Inexperienced but Confident: A Survey of Advanced Life Support Providers and Life-saving Interventions in the Israel Defense Forces

ABSTRACT

Objective

The objective of this study was to assess the current experience of Israel Defense Forces’ (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks.

Methods

This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access.

Results

During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics.

Conclusion

IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.

INTRODUCTION

IDF ALS Providers

Advanced life support (ALS) providers in the Israel Defense Forces (IDF) consist of doctors and paramedics. Doctors graduate 6-year medical school, 1 year of internship, 3 months of officer’s school, and 4 months of training in military medicine before initial deployment. Paramedics undergo 14 months of paramedic training, including 4 months of training in combat casualty care. Because of their different training pathways, doctors are older than paramedics when they are first assigned. Despite the differences, doctors and paramedics are assigned to field units and are used interchangeably as medical team leaders in treating casualties. Both are expected to be able to triage casualties and perform life-saving interventions (LSIs) in the prehospital setting, sometimes in austere environments.

Better skills in performing LSIs have been associated with better outcomes for casualties in the prehospital setting.^1–5 Although not the only factor, previous experience plays a critical role in improving those skills.^6–8 Therefore, the IDF Trauma and Combat Medicine Branch (TCMB) assigned evidence-based benchmarks for the minimal aspired experience with LSIs.

Different thresholds exist in the literature for the experience needed to develop skills in performing LSIs. Following a thorough review of relevant publications, the TCMB decided on benchmarks that were agreed to be most relevant to the prehospital setting of IDF ALS providers. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation,^9–11 3 for cricothyroidotomy,¹² 4 for tube thoracostomy,¹³ and 3 for intraosseous access.¹⁴

The objective of this study was to assess the current experience of IDF ALS providers in performing four most common interventions (endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access), the rate of doctors and paramedics achieving the TCMB benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks.

METHODS

This study was based on a survey delivered to IDF ALS providers. The manuscript was written and edited according to the Strengthening the Reporting of Observational Studies in Epidemiology statement.¹⁴ The IDF Medical Corps institutional review board approved the study and waived the requirement for written consent in this questionnaire study.

Experience-Confidence Survey

The structured survey was built on a web-based platform (Survey Monkey, USA) by the authors of this manuscript. The prespecified structure of the survey did not change throughout the survey dissemination period (March 1 to April 30, 2019). Duplicate responses were not allowed, but updating the response was possible. An invitation to participate in the survey was submitted to IDF ALS providers using existing instant messaging mass groups (WhatsApp Inc., USA) that were used weekly to disseminate clinical pearls in trauma combat medicine to all IDF ALS providers. Participation was voluntary and the identities of respondents were unknown to any investigator.

The first part of the survey focused on demographic characteristics including type of provider (doctor/paramedic), sex (male/female), duty type (active/reserve), and duty role (battalion, brigade, combat training camp, medical training camp, regional ambulance, special force, and non-combat ALS provider). The second part focused on self-reported accumulated and previous year experience with the performance of LSIs. Participants were asked to estimate the number of incidents in which they performed endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access including in hospital and prehospital human patients. The third part focused in confidence in performing each LSI on a real casualty. Participants were asked to report confidence on a Likert scale between 1 (not confident at all) and 5 (highly confident).

Data Analysis

Duty types were grouped into active and reserve. Duty roles were grouped into role 1 and others (roles 2-4 or non-combat roles). Age was calculated based on the date of birth and date of participation in the survey. Achievement of the benchmarks was defined by an experience equal or larger than the benchmarks. High confidence in the performance of a specific LSI was defined as a self-report of being either confident or very confident in the ability to perform the intervention without help.

Continuous variables were presented as median (IQR, interquartile range) and categorical variables as n (%). Chi-square, t, and Wilcoxon rank-sum tests were used as appropriate. All tests used were two-tailed, and P < .05 was considered statistically significant. Data analysis was performed using R version 4.0.2 (R Core Team, Vienna, Austria).

RESULTS

During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it. Of them, 93 (67%) were paramedics. Table I presents the characteristics of the doctors and paramedics who responded fully. The responding doctors and paramedics were mostly men (84 vs. 75%, P = .3), in active duty (98 vs. 96%, P = .7), and serving in role 1 medical teams (84 vs. 82%, P = .9).

TABLE I.

Baseline Characteristics of Respondents

Characteristic	Doctors, N = 45a	Paramedics, N = 93a	P-valueb
Sex			.3
Female	7 (16%)	23 (25%)
Male	38 (84%)	70 (75%)
Age	28 (27, 30)	21 (20, 22)	.007
Duty type			.7
Unknown	0 (0%)	1 (1.1%)
Active	44 (98%)	89 (96%)
Reserve	1 (2.2%)	3 (3.2%)
Duty role			.9
Other	7 (16%)	17 (18%)
Role 1	38 (84%)	76 (82%)

^a

Statistics presented: n (%); median (IQR).

^b

Statistical tests performed: chi-square test of independence; t-test.

Table II presents the accumulated experience and previous year experience of respondents in LSIs. Up to the date of participation in the survey, doctors performed a median (IQR) of 20 (6, 30) intubations, 0 (0, 0) cricothyroidotomies, 0 (0, 2) tube thoracostomies, and 0 (0, 0) intraosseous accesses. In comparison, paramedics performed 50 (35, 60) intubations (P < .001), 0 (0, 0) cricothyroidotomies (P = .4), 0 (0, 1) tube thoracostomies (P = .07), and 4 (2, 10) intraosseous accesses (P < .001).

TABLE II.

Experience in Performing Procedures

Procedure	Doctors, N = 45a	Paramedics, N = 93a	P-valueb
Accumulated
Intubation	20 (6, 30)	50 (35, 60)	<.001
Cricothyroidotomy	0 (0, 0)	0 (0, 0)	.35
Tube thoracostomy	0 (0, 2)	0 (0, 1)	.07
Intraosseous access	0 (0, 0)	4 (2, 10)	<.001
Last year
Intubation	2 (0, 5)	15 (3, 30)	<.001
Cricothyroidotomy	0 (0, 0)	0 (0, 0)	.29
Tube thoracostomy	0 (0, 0)	0 (0, 0)	.97
Intraosseous access	0 (0, 0)	1 (0, 4)	<.001

^a

Statistics presented: median (IQR).

^b

Statistical tests performed: Wilcoxon rank-sum test.

During the previous year, doctors performed a median (IQR) of 2 (0, 5) intubations, 0 (0, 0) cricothyroidotomies, 0 (0, 0) tube thoracostomies, and 0 (0, 0) intraosseous accesses. In comparison, paramedics performed 15 (3, 30) intubations (P < .001), 0 (0, 0) cricothyroidotomies (P = .3), 0 (0, 1) tube thoracostomies (P > .9), and 1 (0, 4) intraosseous accesses (P < .001).

Table III presents the rates of respondents achieving the TCMB benchmarks within the previous year. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark.

TABLE III.

Achievement of the Trauma and Combat Medicine Branch Benchmarks

Benchmark	Doctors, N = 45a	Paramedics, N = 93a	P-valueb
Intubation (20)			<.001
Achieved	2 (4.4%)	40 (43%)
Not achieved	43 (96%)	53 (57%)
Cricothyroidotomy (3)
Not achieved	45 (100%)	93 (100%)
Tube thoracostomy (4)			.99
Achieved	0 (0%)	1 (1.1%)
Not achieved	45 (100%)	92 (99%)
Intraosseous access (3)			<.001
Achieved	0 (0%)	32 (34%)
Not achieved	45 (100%)	61 (66%)

^a

Statistics presented: n (%).

^b

Statistical tests performed: chi-square test of independence.

Figure 1 presents the rate of doctors and paramedics reporting high confidence in performing a specific LSI within the groups of those achieving and not achieving the benchmarks. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics.

FIGURE 1.

Confidence rates in performing life-saving interventions. Each column represents the rate in percentage of respondents reporting high or very high confidence in performing the intervention on a real casualty, out of those participants reporting the same training (doctor/paramedic) and same category of experience (achieved/not achieved the Trauma and Combat Medicine Branch benchmark).

DISCUSSION

This survey found that IDF ALS providers have limited experience in performing critical LSIs, including intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access. Most providers do not achieve the TCMB benchmarks, especially doctors. Within those who do not achieve the benchmark in intubation, a significant rate still feels confident in performing it, especially paramedics.

These results can be explained by the Dunning–Kruger effect, since providers who seem to be unskilled were confident in their ability. But this study did not measure their actual skills and therefore cannot validate this statement.

Prehospital ALS providers rarely apply LSIs,¹⁵ refresher training sessions are short, and competency is infrequently evaluated after initial training.¹⁶ However, the limited experience on real patients reported in our survey (no experience at all for many) is alarming. It explains the high failure rate in prehospital intubations found in a previous study of our group.¹⁷ The high confidence of people with limited experience or competence was observed in many populations including surgeons,^18,19 gastroenterologists,²⁰ and students.²¹

In the context of the literature, the higher confidence in interventions that are either perceived as core interventions (intubation) or as simple interventions (intraosseous access) is not surprising.

Study Implications and Recommendations

Our survey suggests that ALS providers’ current training is insufficient and does not provide adequate experience to acquire and maintain the skills needed to perform LSIs based on the literature. It also suggests that many of those who fail to achieve the benchmark feel confident and thus might not pursue opportunities for additional training, which can negatively impact quality of care and potentially result in unnecessary battlefield deaths. Thus, suggesting that the IDF Medical Corps should create training opportunities and that these should not be voluntary, competence must be carefully monitored—maybe as a part of an annual medical fitness test.

LIMITATIONS

This study has several limitations. First, the chosen benchmarks do not necessarily predict success in performing LSIs. Experience is crucial, but it is only one contributor out of many to skill. Good theory, demonstrations, mannikin training, helpful feedback, and others are important as well. Second, participation in the survey was voluntary, and it is possible that these results do not represent all IDF ALS providers. Third, this study did not measure the actual performance of the responders and thus it is possible that highly confident participants are actually skilled, even though they did not reach the TCMB benchmarks. In addition, it is possible that highly confident participants were modest in their responds, and therefore rated confidence as low. Adjusting for both the second and third biases might aggravate the results of this research and its implications. Fourth, experience was self-reported and was subjected to memory.

Areas for Future Research

A larger replication of this study on a wider sample would help to determine its applicability in other healthcare systems. A matched prospective study based on an objective structured clinical examination would allow more precise exploration of the participants’ performances in these LSI, confirm the correlations between competence and self-rated confidence shown in this research, test the influence of the different methods of training on self-confidence, and might reveal the need for update the TCMB benchmarks.

CONCLUSIONS

IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.

Author notes

Presented at the 2019 Military Health System Research Symposium, Kissimmee, FL; MHSRS-19-01476.