubation using the ILMA but not when using the laryngoscope, these responses are most likely those paramedics not AAM qualified.

Competence in performing ILMA tracheal intubation was indicated to be easier to achieve than laryngoscopic tracheal intubation, by 14% of

respondents indicating the lower clinical practice level of paramedic could perform and ILMA tracheal intubation plus the 31% indicating it should be performed by “all three levels” which includes the lower paramedic level. There was a higher result for ILMA tracheal intubation (31%) to be

performed by all three skill levels than if laryngoscopic tracheal intubation should be performed by all three levels (20%).

This restriction of laryngoscopic tracheal intubation has been reported (Gerbeaux 2005; Bledsoe 2006; Thomas, Abo et al. 2007; Committee 2008) and they justify this approach based upon the requirements needed to maintain competence in this difficult infrequently performed out of hospital skill. This restraint of laryngoscopic tracheal intubation does not appear to be relevant to the easier and less difficult tracheal intubation using the ILMA, where there appears to be a wider acceptance and less complex training required (Reardon and Martel 2001; Caponas 2002; Pandit, MacLachlan et al. 2002; Tentillier, Heydenreich et al. 2007) which is supported in this study.

The confidence of achieving tracheal intubation success by the paramedics who were AAM qualified was increased by having another

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technique to achieve the same outcome. This does indicate a lack of confidence in performing the current method of laryngoscopic tracheal intubation, which must be considered in light of the current skills maintenance program. The inclusion of a secondary device, the ILMA, may improve confidence and thus reduce the frequency of skills practice requirements, as mentioned by this paramedic,

“I felt that I was happy to have another skill that was increasing my level of competence, competence is probably not a good word but my level of intervention is probably a better way of putting it”

The AAM qualified paramedics did indicate the ILMA provided a sense of reassurance for the situations when there was a difficult intubation and the potential of failure with the laryngoscope was increased. A paramedic stated,

“Yes it is a good basis for AAM and those who could do AAM saw the ILMA as a backup for the ones that are grade 3's and 4's14”

The ILMA was reported by respondents as an important airway adjunct for paramedic practice, as testified,

“I still see a primary role in the more difficult intubations with an ILMA”

And another respondent pronounced,

“I would go for the ILMA first because you have a better chance of getting it in, in the case of not being able to intubate via laryngoscopy I would obviously fall back onto that (ILMA)”

Despite the strong traditional paramedic culture of laryngoscopic

tracheal intubation being held in high reverence, following the introduction of the ILMA with a major change in educational methodology, paramedics reported this new approach has an important role in future paramedic practice.

14 _{Classifications of the vision obtained with the mouth wide open, Mallampati class 3 and 4 are}

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The participants did report a high level of confidence in using the ILMA, but they also reported a perception of it being not as quick or easy to use as the laryngoscope, conclusions which appear contradictory. During the PILMAT trial, where the ILMA was used by paramedics as part of their daily practice, analysis of the times which paramedic crews spent ‘on scene’ implementing AAM procedures (commonly tracheal intubation) did demonstrate when the ILMA was used the ambulance scene times were shorter.