Advanced airway (AA) training is a highly important skill for PAs to be credentialed in. However, in my experience, many PAs who need this advanced training are discouraged from becoming credentialed or flat out told “no” by their credentialing hospital system or supervising physician(s).  In 2017, the Physician Assistant Education Association (PAEA)1 conducted a survey of PA program’s clinical curriculum where 91% of 222 responding programs reported requiring Advanced Cardiac Life Support (ACLS) certification before students started clinical rotations, yet many programs do not have the resources to offer more in-depth airway management skills training beyond using a mannequin head. Some programs affiliated with a medical school may have access to training with cadavers; however, advanced airway training on a cadaver, even a soft preserved one, is not as useful as live training in the operating theater alongside an anesthesiologist/nurse anesthetist in a controlled environment.2

Many new graduate PAs do not feel confident with endotracheal intubation and postgraduate training improves their ratings of preparedness.2 The following postgraduate training formats are currently available: online video-based, online certificate courses, online certificate courses with an add-on option for a 1- or 2-day in-person skills workshop, workshops associated with large national (eg, American Academy of Physician Associates [AAPA] or Society of Emergency Physician Assistants [SEMPA]) or smaller state conferences, and 2- to 3-day in-person live courses, some of which include cadaver training sessions.3,4

Why don’t we take a page from the book of paramedic training and conduct advanced airway training on live patients in the operating room (OR) and emergency department?

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In a 2022 review of prehospital clinician training, Dorsett et al5 pointed out, “With regard to advanced skills such as endotracheal intubation, task trainers and low-fidelity mannequins are adequate for entry-level training in skill components, but achieving minimum competence let alone expert longitudinal performance with these devices is difficult if not impossible.”

They added, “While fundamental procedural understanding may be demonstrated through the use of simulation, it is challenging if not impossible to achieve competence without supervised clinical exposure to real patients. The operating room is an ideal education and training location for all levels of prehospital clinicians for both initial and retention of comprehensive airway skills.” Specifically, they noted the following advantages of OR training: live anesthetized patients, expert airway educators, live physiology/pharmacology, and live physiological monitoring.5

A total of 268,420 paramedics were certified in 2020 in the United States and have a minimum standard of training that includes ACLS and advanced airway training as set forth by the National Highway Traffic Safety Administration.5,6 In addition to these advanced techniques, many EMS medical directors have written protocols that allow paramedics to perform rapid sequence induction/intubation (RSI) as a part of their working standards. Rapid sequence induction/intubation uses sedation and neuromuscular blockade medications for use of advanced airway management “for a patient in acute respiratory failure due to inadequate oxygenation or ventilation, and for airway protection in a patient with an altered mental status.”7 Paramedics intubate and use sedation and paralytics, why aren’t more PAs doing the same?

Many PA Specialties Require Advanced Airway Training

More than 148,000 certified PAs practice in the US, according to 2020 data from the National Commission on Certification of Physician Assistants (NCCPA)9 with a total of 18,760 of these PAs who practice in areas that need advanced airway training and credentialing including:

  • Emergency medicine (12,152)
  • Critical care (1241)
  • Anesthesiology (356)
  • Hospital medicine (3086)
  • Obstetrics and gynecology (1117)
  • Otolaryngology (808)

Often, it is just a matter of educating our colleagues on what we are capable of and working together to come to a consensus on what amount of training is sufficient for our institutions and supervising physicians to credential us in advanced techniques (not limited to intubation). Once you complete the necessary didactics, take every opportunity to perform the skill on a live patient in a controlled setting, building competence and confidence.

Dana S. Miles, MS, PA-C, CAQ-EM, has been working in emergency medicine as a PA since 2005 and is currently in the Doctor of Medical Science (DMSc) program at A.T. Still University-Arizona School of Health Sciences.

References

  1. Physician Assistant Education Association. By the Numbers: Curriculum Report 3: Data from the 2017 Clinical Curriculum Survey. PAEA; 2018. doi:10.17538/CR3.2017.001.
  1. Moon MB, Darden A, Hill M, Roberts MK, Varalli-Claypool B, Miller FC. Emergency critical skills training for pre-clinical physician assistant students: mixed method comparison of training method. Med Sci Educ. 2022;32(4):837-845. doi:10.1007/s40670-022-01575-0
  1. Airway Management Education Center, LLC. The Difficult Airway Course™. 2022. Accessed December 17, 2022. https://www.theairwaysite.com/
  1. Provider Practice Essentials. Advanced and Difficult Airway. 2022. Accessed Dec 17, 2022. https://ppemedical.com/advanced-and-difficult-airway-course-for-physician-assistants/
  1. Dorsett M, Panchal AR, Stephens C, et al. Prehospital airway management training and education: an NAEMSP position statement and resource document. Prehosp Emerg Care. 2022;26(sup1):3-13. doi:10.1080/10903127.2021.1977877
  1. National Association of State EMS Officials. 2020 National Emergency Medical Services Assessment. May 27, 2020. Accessed March 28, 2023. https://nasemso.org/wp-content/uploads/2020-National-EMS-Assessment_Reduced-File-Size.pdf
  1. National Highway Traffic Safety Administration. National EMS Scope of Practice Model 2019. Report No. DOT HS 812-666. February 2019. Accessed March 28, 2023.
  1. Schrader M, Urits I. Tracheal rapid sequence intubation. In: StatPearls [Internet]. StatPearls Publishing; 2022.
  1. National Commission on Certification of PAs. Statistical Profile of Certified PAs: Annual Report, 2020. Accessed March 28, 2023. https://www.nccpa.net/wp-content/uploads/2022/04/Statistical-Profile-of-Certified-PAs-2020.pdf

Topics:

Cardiology Emergency Medicine General Pulmonology Hospital Medicine Physician Assistants Practice Management