Читать книгу Emergency Medical Services - Группа авторов - Страница 74

ETI is a complex and difficult procedure, and substantial training is required to attain and maintain proficiency. EMS clinician training requires three components: baseline acquisition of skill, maintenance of skill, and an iterative process of quality management used to identify deficits and guide skills maintenance. EMS agencies universally struggle to provide adequate airway management training.

EMS clinician competency requires a program of initial training followed by periodic skill verification and continuing education. Training should begin with didactics to review basic airway management. Advanced airway procedures should be introduced by discussing indications and contraindications for airway management, an algorithm for airway management, procedural complications, relevant pharmacology, local protocols, and special considerations.

Psychomotor skills should also be taught and verified using a model or low‐fidelity simulator. Skills reviewed should include all the skills necessary for the airway management algorithm, including identification of the indications for airway management, BLS airway skills, invasive airways, and surgical airways when applicable. High‐fidelity simulators may provide added realism for teaching psychomotor skills and also provide the ability to run scenarios to test decision making and practice the procedures needed to move through the airway management algorithm. High‐fidelity simulators can also be used to assess protocol knowledge, teamwork dynamics, and adherence to policies.

Obtaining live intubation training in the operating room or other controlled environment is the criterion standard of airway training. However, access to operating rooms is often limited by availability, liability, and cost [68]. The prevalence of noninvasive forms of airway management in the operating room combined with an increase in the number of trainees and professionals seeking intubation experience (residents, nurse anesthetists, respiratory therapists, etc.) has reduced the opportunity for prehospital clinicians to obtain ETI experience in controlled environments. Furthermore, selection bias introduced by the supervising professional may limit the trainee to only less‐challenging airways. Liability concerns have further curtailed intubation experiences for EMS clinicians.

The optimal number of encounters for maintaining prehsoptial ETI skill is unclear. Current educational guidelines advocate that paramedic students undergo at least 50 advanced airway encounters through a combination of mannequins, simulators, cadavers, and live patients [69]. One older study suggests that paramedic students need at least 20 to 25 live ETI encounters in the operating room, hospital, or prehospital setting to attain baseline ETI proficiency [70]. Most successful prehospital airway management programs require EMS personnel to perform more than five ETIs annually. These programs have access to operating rooms to provide supplemental training. While experience gained through field intubations is optimal, EMS personnel perform surprisingly few airway management cases in clincial practice. In many cases, paramedics may perform ETI less than once per year.

Whenever possible, the medical director should seek opportunities for EMS pracitioners to obtain live patient intubation experience. Ideally this would be done in operating rooms and EDs under close supervision. Contracts and memorada of understanding may help limit medicolegal exposure, define expectations, and improve access to procedures. Cadaveric training may also be useful, providing some of the variability and context of a live intubation while limiting risk. Access to cadavers for intuabtion training, however, is limited and costly.

Many training programs and EMS agencies use mannequins and human simulators for ETI training [71]. Simulators do not accurately recreate the “feel,” range, or variability of live human airway anatomy. However, simulators are convenient, widely available, flexible, and can be relatively less expensive than other adjuncts for airway training. Low‐fidelity human simulators, which often consist of just a mannequin head, are useful for limited psychomotor training. Some EMS medical directors advocate integrating high‐fidelity human simulator‐based training to recreate complex “difficult airway” situations [37]. The rationale for this additional training is to develop airway management decision‐making skills, which cannot be fostered in the controlled operating room setting. It is essential that paramedics develop good airway management decision‐making skills, not just good laryngoscopy skills.