An Economic Education

   One key goal of all EMS systems is to provide quality education to staff; however, the recent economic recession and continuing recovery has led many EMS systems to make financial adjustments. Unfortunately, this often includes significantly reducing training and educational budgets and, in many agencies, eliminating staff educational allowances and/or reimbursement for EMS-related seminars and conferences.

   Though many services looked at and/or moved to online education that could be done by staff members while on shift to significantly reduce costs, this does not adequately address the educational needs of kinesthetic (hands-on) learners. It also is not the best method of reviewing many of the psychomotor skills used by providers at all levels. Many of these skills and interventions (see Prehospital Skills sidebar) require not only practice, but also development of mind-muscle connections for high-demand, low-use interventions like endotracheal intubation, needle chest decompression and surgical airways, to name a few. These psychomotor skills and interventions cannot be practiced online and the mind-muscle connection will not be developed, which may lead to less than optimal performance in high-stress environments like pediatric cardiac arrest, patients requiring medication-assisted airway management and trauma.

   This is not to say that online education does not have its place. Online training and education, balanced with kinesthetic training and education, along with face-to-face (f2f) medical direction involvement, is beginning to emerge as the training and educational model of the future. This will not only lead to financial savings, but will also allow EMS education directors to maintain an aggressive, educational, cutting edge and interesting training schedule for the system's staff. An example of a cost-effective kinesthetic training and education in-service is a two-hour advanced life support (ALS) airway management review that can be easily adapted to BLS or air/ground critical care transport providers.

DEVELOPING GOALS/OBJECTIVES

   The first step in developing any educational offering is to determine the overall goal, or macro-objective, of the in-service. This can be accomplished through reviewing recent 9-1-1 responses, or, even better, determining what type of patients and/or skills staff has not seen or used recently. Choose a selected area from the National Registry of EMT-Paramedic or other provider level core requirements, from discussions with staff, or develop an ABC monthly rotation (see Training Plan Development sidebar). The macro-objective for Adult Airway Management for the Experienced Provider was identified by discussing with EMS Director B.J. Jungmann of the Maplewood (MN) Fire Department what he ultimately wanted to accomplish. He wanted a challenging two-hour f2f airway management review for his paramedics. This was a perfect macro-objective that not only defined what he wanted, but was easily adapted to meet state and national recertification requirements for all levels of providers, could be conducted f2f, and could also be easily modified to a blended online/f2f in-service.

   Next, you need to establish micro-objectives by identifying current resources like PowerPoint, dry-erase boards, or an apparatus bay with large Post-its on the wall. The key to developing and presenting an effective in-service is not the technology/media used, but what individual staff members learn and, ultimately, if what they learn enhances and/or improves their individual or team performance on real-world responses. For the Adult Airway Management review, three comprehension (review), two psychomotor (kinesthetic or hands-on) and one synthesis (formulate a plan in a simulation) micro-objectives were chosen (see Micro-objectives sidebar), intending to have the didactic portion last no more than 30 minutes and the kinesthetic portion make up the other 90 minutes with a short break in between. PowerPoint was chosen for the didactic portion and now needed to be fully developed.

DEVELOPING THE DIDACTIC COMPONENT

   In developing the didactic portion for your presentation, determine what you want staff to learn. From the didactic portion of our in-service, we wanted them to walk away with three key points: what the common complications are in airway management, assessment techniques to determine the potential difficult airway, and how to develop an algorithmic approach to the difficult airway. You can break the common complications down however you choose. For this in-service (ALS provider level), we elected to keep it to four: inadequate ventilations, airway obstruction, esophageal intubation and extubation. This was followed by asking the group how many difficult airways each of them had seen in the past year. We also discussed what they thought qualified as a difficult airway and how skilled they felt they were in using alternative or back-up airways.

   Next, a difficult airway management case was presented as a large group discussion to assess where they were in developing a plan and options for the selected case. (You can use an actual case from your service or from the multitude of cases available on the Internet.) The case presentation was followed by assessment techniques to help determine the potential difficult airway using the mnemonic LEMONS and pictures/diagrams of class 1-4 and grade 1-4 airways. Finally, we discussed the BLS and ALS tools available to providers for their service (see Available Tools sidebar) and how they can be used as an algorithmic approach to the difficult airway. The group was then divided into four small groups and each given a case with a difficult airway management patient, with roughly five minutes to develop an interventional plan. Each group presented its plan, and options or modifications to their plans were discussed, followed by a short break prior to the kinesthetic portion of the in-service.

THE KINESTHETIC COMPONENT

   For this in-service, we chose a brief review of basic airway adjuncts, focusing heavily on suction devices, both manual and battery operated. Suctioning of the airway was chosen for the simple fact that it is often discussed but seldom reviewed. The kinesthetic portion began with basic foods commonly found in a home refrigerator. We started with yogurt, which is very easily suctioned with either manual or battery operated suction, then added foods like noodle soup, bananas, hot dogs, etc. that can be mashed and mixed with water to simulate the consistency of food that might be choked on. Starting with the yogurt, participants took part in a head-to-head competition, with one using manual suction and one using battery powered suction, followed by a short discussion about which suction device seemed to work best. Then, two new participants were selected and the procedure was repeated using the next food item. It is most effective if you work with various foods before the in-service to find which are more effectively suctioned by one or the other device. Last, one or two food items were placed on the table and both participants worked together using both the manual and battery operated suction to clear the food item. This not only demonstrated effectiveness and sometimes the need for using two suction devices, but also developed team work, which was definitely needed when the in-service moved into the simulation portion.

THE SIMULATION COMPONENT

   The capstone of the in-service is simulation, once again building on what was learned/reviewed in the didactic and kinesthetic portions. The objective of this component is synthesis, which, in this case, is developing an effective plan or applied algorithm to manage a simulated difficult airway patient. For this component, an old airway simulator works best, though a new one can be adapted. The stomach portion can be pulled off and clamped closed and the lungs can be replaced with surgical gloves for easy cleaning, since this component gets messy. This time, food items found in your kitchen serve as vomitus.

   To simulate a 23-year-old intoxicated male choking on chips and chili dip, place the chips and chili in a Ziploc bag, mash to the consistency desired, and place into the mouth and/or nose. Further patient information can be added as desired and needed to complete the simulation. Begin with a challenging scenario, making each subsequent situation more complex. Each simulation typically lasts about 10 minutes, which includes time for a short debrief. Clean the simulator quickly and set it up for the next team to manage.

   Depending on the number of participants, teams can range from two to four. Two is the optimal number to allow both participants to be significantly engaged. We have found that direct engagement declines as participants are added. If a service operates with three- or four-person crews, however, having a four-person team would more accurately reflect a real-world response. Multiple simulations can be run simultaneously with multiple facilitators, but it is not necessary and may actually be counter-productive, since it limits the chance for others to observe the simulations and share their ideas and observations during the post-simulation debrief.

   The final debrief is a review of what worked and what didn't from all the simulations. What posed the greatest challenges? What caused the greatest frustration? What seemed to work best to clear the airways? Ask each participant to share one thing he or she learned that they know they will use on the next difficult airway.

BUILDING ON THE IN-SERVICE

   Following the in-service, discussion leads to what to do for the next training session. One option is to obtain a wrecked car from a scrapyard and work with the local fire service's training officer to develop a session on trapped trauma patients with difficult airways. Not only can the EMS crew review airway management, but integrating with an engine and/or rescue company to perform an extrication allows for coordination and team-building between EMS and fire. Other options for review are pediatric difficult airway management, surgical airway management or back-up/secondary airway management. Following the ALS in-service for Maplewood Fire paramedics, a BLS version was developed and presented to their BLS staff.

CONCLUSION

   As EMS service directors are forced to reduce operating budgets, educational budgets will not escape scrutiny. More for less has been, and will be for the foreseeable future, the operating environment for EMS services. This does not mean the quality of EMS education has to suffer, but it should be looked at as a unique challenge. What it does mean is that EMS educators, coordinators and directors entrusted with initial and ongoing EMS education will realize that creativity is the most valuable skill at all levels.

SIDEBAR 1: PREHOSPITAL SKILLS

PSYCHOMOTOR SKILLS AND INTERVENTIONS

Intraosseous insertion
Splinting
Magill forceps
Combitube
King airway
Cardiac pacing
Cardioversion
LUCAS device
IV insertion

HIGH-DEMAND/LOW-USE

ET intubation
Surgical airways
Needle chest decompression
Pericardiocentesis
Rapid sequence induction

SIDEBAR 2: AVAILABLE TOOLS

BLS (SOME CROSSOVER TO ALS IN SYSTEMS)

Positioning
Suction
BVM
Oral
Nasal
Abdominal /Chest Thrusts
King Airway/Combitube/LMA

ALS

E.T. intubation (oral/nasal)
Tracheal tube introducer
Magills
Surgical
Rapid Sequence Induction

SIDEBAR 3: Training Plan Development

ABC (AIRWAY, BREATHING, CIRCULATION) MONTHS

   January (Airway)

   Use of secondary airways:

• Oral/nasal airways
• King airway/LMA
• Combitube

   February (Breathing)

   Review of nebulizers:

• Nebulizers
• Bag nebs

   March (Circulation)

   Review of cardiac arrest management:

• Integration of cardiac defibrillation with the LUCAS device
• Integration of ET intubation with the LUCAS
• Alternative sites for EZ-IO insertion

SIDEBAR 4: MICRO-OBJECTIVES

COMPREHENSION

• Describe the most common complications in airway management.
• Discuss assessment techniques to assist in determining a difficult airway.
• Discuss common airway problems and algorithmic approaches to managing them.

PSYCHOMOTOR

• Review the use of basic adjuncts for airway maintenance.
• Demonstrate various suctioning techniques.

SYNTHESIS

• Demonstrate managing simulated airway problems on an airway simulator.

Bibliography

American Society of Anesthesiologists. www.asahq.org/.

Bledsoe BE, Porter RS, Cherry RA. Paramedic Care: Principles and Practice, 3rd ed. Upper Saddle River, NJ: Prentice-Hall, 2008.

Cannon-Bowers JA, Salas E. The science of training: A decade of progress. Ann Rev Psych 52: 471-499, 2001.

Driskell JE, Salas E. Stress and Human Performance. Mahwah, NJ: Erlbaum, 1996.

Galbraith MW. Adult Learning Methods, 2nd ed. Malabar, FL: Krieger, 1998.

Inzana CM, Driskell JE, Salas E, Johnson JH. Effects of preparatory information on enhancing performance under stress. J Appl Psych 81(4): 429-435, 1996.

Miller WR, Miller MF. Instructors and Their Jobs, 2nd ed. Harrisonburg, VA: Banta, 1998.

   Scott Tomek, MA, EMT-P, has been a paramedic for 25 years, 23 with Lakeview Hospital EMS in Stillwater, MN. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.