A pilot study on physiological indicators of expertise in pre-hospital emergency medical services (EMS) providers during endotracheal intubation

Prehospital intubation is a high risk, low frequency skill. Manikin intubations, the most common means of evaluating providers’ competency, may be insufficient to predict procedural success. The objective of this pilot study was to explore whether physiological measures, including gaze behavior, pupil response, and cortical activation, differed between groups of pre-hospital emergency medical services (EMS) providers during simulated endotracheal intubation. Fifteen certified paramedics (expert clinicians) and fifteen Advanced Emergency Medical Technicians (intermediate clinicians) participated in this pilot study. Each participant performed three intubations on a standard airway manikin. During the intubations, pupillometry and gaze data were collected using eye tracking glasses and brain activation using functional near infrared spectroscopy (fNIRS). Groups were compared based on the eye tracking and neuroimaging metrics. Twenty-seven out of 30 participants successfully intubated the manikin across all repetitions, and expert clinicians finished the task on average 11.6s faster than intermediate clinicians. Experts spent less task time in gaze fixation (39.8 % vs. 55.2 %, p = 0.03). Peaks in pupil diameter during the task most often occurred during the sub-task of inserting the tube in the trachea (76% of the time). Neuroimaging results revealed significant group-level differences in the left supramarginal gyrus. This study explored physiological responses during simulated intubation by pre-hospital emergency medicine providers. While some group-level differences were observed in gaze behavior and brain activation, these findings were not sufficient to differentiate expertise. Further research is needed to better understand how physiological responses may reflect task demands in clinical settings.