The Ambulance Science Podcast: Lies, Damn Lies and Statistics….

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Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome: A Controlled Clinical Trial by Gausche, M et. al.

Paramedic Self”efficacy and Skill Retention in Pediatric Airway Management by Youngquist, S.T. et. al.

Gausche Study: Criticism

1. Good study design, bad application and interpretation

-Intent to Treat Model, when 115 of 420 “Treat” patients had no intervention attempted at all, drives difference between groups to the null hypothesis.
-Non-intubation was not considered a protocol violation: “Given that the data were analyzed by intention to treat, it is unlikely this 2.3% protocol violation rate had any effect on study results.”

Except that, of course, this was exactly what the study was about!

Previous:

2. It is the system, not the clinician!
-Six hours of training.
-No significant clinical exposure to pediatric intubation in operating room, emergency department, or prehospital settings.
-Most had no retraining at all.  Two-hundred and twelve did (see second study attached) and only 66% of paramedics tested (139 ⁄ 211) passed skills testing with BMV (with a score of pass or higher), while 42% passed skills testing with ETI (88 ⁄ 212), with the odds of scoring among the higher grade levels on ETI skills testing was statistically lower for each additional month elapsed since initial training.
-Here’s the problem: They don’t recognize that the clinician isn’t the problem, the problem is their system’s educational methodology (including continuing education): “These results call into question the current practice of paramedics intubating children in an urban, out-of-hospital setting….”  

It is the system, not the clinician!: Endotracheal Intubation: Factors for Success:

Experience2
One study reported that healthcare personnel needed to perform a minimum of 57 intubations before achieving a 90% success rate with this procedure. The authors of this meta-analysis believe that practitioners who intend to perform prehospital advanced airway management are unlikely to achieve high levels of competence without a period of in-hospital anesthetic training followed by an adequate number of intubations to maintain skill levels. 

Exposure1
Exposure counts:
-Experienced: 99% success (‘experienced consultant anesthetists’),
-Intermediate: 99% success (“˜physicians in training in emergency medicine and anesthesia with some anesthetic experience’),
-Basic: 92% success (“˜non-physicians or those physicians with only limited anesthetic experience’)

Environment2

Prehospital ETI cannot automatically be compared to ETIs performed in the emergency department or in the operating theatre, for two main reasons. Firstly, the majority of prehospital ETIs are done in CA patients or after major trauma in challenging settings, while the majority of in-hospital ETIs are done in a controlled environment. Secondly, prehospital ETIs are challenged by a number of environmental factors that may influence the failure rates and increase adverse events, including….

-Restricted patient access

-Suboptimal patient and operator positioning

-Limited equipment 

-Difficult or hazardous operating environments

Equipment3,1

Physician median (range) ETI success rates were 0.991 (0.973, 1.000) (all had RSI)
Paramedic/Nurse c No Medications median (range) ETI success rates for non-physicians were 0.675 (0.491, 0.968)
Paramedic/Nurse c Some Medications median (range) ETI success rates for non-physicians were 0.810 (0.755, 0.905)
Paramedic/Nurse c RSI median (range) ETI success rates for non-physicians were 0.967 (0.758, 1.000)

A large recent study reported a doubling of the odds of intubation failure where no drugs were used.1
Comparing apples-to-apples for tools, ETI success was 99% for physicians vs 97% for paramedics/nurses….

But they still used biased language, not comparing apples-to-apples for tools (let alone experience or exposure)…

“When comparing physicians to non-physicians, the corresponding median (range) ETI success rates were 0.991 (0.973, 1.000) versus 0.849 (0.491, 0.990).” 

References

1. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1603-7.

2. Airway management by physician-staffed Helicopter Emergency Medical Services — a prospective, multicentre, observational study of 2,327 patients. https://sjtrem.biomedcentral.com/articles/10.1186/s13049-015-0136-9.

3. Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers. https://ccforum.biomedcentral.com/articles/10.1186/cc11189.

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