Effectiveness of Human Simulation on Paramedic Students Endotracheal Intubation - Essay Example

A Critical Appraisal of the Effectiveness of Human Simulation on Paramedic Endotracheal Intubation Introduction This is a critical appraisal of the paper, "Human Patient Simulation Is Effective For Teaching Paramedic Students Endotracheal Intubation" by Hall, R.E., Plant, J.R., Bands, C.J., Wall, A.R., Kang, J. and Hall, C.A., published in Academic Emergency Medicine, volume 12, pages 850-855, in the year 2005. This article was retrieved, studied, and reflected upon in order to appraise critically using the critique framework of Bellini and Rumill (1999) described in Research in Rehabilitation Counselling. This would help the writer to understand the implications of a research framework, comprehend the study report better, and enable better to undertake and document a research in future. Essentially, this exercise enables the student to apply a scientific approach with sufficient rigour to produce valid conclusion. Title: This is a study of educational advances in the area of health sciences, where many procedures are currently being performed by care providers other than doctors even outside the hospital setting. Therefore, training is an important part of such practice. The adequacy of training in critical and technically difficult procedures is significant to ensure quality of services that essentially belong to the services in the healthcare. Human patient simulation has been used to train paramedics, and even though, it is observed that the paramedics are successful in endotracheally intubating the patients in transit to the hospital, organized research might throw some light on the efficacy of such educational advances. Thus, the title describes the study accurately. From the above discussion, it is evident that the key words represent actually the key elements of the title concisely without digression. Abstract : The abstract is concise and succinct in that it summarizes the purpose, methods, and the findings of the study. The authors rightly state that the purpose of the study was to investigate endotracheal intubation training using a human simulator was as effective as live training in the operating room for the technicians. The authors developed an appropriate methodology for the intended study that aims to study the effectiveness of simulator training of endotracheal intubation as a training method. The successful intubation rate was identified as the dependent variable with the secondary dependent variable being the complication rate. It is implied that the independent variable will be training in endotracheal intubation; although, no quantifiable data has been enumerated in the abstract. The abstract is well written and precise and does include all the major premises and findings presented in the article. It is also articulate in the sense that it arouses inquisitiveness in the reader so he becomes interested to go through the whole literature. Introduction : The authors clearly identify the research problem and state that unequivocally in the introduction. The "primary purpose of the study was to determine whether the intubation success rate is different among paramedic students trained on a human patient simulator versus on human subjects in the operating room." The authors go ahead to hypothesize that human simulator training of the paramedics to perform an endotracheal intubation produces equivalently effective performance of the paramedics. Endotracheal intubation is a critical procedure in the sense that if it is not done in the appropriate time, it produces worse outcome leading to enhancement of mortality. This demands out-of-hospital endotracheal intubation by the paramedics. If this is a treatment option, the quality and quantity of training of the paramedics are crucial since they need to intubate patients in less-than-ideal situations. This is the area to which the authors draw attention of the reader by highlighting the problems involved in training of the paramedics. They mention many methods, but the ideal method of training remains controversial. By explaining the theoretical rationale of the study, the authors establish the conceptual framework for the study. The significance of the problem has been adequately and appropriately identified that leads directly to the perceived need to study the subject more. Thus, the major construct of the study is to investigate the effect of the current practice of paramedics to be trained in endotracheal intubation with lectures and mannequins followed by intubations on human subjects in the operating room. This explains the theoretical rationale and the framework. This conceptual framework seems appropriate in the light of the research problem of finding the most effective means of training the paramedics in endotracheal intubation since simulators have been evaluated in other areas of medical education, and studies are prominently lacking in the area of training endotracheal intubation. The literature review finds a paucity of literatures that document success rates of intubation by the paramedics on human subjects after training them on a human patient simulator. The authors facilitate the reader's understanding of how this idea will be studied and why they are important in practice of emergency airway management. There is much justification given when the authors hypothesize the suitability of simulator training in effective endotracheal intubation giving a directional clue to the section of methods where data are collected and analyzed to arrive at a diagnosis that simulator training can be the preferred method for such training. Method: The sample has been clearly enumerated in terms of size, relevant characteristics, selection and assignment procedures. There was no inducement involved to solicit subjects. The authors randomly selected 42 second-year paramedic students from a teaching institute. All the students received the same initial didactic and mannequin airway training during the paramedic curriculum. All students met inclusion criteria, and therefore, none met exclusion criteria. Verbal and written informed consent was taken from all the students after ethical clearance. Six students did not consent; hence the sample size was 36. These students were assigned randomly to either simulator training or operating room training. It can be commented that the sample size is greater than 30, so the results would be good. The design is longitudinal and comparative. This is a nonexperimental design because there is no manipulation of the independent variable. Longitudinal designs obtain data for a long period. In this case, the data were obtained over a 10-month period and were used to establish comparative means between the two groups. Therefore, the design is consistent with the purpose of comparing groups of paramedics trained in endotracheal intubation on a patient simulator or in the operating room. The control group received the current local standard of 15 training intubations in the operating room. From the conceptual framework, the reader anticipates that the authors will be collecting information on an identical test situation provided to both the groups where other than the number of intubations, there was no standardization of instructions from the supervising anesthesiologists. Since the operating room group was serving as the control group, during the study period, they did have no exposure to the patient simulator. Thus, the authors describe this study appropriately as a prospective randomized controlled trial, and the design is consistent with the purpose of the study to compare performance of simulator trained group of paramedics to that of operating room group. The instruments described seem to be appropriate for the measure of the study since the authors applied the standardized simulator session that included each basic step of intubation and repetition of the technique with various airways and case scenarios, such as, simulating advancing levels of airway difficulties by cervical spine immobilization and using simulator options of tongue swelling, oropharyngeal swelling, and laryngospasm. To avoid bias, no training was provided to either group between training and testing. The instruments have been elaborately delineated, and these instruments encompassed all possible situations. The outcomes were clearly defined as to which is success and which is failure. The difficulty levels of the intubation were decided by patient measurements and ultimately decided by the attending anesthesiologist. The failures were recorded as a second-attempt failure along with record of complications. Threats to internal validity are germane to experimental research, and the threats are perceivable by the design of the instrument, but the authors do not mention them in the study. Thus, it can be commented that there is insufficient information about the psychometric properties of the study, but the authors have distinctly set up the criteria of the materials used in the study, so the reader can easily understand the appropriateness of the method of data collection. In fact, the authors have described the steps of measurements involved in the study with explanations related to each scientific procedure in each step in an accurate chronological order in the protocol section so if the reader desires to replicate the study, he has a ready protocol. It may be commented that generalizability of the study is limited to the sample because of the effect of nonprobability convenience sampling. From the conceptual framework, the reader anticipates that the authors will design measurements by collecting data from the test intubations by the members each of the groups. The information can be grouped into primary outcome, secondary outcome, first attempt success, number of cases where second attempts were necessary, and rates of secondary complications. The patients' data were collected. It has been mentioned earlier that the authors did mention the design of the study. Results: The authors present a well-written and well-organized results section. The coding of all the scales used in the study was detailed to assist the reader in interpreting the results. For example, the authors classify the patient data to present in table 1 that can be used as predictors of airway difficulty. The reader clearly understands that the difficulty level indicated by body mass index, dentures, Mallampatti scores, and thyromental distance were almost equally dispersed among the two groups. Intubation success rates were presented in table 2, and complications were tabulated in table 3. The tables were clearly labeled and easy to understand for the reader. The key concepts being measured in these subscales actually indicate the performance level of the two groups of paramedics in the test situation. All these variables are measured in a nominal scale. Descriptive statistics were reported as means and standard deviations both in the tables and in the text, where a small amount of repetition of results highlights the findings. Patient demographics were calculated using means for continuous variables and using percent frequency of occurrence for categorical variables. To see whether there is any difference in patient assignment, the authors did an unpaired-t test of the study groups on continuous demographic variables. There was repeat assessment for each student. So there were students performing multiple intubations in the test situation. The authors, therefore, used generalized estimating equation (GEE) to perform the primary analysis. GEE is the best statistical tool to account for the cluster structure in the design that arose from the repeat assessments for each student. However, this has a limitation, and the authors have accepted that. There were no available data for variance within the students performing multiple intubations, and the authors could not perform an appropriate correction for repeated measures. The error has been avoided to a great extent by GEE model that had taken into account the correlation among outcomes by specifying the cluster units that indicate a group of observations highly correlate with one another. The use of regression analysis is appropriate in such a situation to obtain information on which independent variables explain the variance of dependent variables, the success rate of intubation or the performance status of the students. Therefore, it can be commented that the analysis of data and the salient results thereof connect directly to the objective, hypothesis, and the aim of the study. Discussion and Conclusion: The authors conclude that this study proves the hypothesis that the paramedic students trained on a simulator demonstrate comparable, may be even better success rates and similar complications rates to the students trained in the operating room. There were very narrow confidence intervals surrounding differences between the groups for first-attempt success and complication rates. The validity and reliability of the study has been established by attempt on the part of the authors to obviate bias by excluding differences between study groups in factors related to airway difficulty levels. The reader can observe that there was no significant learning curve. This indicates both the training methods led to sufficient skill acquisition before testing signifying acceptable level of training. It is evident that the authors are discussing the findings in terms of research problem, conceptual framework, and the hypothesis. The results indicate that using patient simulators to teach endotracheal intubation to the paramedic students can be an effective and acceptable method of training. The authors clearly delineate the limitations of the study in a separate section. The data were objective, yet to achieve generalizability, it would have been better to blind the anaesthesiologists and data collectors to the training group of students. Training and testing at different locations would have been ideal, but that was not accomplished. The internal validity of the study had further been compromised by inability to eliminate interobserver reliability of assessment of difficulty levels of individual patients, and the anesthesiologist assessment of the patients were not validated. The patient groups did not include paediatric patients, and testing situation was operating room, whereas the paramedics were supposed to intubate any patient in the off-hospital setting. These further compromise the hypothesis. The implications in the future healthcare practice have been delineated in that simulator training can be the future method of choice for training the paramedics, but the authors did not mention the implications or scope of future research on this topic. In light of the results, the authors' conclusion seems to be appropriate and justified. References : The authors have cited 19 references from authentic journals, and they span from year 1982 to 2003, and depending on the relevance of the topic, they seem to be sufficiently current, and they indeed encompass all the relevant literatures encompassing different aspects of the study. The text citations are appropriate, and a documentation exercise reveals that all are accurate. General: In general, this is a well-written, organized article that addresses a valid problem in emergency health care and reveals a means to address the problem. This article teaches us how a hypothesis can be framed on the theoretical framework, how a study design can be made, and how data can be collected and interpreted to reach a conclusion that might solve a problem in an area of practice. The most compelling strength of the study is its simplicity that the reader feels in every step and the lucid style of presentation. If the limitations were avoided, this could have been the absolute study in this area. References Bellini, J. L., & Rumrill, P. D., Jr, (1999) Research in Rehabilitation Counseling. Springfield, Ill: Charles C. Thomas. Hall, R.E., Plant, J.R., Bands, C.J., Wall, A.R., Kang, J. and Hall, C.A. (2005) Human patient simulation is effective for teaching paramedic students endotracheal intubation Academic Emergency Medicine 12: 850-855. Read More