Successful Surgical Airway Performance in the Combat Prehospital Setting: A Qualitative Study of Experienced Military Prehospital Providers.

Introduction: Military first responders are in a unique category of the healthcare delivery system. They range in skill sets from combat medic and corpsman to nurses, physician assistants, and occasionally, doctors. Airway obstruction is the second leading cause of preventable battlefield death, and the decision for intervention to obtain an airway depends on the casualty's presentation, the provider's comfort level, and the available equipment, among many other variables. In the civilian prehospital setting cricothyroidotomy (cric) success rates are over 90%, but in the US military combat environment success rates range from 0-82%. This discrepancy in success rates may be due to training, environment, equipment, patient factors and/or a combination of these. Many presumed causes have been assumed to be the root of the variability, but no research has been conducted evaluating the first-person point of view. This research study is focused on interviewing military first responders with real-life combat placement of a surgical airway to identify the underlying influences which contribute to their perception of success or failure.

Materials and methods: We conducted a qualitative study with in-depth semi-structured interviews to understand participants' real-life cric experiences. The interview questions were developed based on the Critical Incident Questionnaire. In total, there were 11 participants-4 retired military and 7 active-duty service members.

Results: Nine themes were generated from the 11 interviews conducted. These themes can be categorized into 2 groups: factors internal to the provider, which we have called intrinsic influences, and factors external to the provider, which we call extrinsic influences. Intrinsic influences include personal well-being, confidence, experience, and decision-making. Extrinsic influences include training, equipment, assistance, environment, and patient factors.

Conclusions: This study revealed practitioners in combat settings felt the need to train more frequently in a stepwise fashion while following a well-understood airway management algorithm. More focus must be on utilizing live tissue with biological feedback, but only after anatomy and geospatial orientation are well understood on models, mannequins, and cadavers. The equipment utilized in training must be the equipment available in the field. Lastly, the focus of the training should be on scenarios which stress the physical and mental capabilities of the providers. A true test of both self-efficacy and deliberate practice is forced through the intrinsic and extrinsic findings from the qualitative data. All of these steps must be overseen by expert practitioners. Another key is providing more time to focus on medical skills development, which is critical to overall confidence and overcoming hesitation in the decision-making process. This is even more specific to those who are least medically trained and the most likely to encounter the casualty first, EMT-Basic level providers. If possible, increasing the number of medical providers at the point of injury would achieve multiple goals under the self-efficacy learning theory. Assistance would instill confidence in the practitioner, help with the ability to prioritize patients quickly, decrease anxiety, and decrease hesitation to perform in the combat environment.