Structure and Processes

ILMA tracheal intubation training has been reported by paramedics to require a shorter and less complex course than the typical laryngoscopic training course. After having completed the ILMA training program and the majority had used the ILMA in a clinical situation, 74% of respondents stated it requires less training than the laryngoscopic tracheal intubation program, and 23% paramedics disagreed that the ILMA required less training. The ILMA training consisted of two main components: a review of knowledge and then a skill based practical component of approximately

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four hours which involved numerous successful ILMA tracheal intubations using a manikin.

In further evaluation of the traditional AAM training program the paramedics reported a high degree of acceptance for all of the course components.

Table 21: Frequency of response to the question “The following elements are essential for paramedic laryngoscopic tracheal intubation training?”

Agree Disagree Missing p value

Precourse theory 100.0% (35/35) 0.0% (0/35) 0.0% (0/35) *

In theatre training 94.3% (33/35) 5.7% (2/35) 0.0% (0/35) *

Guidance by Anaesthetist 85.7% (30/35) 14.3% (5/35) 0.0% (0/35) .000

Manikin training 94.3% (33/35) 2.9% (1/35) 2.9% (1/35) *

CSO classroom training 85.7% (30/35) 14.3% (5/35) 0.0% (0/35) .000

Note: p values relate to chi-square analysis performed without missing category in each variable. * p value not possible due to insufficient data and therefore <5 distribution in categories.

The components contained in the traditional AAM primarily laryngoscopic course were:

1) precourse theory; which not only reviewed previous knowledge but also introduced new knowledge and concepts which the student could study and become familiar with some days and often weeks before attending the course,

2) in theatre training; where a period of several days was spent attempting to obtain as much experience as possible in both general and advanced airway skills in the hospital theatre environment on live patients,

3) guidance by an anaesthetist; which was somewhat unstructured, if the student was lucky they spent a full day or two with the same anaesthetist and received direction and feedback, whereas other times were spent wandering between theatres in an attempt to ‘chase’ the AAM skills and thus no connection with the anaesthetist, 4) manikin training; where short periods of time was spent alone

practicing the AAM skills, and

5) CSO classroom training; a more formal training experience where the CSO would teach, support and provide feedback on the

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performance of specific AAM skills using a manikin-based simulation.

All the components of the laryngoscopic tracheal intubation training program were deemed of high importance. The in-service (CSO classroom training) and in-theatre components were reported to be of comparable importance although not the most essential in the

laryngoscopic tracheal intubation training program.

The new ILMA training program was developed without having any reference to the conventional laryngoscopic tracheal intubation training program. The ILMA training program was deliberately based on the premise of having strong foundational knowledge through the detailed precourse theory and exclusively using manikins for skill achievement and competency in contrast to the established in-theatre real patient training component.

The survey respondents, who were AAM qualified and had participated in the laryngoscopic tracheal intubation training program, were asked to rate, based on their experience, which of the laryngoscopic tracheal intubation training program components they believed essential for ILMA tracheal intubation training.

The precourse theory, in theatre training and manikin training were all deemed highly essential for paramedic laryngoscopic tracheal intubation training. Guidance by the anaesthetist was rated as the least essential component (49%) for ILMA tracheal intubation training. The in theatre component was rated as more essential than the anaesthetist. Instead the paramedics preferred the pre-course theory, manikin and CSO in- service components. This is a major change in training methodology which may be attributed to the reported ease of use of the device (ILMA) or the paramedics’ previous confidence and experience obtained from the laryngoscopic tracheal intubation training program.

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Table 22: Frequency of response to the Question “The following elements are essential for paramedic ILMA tracheal intubation training?”

Agree Disagree Missing p value

Precourse theory 94.3% (33/35) 5.7% (2/35) 0.0% (0/35) *

In theatre training 62.9% (22/35) 34.2% (12/35) 2.9% (1/35) .086

Guidance by Anaesthetist 48.5% (17/35) 48.5% (17/35) 2.9% (1/35) 1.000

Manikin training 97.1% (34/35) 2.9% (1/35) 0.0% (0/35) *

CSO classroom training 97.1% (34/35) 2.9% (1/35) 0.0% (0/35) *

* p value not possible due to insufficient data and therefore <5 distribution in categories.

With the medical supervision (in-theatre and guidance by anaesthetists) components reported as least essential for ILMA tracheal intubation

training, other training components become critical. The most essential components for an ILMA tracheal intubation training program has been reported to be the manikin training (97%) and the CSO classroom training. This change in emphasis from the in theatre tracheal intubation training, which has posed a number of logistical difficulties, to the more controlled efficient manikin-based simulation training has been supported by the paramedic intubation success rates when using the ILMA. The PILMAT trial which exclusively used manikin training, concluded “intubation via the ILMA was as successful as conventional laryngoscopic intubation“

(McCall, Reeves et al. 2008).

In an attempt to remove the influence of previous AAM training, especially laryngoscopic tracheal intubation, the reported ILMA tracheal intubation components considered essential were evaluated from the five respondents who were not AAM qualified and had only used the ILMA for tracheal intubation.

The five non-AAM qualified respondents reported all components essential except for the guidance by an anaesthetist. There is clearly a difference in what paramedics consider the essential tracheal intubation training components between the two devices: the laryngoscope and the ILMA. These variations may have a substantial effect not only on the

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ability to achieve more effective training outcomes but also on the decision on which level of practitioner may be suited to having these skills as part of their clinical practice. It is evident in this small study; tracheal intubation via the ILMA can be successfully implemented into paramedic practice without an extensive in-hospital training component.

Table 23: Frequency of response to the Question “The following elements are essential for paramedic ILMA tracheal intubation training?”

Agree Disagree Missing p value

Precourse theory 100% (5/5) 0% (0/5) 0% (0/5) *

In theatre training 100% (5/5) 0% (0/5) 0% (0/5) *

Guidance by Anaesthetist 40% (2/5) 60% (3/5) 0% (0/5) *

Manikin training 100% (5/5) 0% (0/5) 0% (0/5) *

CSO classroom training 100% (5/5) 0% (0/5) 0% (0/5) *

* p value not possible due to insufficient data and therefore <5 distribution in categories.

1. This data was from the 5 respondents who were not AAM qualified

The preferred training components across both training programs didn’t differ except for the in-theatre (ILMA 64.3%, laryngoscope 95.5%) and guidance by anaesthetist (ILMA 46.4%, laryngoscope 95.5%)

components. Using the traditional AAM training program as a comparison and having completed the new ILMA training program, paramedics were able to compare the components of each training course. The two main differences, manikin/simulation training and in-theatre training, were main components for the interviews.

A crosstab analysis showed in theatre training (ILMA tracheal intubation 64.3%, laryngoscopic tracheal intubation 95.5%, p.031) and guidance by anaesthetist (ILMA tracheal intubation 46.4%, laryngoscopic tracheal intubation 95.5%, p.022) are less significant training components for confidence in ILMA tracheal intubation. This contributed nothing further to the data analysis.

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Table 24, Tracheal intubation confidence for the different training components when using both devices.

confidence in ILMA confidence in Laryngoscopic tracheal intubation tracheal intubation

yes p-value yes p-value

Precourse theory yes 96.4% (27/28) 100.0% (22/22) no 3.6% (1/28) .204 0.0% (0/22) − In theatre training yes 64.3% (18/28) 95.5% (21/22) no 35.7% (10/28) .031 4.5% (1/22) 0.749 Guidance by Anaesthetist yes 46.4% (13/28) 95.5% (21/22) no 53.6% (15/28) .022 4.5% (1/22) 0.022 Manikin training yes 100.0% (28/28) 95.2% (20/21) no 0.0% (0/28) .019 4.8% (1/21) 0.869 CSO classroom training

yes 100.0% (28/28) 86.4% (19/22)

no 0.0% (0/28) .019 13.6% (3/22) 0.679

1. There were 28 complete responses to the crosstab of ILMA tracheal intubation confidence and the training components and 22 complete responses to laryngoscope tracheal intubation confidence and the training components.

The in-theatre training was reported as essential (n33, 95%) but during the interviews a number of shortfalls were identified with this training component, one respondent reported:

“.. because you can’t get enough real people and also you can’t get the complicated intubation”

The learning curve for paramedic tracheal intubation has been shown in a study by Wang et al (Wang, Seitz et al. 2004) to be the best in the out of hospital and ICU settings. The learning curve for paramedic tracheal intubation in the theatre environment was lower despite providing the greatest opportunity by way of patient numbers for skill practice. During the interviews a number of comments were made regarding the in theatre training environment, commonly statements regarding the decreasing practice of tracheal intubation and competition with other medical trainees were cited as consistent problems with in theatre paramedic AAM training.

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The initial Tasmanian AAM training program specified a minimum number of laryngoscopic tracheal intubation attempts (30) were to be achieved during the in theatre training component in order to successfully complete the program. The majority (33/35) of respondents in this survey did indicate the in theatre training for laryngoscopic tracheal intubation highly essential with the guidance provided by anaesthetists slightly lower. This suggests the live patient experience for laryngoscopic tracheal

intubation a critical component of the training process and the

anaesthetists’ involvement of slightly lesser importance. This also may indicate the guidance by an anaesthetist critical during the first attempts until the paramedic has experienced success and received adequate feedback to provide a suitable level of confidence, after which the

paramedic relies less on the anaesthetist guidance but continues to value the live experience.

The desire to experience ILMA use on a live patient, as evidenced by the reported level of in theatre training, was supported during the

interviews. One respondent stated,

“To feel the ILMA going into a real person once or twice in theatre, that's all it would take I feel and that's based on experience since then, that I would be more confident going on doing it the first time”

The notion of having to experience laryngoscopic tracheal intubation before being able to truly appreciate a blind tracheal intubation technique (ILMA) was only a recommendation made by paramedics who were AAM qualified. Performing tracheal intubation is the only time when paramedics have traditionally been able to view inside the human body, potentially adding to the exclusiveness which many AAM qualified paramedics feel. Therefore for the AAM qualified paramedics to suggest laryngoscopic tracheal intubation is a prerequisite for ILMA tracheal intubation may be an attempt to maintain their superiority. The AAM qualified paramedics, who had viewed the anatomy of the upper airway by using a laryngoscope, believed they were better equipped to provide alternative methods of

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airway management especially when introducing new techniques such as the ILMA, as one AAM qualified paramedic declared,

“If you don't need a laryngoscope and you just go in with an ILMA there is going to be some doubts in your mind what you are dealing with, you don't truly appreciate the oropharynx”