Out-of-Hospital Surgical Airway Management: Does Scope of Practice Equal Actual Practice?

Abstract

IntroductionPennsylvania, among other states, includes surgical airway management, or cricothyrotomy, within the paramedic scope of practice. However, there is scant literature that evaluates paramedic perception of clinical competency in cricothyrotomy. The goal of this project is to assess clinical exposure, education and self-perceived competency of ground paramedics in cricothyrotomy.MethodsEighty-six paramedics employed by four ground emergency medical services agencies completed a 22-question written survey that assessed surgical airway attempts, training, skills verification, and perceptions about procedural competency. Descriptive statistics were used to evaluate responses.ResultsOnly 20% (17/86, 95% CI [11–28%]) of paramedics had attempted cricothyrotomy, most (13/17 or 76%, 95% CI [53–90%]) of whom had greater than 10 years experience. Most subjects (63/86 or 73%, 95% CI [64–82%]) did not reply that they are well-trained to perform cricothyrotomy and less than half (34/86 or 40%, 95% CI [30–50%]) felt they could correctly perform cricothyrotomy on their first attempt. Among subjects with five or more years of experience, 39/70 (56%, 95% CI [44–68%]) reported 0–1 hours per year of practical cricothyrotomy training within the last five years. Half of the subjects who were able to recall (40/80, 50% 95% CI [39–61%]) reported having proficiency verification for cricothyrotomy within the past five years.ConclusionParamedics surveyed indicated that cricothyrotomy is rarely performed, even among those with years of experience. Many paramedics felt that their training in this area is inadequate and did not feel confident to perform the procedure. Further study to determine whether to modify paramedic scope of practice and/or to develop improved educational and testing methods is warranted.

Characteristics and outcomes of prehospital and emergency department surgical airways

“…Although our sampling methodology precludes a formal calculation of procedure incidence, and the study is underpowered to draw statistical conclusions, several results are hypothesis generating and have important clinical implications. Forty‐five states include surgical airways in paramedic scope of practice, 17 and the ability to perform a surgical airway is imperative for emergency medicine physicians. Understanding expected immediate complications and downstream adverse events secondary to the procedure can specifically guide how the procedure is taught and reviewed with prehospital and ED operators.…”

“…4,5 Although our sampling methodology precludes a formal calculation of procedure incidence, and the study is underpowered to draw statistical conclusions, several results are hypothesis generating and have important clinical implications. Forty-five states include surgical airways in paramedic scope of practice, 17 and the ability to perform a surgical airway is imperative for emergency medicine physicians.…”

Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients

“…A more recent scoring tool from Japan, developed by Okada et al, also sought to predict emergency front of neck airway access, but studied both cricothyroidotomy and emergency needle cannula and lacked external generalizability [ 8 ]. Definitive airway management by pre-hospital emergency medical services was included in their scoring tool, a practice which is generally discouraged and remains controversial in much of the United States [ 27 , 28 ]. Furthermore, they did not find penetrating trauma to be a significant predictor of emergency airway access, although this may be because Japan, overall, has a much lower incidence of penetrating violence, compared to the United States [ 29 , 30 ].…”

Prehospital Surgical Airway Management Skills in a Rural Emergency Medical Service System

“…Prehospital surgical airway skills are rarely performed but remain important in the skill set of ALS providers with respect to advanced airway management [ 3 ]. In fact, many EMS personnel feel inadequately trained in the procedure [ 14 ]. Military data indicate that airway-related issues remain the third leading cause of preventable death on the battlefield [ 7 ].…”