Many paramedics do not get enough clinical experience in insertion of emergency breathing tubes

Across the United States, many patients require insertion of emergency breathing tubes before arriving to a hospital, but emergency medicine researchers at the University of Pittsburgh School of Medicine have found that many paramedics - the highest level of prehospital providers - do not get enough clinical experience in this life-saving skill. These findings are reported in the August issue of the journal Critical Care Medicine.

Endotracheal intubation (ETI) is an emergency medical procedure whereby trained medical personnel place a clear, flexible plastic tube into a patient's windpipe to deliver oxygen to the lungs. Paramedics collectively perform approximately 12,000 intubations every year in Pennsylvania.

Using patient data from the Pennsylvania Emergency Medical Services Patient Care Report from Jan. 1 to Dec. 31, 2003, the Pittsburgh researchers looked at the frequency of intubation performed by individual paramedics. They found that two-thirds of Pennsylvania paramedics performed intubation less than three times per year, and 40 percent performed no intubations at all.

"We need to find better ways to train paramedics to perform this very difficult procedure or find better and simpler ways to manage the airway," said Henry E. Wang, M.D., M.P.H., assistant professor of emergency medicine and lead author of the study.

Previous studies of complex medical procedures have shown that the occurrence of errors, adverse events and poor outcomes is associated with the volume of procedural experience.

Paramedic students in the United States are required to perform only five intubation procedures before graduation, compared to emergency medicine residents, who are required to perform 35, or anesthesiology residents, who must complete 50, before graduation.

"The entire health care delivery system is going through an evolutionary process, and everyone, from paramedics to trauma surgeons, is reexamining many medical procedures to assess their usefulness," added Donald M. Yealy, M.D., professor and vice chairman of emergency medicine and one of the study authors. "This study strongly suggests that our national health care system needs to change to better care for those in need of this breathing aid, including this important and complicated procedure."

While the study showed that air medical and urban paramedics were exposed to slightly more intubation procedures, these differences were small.

"Rapid airway management is a skill that paramedics can learn and master, however, many paramedics get little chance to master the skill because they see so few cases. Almost half of paramedics don't perform an intubation procedure in one year," said Ronald N. Roth, M.D., associate professor of emergency medicine and medical director of the City of Pittsburgh, Bureau of EMS.

"While the technique of training paramedics to perform intubation in the field was pioneered here in Pittsburgh more than 20 years ago, the original concept involved training small groups of motivated, highly skilled rescuers," commented Dr. Wang. "It is unrealistic to expect every paramedic in every pocket of the United States to master this incredibly difficult skill. Further studies need to be done to determine if the procedure needs to be modified, or if we need to do a better job as health care educators to train and maintain paramedics' rapid airway management skills."

Collaborating with Drs. Wang and Yealy include, David Hostler, Ph.D., NREMT-P., visiting research instructor, department of emergency medicine at the University of Pittsburgh; Judith R. Lave, Ph.D., department chair of health policy and management, University of Pittsburgh Graduate School of Public Health; Douglas Kupas, M.D., from the Geisinger Medical Center in Danville, Pa.; and Robert Cooney, M.S., from the Pennsylvania Department of Health.