01-김재혁

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1 대한응급의학회지제 22 권제 2 호 Volume 22, Number 2, April, 2011 원 저 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 가천의과학대학교응급의학교실 김재혁 조진성 임용수 이수복 현성열 김진주 근 양혁준 일 The Current State of Airway Management and Ventilation at the Pre-Hospital Stage by Emergency Medical Technicians Jae Hyuk Kim, M.D., Jin Seong Cho, M.D., Yong Su Lim, M.D., Soo Bock Lee, M.D., Sung Youl Hyun, M.D., Jin Joo Kim, M.D., Gun Lee, M.D., Hyuk Jun Yang, M.D., Il Rheu, M.D. 책임저자 : 조진성인천광역시남동구구월동 1198 가천의과학대학교응급의학교실 Tel: 032) , Fax: 032) 접수일 : 2010년 10월 13일, 1차교정일 : 2010년 11월 12일게재승인일 : 2010년 12월 12일 129 Purpose: Airway management and ventilation at the prehospital stage are essential and very critical to patient welfare. In Korea, however, methods other than the use of a bag valve mask are hardly used at the pre-hospital stage by emergency medical technicians (EMTs). This study survey the current state of airway management and respiratory first aid at the pre-hospital stage. Methods: A questionnaire survey of 356 EMTs was conducted by distributing questionnaires directly to first-class EMTs who participated in clinical training at emergency centers or by sending questionnaires and receiving answers by . The questionnaire solicited information concerning general characteristics of EMTs, monthly frequency of pre-hospital airway management of patients and the will of EMTs. Subjects were divided into two groups according to governmental subdivision or presence of training within 1-year. Results: Concerning airway management and ventilation at the pre-hospital stage, the use of methods other than nasal prong and simple mask was very rare. As to the reasons, the respondents mentioned the shortage of manpower and lack of knowledge/experience. There was no significant difference in the ratio of pre-hospital airway management between urban and suburban/rural settings. Training within 1-year was not related to increased enforcement of airway management. Conclusion: In Korea, pre-hospital airway management is not well implemented by EMTs. Causes are deficiency of rescuer, less actual patient treatment experience and deficiency of knowledge/experience. Education and work experience can influence pre-hospital airway management. But, most pre-hospital airway management is unaffected by education and work experience. Key Words: Prehospital airway management, Emergency medical technicians, Education Department of Emergency Medicine, Gachon University of Medicine and Science 서 병원전단계에서의기도유지및호흡처치는병원이외에서심정지가발생한환자및의식소실을보이고있는환자, 지속적인기도유지가불가능하거나두경부의손상으로호흡유지가어려운환자의처치에서필수적이고중요한요소이다 1). 미국의경우병원전단계에서의기도유지및호흡처치에서응급구조사에의해기관내삽관이나여러가지기도유지및호흡처치장비들이사용되고있으며, 그에따른적절성의효과및부작용에대한연구가활발히진행되고있다 2-4). 하지만, 우리나라는병원전단계에서의기도유지및호흡처치에서응급구조사에의한단순백밸브마스크환기이외에다른방법은거의시행되지않고있으며, 적절성또한매우낮은실정이다 5). 이는병원전단계에서의환경이병원단계에서보다더취약하여공간적인제약, 시간의부족등때문일수도있겠으나그이외에구급대원들의임상훈련부족, 적절한의료지도체계의부재, 환자및보호자의문화적편견, 인력과장비부족, 현장처치이후의사후평가의결여등과같은여러요인으로부터기인 론

2 130 / 대한응급의학회지 : 제 22 권제 2 호 2011 하는복합적인문제일가능성이더높다. 이에본연구는병원전단계에서활동중인 1급응급구조사들을대상으로병원전단계에서의기도유지및호흡처치의시행현황및관련요인을파악하고자하였다. 특히대도시와중소도시의지역적차이로인하여시행빈도의차이가발생하는가와최근 1년이내의교육을받음으로시행빈도의증가를보이는가를분석하였다. 대상과방법 1. 연구대상및자료수집방법병원임상수련을위해중앙소방학교에교육을받으러온 1급응급구조사를대상으로 2008년도에 3회 2009년도에 1회에걸쳐설문을시행하였다. 직접설문지를나눠주어설문지를작성하는방법과전자우편을통하여설문지를발송하여작성후메일을통하여설문지를받는두가지방법을이용하여설문조사를실시하였다. 설문지에는나이, 성별, 직위, 근무기한, 근무지역등의기본적인항목과병원전단계에서의기도유지및호흡처치의현황을알아보기위해기도유지 ( 도수기도유지, 구인두기도유지기 ), 호흡처치 ( 비강캐뉼라, 단순마스크, 비재호흡마스크, 후두마스크, 기관내삽관 ), 평가 ( 호흡음청진, 맥박산소측정기 ), 약물 ( 계량흡입기, 분무기 ) 의 4개의분류와그에포함된 11개의항목을각각한달에시행하는평균횟수로응답하도록하였다. 또한현장의기도유지및호흡처치를방해하거나시행횟수가적은이유에대한질문으로 1) 업무관련법률적지식부족, 2) 지식 / 경험부족, 3) 인원부족, 4) 술기가익숙하지않음, 5) 필요성못느낌, 6) 시간부족, 7) 보호자의거부, 8) 실제처치할환자가적음, 9) 장비부족, 10) 법적소송의가능성이렇게 10개의항목을정하여전혀동의않을경우 1점, 매우동의할경우 9점까지총 1점부터 9점까지중에선택하도록하였다. 응급구조사취득이후에기도유지및호흡처치에대한교육을받은횟수와최근 1년이내에교육유무에대해서도조사하였다. 대도시와중소도시및농촌에서응급구조사의호흡처치빈도에차이가있는가보기위해각응급구조사가소속되어있는행정구역에따라구, 시, 군으로분류를하였다. 구, 시, 군은우리나라행정구역분류상중분류에해당하는데, 구는대도시, 시는중소도시, 군은시골로간주하였다. 2. 통계처리방법설문에서얻은자료는코딩을거쳐서 SPSS 18.0(SPSS Inc, Chicago, USA) 의통계프로그램을이용하였다. 설문조사에참여한응급구조사들의일반적특성을알아보기위해서성별, 직위, 근무경력, 근무지역, 교육받은횟수, 1년내교육유무및구, 시, 군별분포등을조사하였다. 병원전단계에서의기도유지및호흡처치의현황및기도유지및호흡처치에대한본인의능력수준에대해서는빈도수조사를하였고, 현장의기도유지및호흡처치를방해하거나시행횟수가적은이유에대해서는중위수를구하였다. 기도유지및호흡처치의현황및기도유지및호흡처치에대한차이가있는가에대한것은카이제곱검정을이용하여분석하였고, 호흡처치시행시문제점과호흡처치시행의지에대한평균값분석은 Mann-Whitney U 검정을이용하였다. 통계적으로유의한차이는 p<0.05를기준으로하였다. 추가로각각의병원전호흡처치에대해상위 50% 를고시행군, 그이하를저시행군으로나누었다. 그리고, 이에대해서일반적특성인나이, 성별, 직위, 1년내교육유무와응급구조사가호흡처치를하기어려운이유로대답한것들중에서응급구조사의인력부족, 이송시간의부족, 실제로처치할환자수의부족, 보호자의거부의변수를가지고서다변량로지스틱회귀분석을사용하였다. 결과 1. 대상의일반적특성설문에참석한인원은 356명으로연령대는중위수가 30 세이며사분위수가 28~33세이었다. 그리고, 남성 186명, 여성 162명으로성비는 1.1:1의비율을보였다. 구급대근무경력은중위수가 54개월이고사분위수가 32~83개월이었으며직위는각각소방사 173명, 소방교 84명, 소방장 13명, 기타 35명이었다. 근무지역별로보았을때는서울을포함하여전국의도단위에서모두참여하였고, 이를다시구 / 시 / 군별로나누었을때는구 187명, 시 118명, 군 38명의분포를보였다 (Table 1). 2. 기도유지및호흡처치의빈도현장에서시행하는호흡처치중, 비강캐뉼라와맥박산소측정기는빈도수에서다른항목에비하여자주시행되는것으로확인되었고, 이외에도단순마스크, 도수기도유지법, 구인두유지기는다른처치들에비하여비교적흔히사용하고있었다. 그러나기관내삽관을포함한전문기도처치는매우낮은빈도로조사되었다 (Table 2). 또한대도시와그외에지역비교를위해서구와시 / 군을비교하였을때, 구강흡인이외에는큰차이를보이지않았다. 그리고 1년이내에교육을받은군과그렇지않은군간에비교에서도단순마스크와호흡음청진시행에서만차이를보였다 (Table 3).

3 김재혁외 : 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 / 기도유지및호흡처치를방해하는이유현장에서의기도유지및호흡처치가적은이유에대해서조사한설문에대해서는법적업무밖임, 지식과경험부족, 술기가익숙하지않음, 시간부족, 보호자의거부, 법적소 송의가능성에대해서중위수는 5로중간적입장이었고, 인원부족에대해서는중위수 7로인원부족으로인한기도유지및호흡처치가어려운것으로응답하였다 (Table 4). Table 1. Basic characteristics of Emergency Medical Technician Gu* (n=187) Si* (n=118) Gun* (n=38) Total Position, n (%) Fire fighter 104 (55.6) 54 (45.8) 14 (36.8) 173 (48.6) Senior fire fighter 039 (20.9) 30 (25.4) 14 (36.8) 084 (23.6) Fire sergeant 004 (02.1) 05 (04.2) 4 (10.5) 013 (03.7) Others 020 (10.4) 12 (10.2) 02 (05.3) 035 (09.8) Age (yr), median (IQR) 29 (28-32) 31 (29-34) 31 (29-36) 30 (28-33) Sex (male ratio) 105 (56.1) 62 (52.5 ) 16 (42.1) 186 (52.2) Work experience (month), median (IQR) 42 (24-76) 59 (42-80) 68 (31-129) 54 (32-83) Number of moving in a month, median (IQR) 200 ( ) 120 (90-190) 80 (60-120) 150 ( ) Work area N (%) Seoul 65 (18.3), Incheon 17 (4.8), Daejeon 18 (5.1), Daegu 10 (2.8), Gwangju 11 (3.1), Ulsan 8 (2.2), Busan 22 (6.2), Gyeonggi 79(22.2), Gangwon 3 (0.8), Chungbuk 12 (3.4), Chungnam 20 (5.6), Chonbuk 15 (4.2), Chonnam 15 (4.2), Kyongbuk 23 (6.5), Kyongnam 23 (6.5), Jeju 11 (3.1) Education within a year, person 200 (56.2) Nember of person educated wityin a year, n (%) IQR: Interquartile range * Gu, Si, Gun is administrative distinct of Korea and each is suitable for urban, suburban, rural, respectively. Table 2. Monthly data of field airway management N Monthly performed frequency in the field (%) High implementation group >20 above Nasal cannula (01.1) 032 (09.0) 60 (16.9) 38 (10.7) 30 (8.5) 191 (53.8) - Simple mask (02.9) 091 (26.4) 68 (19.7) 27 (07.8) 30 (8.7) 119 (34.5) 16 Non-rebreathing mask (22.0) 119 (36.4) 52 (15.9) 16 (04.9) 16 (4.9) 052 (15.9) 06 Manual airway maintenance (03.8) 097 (28.8) 48 (14.2) 36 (10.6) 24 (7.1) 121 (35.7) 16 Oropharyngeal airway (04.6) 147 (42.4) 64 (18.4) 24 (06.9) 13 (3.7) 083 (23.9) 11 Laryngeal mask airway (80.9) 059 (18.2) 02 (00.6) 0.(0.0) 01 (0.3) 000 (00.0) 01 Intubation (75.2) 071 (21.7) 05 (01.5) 01 (00.3) 00 (0.0) 004 (01.2) 01 Bag valve mask (04.0) 197 (56.3) 43 (12.3) 22 (06.3) 19 (5.4) 055 (15.7) 06 Flow limited resuscitator (65.9) 081 (26.2) 10 (03.2) 02 (00.6) 03 (0.9) 010 (03.2) 01 Heimlich maneuver (45.3) 167 (49.4) 07 (02.1) 05 (01.5) 01 (0.3) 005 (01.5) 06 Oral suction (12.6) 218 (62.5) 33 (09.5) 10 (02.9) 13 (3.7) 031 (08.9) 06 Foreign body removal by (65.0) 109 (32.3) 05 (01.5) 01 (00.3) 02 (0.6) 001 (00.3) 01 magill forcep Metered-dose inhaler (35.8) 201 (58.1) 09 (02.6) 04 (01.2) 02 (0.6) 006 (01.7) 06 Nebulizer kit (90.1) 029 (09.0) 01 (00.3) 01 (00.3) 00 (0.0) 001 (00.3) 01 Auscultation (36.7) 131 (38.2) 32 (09.3) 13 (03.8) 06 (1.7) 035 (10.2) 06 Pulse oximeter (00.6) 029 (08.2) 22 (06.3) 18 (05.1) 25 (7.1) 255 (72.6) -

4 132 / 대한응급의학회지 : 제 22 권제 2 호 2011 Table 3. Monthly data of prehospital airway management N (%) Subject Performed frequency according to Gu/SiGun* Performed frequency according to education within one year Area p Education p Nasal cannula Gu (187) 002 (01.1) 050 (26.7) 135 (72.2) Yes (205) 004 (01.1) 057 (27.8) 144 (70.2) Si/Gun (155) 002 (01.3) 038 (24.5) 115 (74.2) No (136) 000 (00.0) 028 (20.6) 108 (79.4) Simple mask Gu (180) 005 (02.8) 089 (49.4) 086 (47.8) Yes (201) 002 (01.0) 099 (49.3) 100 (49.8) Si/Gun (152) 005 (03.3) 063 (41.4) 084 (55.3) No (131) 008 (06.1) 052 (39.7) 071 (54.2) Nonrebreathing mask Gu (176) 032 (18.2) 103 (58.5) 041 (23.3) Yes (185) 035 (18.9) 106 (57.3) 044 (23.8) Si/Gun (138) 035 (25.4) 062 (44.9) 041 (29.7) No (128) 034 (26.6) 058 (45.3) 036 (28.1) Mannual airway maintenance Gu (175) 007 (04.0) 077 (44.0) 091 (52.0) Yes (197) 004 (02.0) 083 (42.1) 110 (55.8) Si/Gun (151) 006 (04.0) 061 (40.4) 084 (55.6) No (129) 008 (06.2) 057 (44.2) 064 (49.6) Oropharyngeal airway Gu (182) 005 (02.7) 120 (65.9) 057 (31.3) Yes (198) 009 (04.5) 124 (62.6) 065 (32.8) Si/Gun (153) 010 (06.5) 085 (55.6) 058 (37.9) No (133) 007 (05.2) 076 (56.3) 052 (38.5) Laryngeal mask airway Gu (171) 134 (78.4) 036 (21.1) 001 (00.6) Yes (181) 144 (79.6) 036 (19.9) 001 (00.6) Si/Gun (141) 118 (83.7) 023 (16.3) 000 (00.0) No (129) 105 (81.4) 024 (18.6) 000 (00.0) Endotracheal intubation Gu (170) 128 (75.3) 041 (24.1) 001 (00.6) Yes (184) 133 (72.3) 049 (26.6) 002 (01.1) Si/Gun (144) 108 (75.0) 033 (22.9) 003 (02.1) No (130) 101 (77.7) 026 (20.0) 003 (02.3) Bag valve mask Gu (164) 005 (02.7) 132 (71.7) 047 (25.5) Yes (203) 009 (04.4) 137 (67.5) 057 (28.1) Si/Gun (153) 007 (04.6) 100 (65.4) 046 (30.1) No (133) 004 (03.0) 094 (70.7) 035 (26.3) Flow-limited resuscitator Gu (168) 113 (67.3) 051 (30.4) 004 (02.4) Yes (175) 105 (60.0) 061 (34.9) 009 (05.1) Si/Gun (137) 086 (62.8) 041 (29.9) 010 (07.3) No (128) 093 (72.7) 030 (23.4) 005 (03.9) Heimlich maneuver Gu (179) 083 (46.4) 091 (50.8) 005 (02.8) Yes (191) 078 (40.8) 108 (56.5) 005 (02.6) Si/Gun (137) 065 (44.2) 077 (52.4) 005 (03.4) No (133) 066 (49.6) 062 (46.6) 005 (03.8) Oral suction Gu (182) 033 (18.1) 129 (70.9) 020 (11.0) Yes (202) 026 (12.9) 146 (72.3) 030 (14.9) Si/Gun (154) 011 (07.1) 111 (72.1) 032 (20.8) No (133) 017 (12.8) 094 (70.7) Foreign body removal Gu (182) 115 (65.0) 061 (34.5) 001 (00.6) Yes (191) 114 (59.7) 075 (39.3) 002 (01.0) by magill forcep Si/Gun (147) 094 (63.9) 050 (34.0) 003 (02.0) No (132) 094 (71.2) 036 (27.3) 002 (01.5) Metered-dose inhaler Gu (182) 058 (32.2) 117 (65.0) 005 (02.8) Yes (200) 063 (31.5) 129 (64.5) 008 (04.0) Si/Gun (153) 060 (39.2) 086 (56.2) 007 (04.6) No (132) 054 (40.9) 074 (56.1) 004 (03.0) Nebullizer kit Gu (168) 149 (88.7) 017 (10.1) 002 (01.2) Yes (182) 160 (87.9) 020 (11.0) 002 (01.1) Si/Gun (143) 132 (92.3) 011 (07.7) 000 (00.0) No (127) 117 (92.1) 010 (07.9) 000 (00.0) Auscultation Gu (178) 063 (35.4) 091 (51.1) 024 (13.5) Yes (197) 057 (28.9) 103 (52.3) 037 (18.8) Si/Gun (152) 059 (38.8) 064 (42.1) 029 (19.1) No (132) 064 (48.5) 051 (38.6) 017 (12.9) Pulse oximeter Gu (182) 001 (00.5) 021 (11.5) 160 (87.9) Yes (205) 001 (00.5) 031 (15.7) 172 (84.3) Si/Gun (146) 001 (00.6) 026 (16.7) 129 (82.7) No (133) 001 (00.8) 018 (13.5) 114 (85.7) * Gu, Si, Gun is administrative distinct and each is suitable for urban, suburban, rural, respectively.

5 김재혁외 : 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 / 133 Table 4. The cause of disturbance of airway management Median (interquartile range) Education experience Location within 1 year Subject Total p Gu* Si/Gun* Yes No Out of the legally allowed service 4 (2-5) 3 (1-5) 5 (2-5) (1-5) 4 (3-5) Deficiency of knowledge and experience 5 (3-5) 5 (3-5) 5 (3-6) (2-5) 5 (3-6) Deficiency of rescuer number per ambulance 7 (5-9) 7 (5-9) 7 (5-9) (5-9) 7 (5-9) Unfamiliar technique 5 (3-7) 5 (3-7) 5 (3-7) (3-7) 5 (3-7) Unnecessariness 3 (1-5) 3 (1-4) 3 (1-5) (1-5) 3 (1-4) Short interval for treatment 5 (3-6) 5 (5-7) 5 (3-7) (4-7) 5 (3-7) Refusal by guardians 5 (3-6) 5 (3-6) 5 (3-5) (3-6) 5 (3-6) Low case volume 6 (5-7) 6 (5-7) 5 (5-7) (5-7) 5 (5-7) Shortage of equipment 3 (3-5) 3 (3-5) 4 (3-5) (3-5) 4 (3-5) Possibility of being suited 5 (4-7) 5 (3-7) 5 (4-7) (3-7) 5 (4-7) * Gu, Si, Gun is administrative distinct and each is corresponding for urban, suburban, rural, respectively. p 4. 기도유지및호흡처치를방해하는요인이해결되었을때시행의지 소방교의교차비가 1.160으로소방교에서고시행군의빈도가높은것으로조사되었다 (Table 6). 위에서언급된바와같은문제들이해결되었을때, 응급 구조사들은기관내삽관을포함한모든처치의시행에대한의지가중위수 7~9로모두긍정적인대답으로변하는것으로나타났다 (Table 5). 5. 기도유지및호흡처치의고시행군과저시행군의차이 다변량로지스틱회귀분석을사용하여고시행군과저시행군에서차이가나는변수를찾아보았을때는도수기도유지, 기관내삽관, 구강흡인, 유량제한성인공호흡기, 후두경을이용한이물제거, 계량흡입기에서의미있게분석되었다. 도수기도유지는처치해야하는환자의숫자가적다고생각할수록고시행군의빈도가낮았다. 기관내삽관은남성과여성의교차비가 0.175로여성에서고시행군의빈도가낮았고, 또한처치시간이부족하다고생각할수록교차비는 0.825로낮았다. 구강흡인은구와시의교차비가 2.009로시에서고시행군의빈도가더높게분석되었다. 유량제한성인공호흡기는소방사에비해서소방교의교차비가 2.113으로소방교가소방사에비해고시행군이더많았고, 최근 1년이내에교육을받은군이교육을받지않은군과비교하여교차비가 2.054으로분석되었다. 후두경을이용한이물제거는소방사에비해서소방교의교차비가 1.911로소방교에서고시행군의빈도가높았고, 최근 1년이내에교육을받은군과교육을받지않은군의교차비가 1.669으로최근교육을받은군에서고시행군이많았다. 또한실제로처치해야하는환자가적다고생각할수록고시행군의빈도는적었다. 계량흡입기의경우는소방사와 고찰병원전단계에서의응급구조사에의한기도유지및호흡처치방법중기관내삽관은 1970년대부터미국에서시행되어왔으며, 최근까지가장표준적이고확실한기도유지및호흡처치방법으로여겨지고있다 6,7). 또한여러연구에서안전하며, 다양한임상상황에서환자의생존율과예후를향상시킨다는보고가있었다 8-10). 그러나최근발표되고있는다른연구들에따르면병원전단계에서응급구조사에의해시행된기관내삽관의경우기관삽관튜브가부적절한위치에고정된경우가 25% 에달했으며, 두부손상환자의경우에는기관내삽관을시행한경우가백밸브마스크환기를시행한경우보다오히려사망률이높았다고하였다 2,11). Cooper 등 14) 의연구에서도소아외상환자에서병원전단계에서기관내삽관을한 479명의환자와병원전단계에서백밸브마스크환기만한 99명의환자를비교한결과사망률에는아무런차이가없었다고하였다. 이와같이병원전단계에서의기관내삽관이사망률을감소시키거나신경학적예후를향상시키는데효과가없게나온이유는환자의생리학적기전뿐만아니라기관내삽관이시행되는환경및시행하는응급구조사의교육정도와실력및기술, 근이완제의사용여부등여러가지요소에의해결정될것이다 15,16). Jane 등 17) 의연구에서 2006년미국피츠버그에서활동하고있는응급구조사 14명과의사 6명을인터뷰하여병원전단계에서의응급구조사에의한기관내삽관에대해어떻게생각하고있는지에대해서조사한바에따르면응급구조사에의해단독으로병원전단계에서근이완제

6 134 / 대한응급의학회지 : 제 22 권제 2 호 2011 가사용되는부분에대해서는서로의견차이를보였지만병원전단계에서응급구조사에의한전문기도관리는꼭필요한부분이며응급구조사에게적절한교육과실습기회를제공하여기술및처치능력을향상시키는것이가장중요한요소라는것에는모두동의하였다. 또한실제로응급구조사에게지속적인교육과실습기회를제공한결과병원전단계에서의기관내삽관의성공률이향상되었다는보고가있다 18,19). 병원전단계에서기관내삽관을대체할수있는다른기도유지및호흡처치장비들도최근활발히사용되어지고있으며좋은효율성을보여주고있다. 후두마스크 (laryngeal mask airway), 식도기관콤비튜비 (esophageal tracheal combitube), 식도폐쇄기도유지기 (esophageal obturator airway) 등의장비는기관내삽관이실패했거나용이하지않은상황에서대체할수있으며, 성공률이높고 Table 5. The will of airway management, being resolved the cause of disturbing airway management Subject Median (IQR) Laryngeal mask airway 7 (5-9) Endotracheal intubation 7 (5-9) Flow-limited resuscitator 7 (5-8) Heimlich maneuver 7 (7-9) Foreign body removal by magill forcep 7 (5-9) Metered-dose inhaler 7 (5-9) Nebulizer kit 7 (5-9) Oral suction 9 (7-9) Auscultation 7 (5-9) Pulse oximeter 9 (8-9) IQR: Interquartile range 합병증이적으며, 배우기쉽다는장점이있어최근사용빈도가높아지고있으며여러연구에서도응급구조사가기관내삽관을대신해야하는경우를대비해서필수적으로사용할수있어야한다는필요성이주장되고있다 3,4). 우리나라의경우를살펴보면, 소방방재청의발표자료에따르면 2007년한해구급대의구급활동출동건수는 1,686,138회였으며이중 1,235,609명에대해서현장응급처치및병원에이송을하였다. 이중환자의의식상태에따른평가를보면총환자중 83.5% 가의식이명료한환자였으며나머지 16.5% 의환자가의식이명료하지않아기도유지및호흡처치가필요한환자였다 20). 그러나, 병원전기도유지및호흡처치에관한연구에서는 1996년도이승한등 23) 이조사한논문이있었으나, 심폐소생술에집중된자료였고, 응급구조사의경험빈도에대한조사만이이루어졌었다. 실제로기도유지및호흡처치가얼마나시행되어졌는가와기도유지및호흡처치를시행하기어려운이유에대한연구는없었던실정이다. 교육에대해서살펴보면, 미국의경우응급구조사를우리나라와달리응급구조사-초급 (EMT-Basic), 응급구조사-중급 (EMT-Intermediate), 응급구조사-고급 (EMT- Paramedic) 3개로구분하고있으며, 각각의자격에따라요구되는업무범위가다르므로그에맞는자격요건및교육시스템이마련되어있다. 또한각자격증의유효기간은 2년으로미국국가등록응급구조사 (National Registry of Emergency Medical Technicians) 시험기관에서요구하는보수교육과정을수료해야만지속적으로구조사로서의임무을수행할수있도록했으며, 지속적인교육과정개발을통한구조사들의역량개발에도많은관심을두고있다 21). 또한 Wang 등 13) 의연구결과에서도응급구조사의술기 Table 6. Multi-variates logistic regression model of each airway management Outcome variable Predictor variables Adjusted Odds Ratio* 95% Confidence Interval Manual airway maintenance Low vs. high case volume ~0.961 Endotracheal intubation Female vs. male ~0.371 Short vs. long treatment time ~0.957 Oral suction Si vs. Gu ~3.599 Flow-limited resuscitator Senior fire fighter vs. fire fighter ~4.194 Educated vs. non-educated provider within 1 year ~3.480 Foreign body removal using Magill forcep Senior fire fighter vs. fire fighter ~3.508 Educated vs. non-educated provider within 1 year ~2.752 Low vs. high case volume ~0.985 Metered-dose inhaler Senior fire fighter vs. fire fighter ~4.607 * Adjusted for age, sex, location, position, case volume, education experience within 1 year.

7 김재혁외 : 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 / 135 경험이병원전기관내삽관환자의예후와연관이되어있다고하여이러한내용들을뒷받침하고있다. 본연구의결과를보면병원전단계에서응급구조사에의해시행되고있는기도유지및호흡처치는비강캐뉼라나단순마스크의경우실제현장에서시행되고있는비율이높은반면후두마스크나기관내삽관, 후두경을이용한이물질제거등은실제로거의시행되고있지않은것으로나타났다. 그러나, 시행빈도는낮았지만, 병원전단계에서전문기도유지시행을막는문제점들이해결된다면적극적으로시행하겠다는의지는상대적으로높았다. 이러한문제점을중위수로분석하였을때에는응급구조사의인력부족및지식과경험의부족, 소송에걸릴가능성, 보호자가거절하는등의이유가큰것으로나타났다. 또한각각의기도유지및호흡처치항목을다변량회귀분석으로분석하였을때에는응급구조사의직위, 최근 1년이내의교육유무가영향을미치고있음을알수있었다. 유량제한성인공호흡기와후두경을이용한이물제거, 계량흡입기는소방사에비해서소방교가더많이시행하고있음을보여주고있다. 소방교는소방사가최소 2년이상근무경력이있어야하며, 50% 는시험이없이, 50% 는시험을쳐서승진을하게된다. 따라서응급구조사의직위가경력과어느정도비례한다고간주한다면, 이는환자에대한경험으로인해시행빈도의차이가발생하고있다고생각할수있겠다. 또한교육에있어서는실제임상에서자주경험하지못하는것들, 유량제한성인공호흡기와후두경을이용한이물제거는최근 1년이내의교육을받은군이더많이시행하고있는것으로보이고있었다. 그러므로, 임상에서자주겪지못하는술기는지속적이고반복적인교육을통해서시행빈도를늘릴수있을것으로예상이된다. 또한, 기관내삽관은남성이여성에비해서더많이시행을하였는데, 이는기관내삽관은시행시물리적인힘이많이필요하는것과연관되어서남성이더많이시행하지않을까추정해볼수있다. 기관내삽관은시간부족으로인하여서도시행빈도가떨어지는것으로조사되었는데, 향후좀더전문적인기도유지를위한쉬운전문기도장비들의개발이필요한시기라생각된다. 한편, 이번연구는 2008년당시우리나라의소방서에서근무하는 1급응급구조사가총 1,333명이었는데, 이중 356명의응급구조사에게설문조사를실시하여더많은수의조사가필요할것으로여겨진다. 또한, 설문조사에근거하여작성된것으로서, 설문대상의주관이크게작용하였고, 호흡처치를방해하는문제점에대한해결방안에대하여응급구조사들의답변이들어있지못했다. 구, 시, 군에대한분류는통계청에서제시한분류를사용하였는데, 이는현재까지우리나라에서도시화를구분짓는유일한자료이다. 하지만이것또한명확한도시화의구분자료가되지못할수도있을것으로생각된다. 마지막으로, 향후 응급구조사에의해내원한환자가바로전문기도처치가필요한상황인데시행하지않은비율등에대한추가적연구가필요할것으로생각된다. 이는기도유지와호흡처치빈도가낮은이유중에처치해야할환자가적다는응답이중위수가 6으로높다. 그러나, 실제로처치해야할환자가적은것인지, 아니면전문기도유지및호흡처치를시행해야하는데그렇게하지않고응급실에내원한것인지다시한번확인해보아야할것이다. 결 우리나라의병원전단계에서응급구조사에의해시행되고있는기도유지및호흡처치는비강캐뉼라나단순마스크와같은기본적인기도호흡처치이외에는거의시행되지않는것으로조사되었다. 호흡에대한평가도맥박산소측정기의사용빈도는높았으나호흡음청진은잘시행되지못하고있었다. 방해요소로가장많은비율을차지한것이인력부족, 실제처치환자수의부족, 지식 / 경험의부족이었다. 또한, 구급대원에대한최근의교육의실시와, 구급대원의경력이증가함에따라기도유지및호흡처치빈도가일부에서증가하는것으로보여졌지만, 그외의대부분의처치는교육이영향을미치지않는것으로나왔다. 론 참고문헌 01. Nolan JP, Soar J. Airway techniques and ventilation strategies. Curr Opin Crit Care 2008;14: Franschman G, Peerdeman SM, Greuters S, Vieveen J, Brinkman AC, Christiaans HM, et al. Prehospital endotracheal intubation in patients with severe traumatic brain injury; guidelines versus reality. Resuscitation 2009;80: Guyette FX, Greenwood MJ, Neubecker D, Roth R, Wang HE. Alternative airway in the prehospital setting (Resource document to NAEMSP position statement). Prehosp Emerg Care 2007;11: Davis DP, Valentine C, Ochs M, Vilke GM, Hoyt DB. The combitube as a salvage airway device for paramedic rapid sequence intubation. Ann Emerg Med 2003;42: Available at: Accessed July 28, Available at: Accessed July 28, Jacobs LM, Berrizbeitia LD, Bennett B, Madigan C. Endotracheal intubation in the prehospital phase of emergency medical care. JAMA 1983;250:

8 136 / 대한응급의학회지 : 제 22 권제 2 호 Stewart RD, Paris PM, Winter PM, Pelton GH, Cannon GM. Field endotracheal intubation by paramedical personnel. Chest 1984;85: Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, et al. Advanced life support for out-of-hospital respiratory distress. N Engl J Med 2007;356: Germann CA, Baumann MR, Kendall KM, Strout TD, McGraw K. Performance of endotracheal intubation and rescue techniques by emergency services personnel in an air medical service. Prehosp Emerg Care 2009;13: Katz SH, Falk JL. Misplaced endotracheal tube by paramedics in an urban emergency medical services system. Ann Emerg Med 2001;37: Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med 2004;44: Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM. Out-of-hospital endotracheal intubation experioence and patient outcomes. Ann Emerg Med 2010;55: Christensen EF, H yer CC. Danish observational study. Prehospital tracheal intubation in severely injuried patients a Danish observational study BMJ 2003;327: Nolan JD. Prehospital and resuscitation airway care: should the gold standard be reassessed? Curr Opin Crit Care 2001;7: Davis DP. Should invasive airway management be done in the field? CMAJ 2008;178: Thomas JB, Abo BN, Wang HE. Paramedic perceptions of challenges in out-of-hospital endotracheal intubation, prehospital emergency care. Prehosp Emerg Care 2007;11: Wayne MA, Friendland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care 1999;3: Pepe PE, Copass MK, Joyce TH. Prehopital endotracheal intubation: rationale for training emergency medical personel. Ann Emerg Med 1985;14: Available at: Accessed July 28, Available at: Accessed July 28, Available at: Accessed August 12, Available at: Accessed October 2, 2010.

9 김재혁외 : 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 / 137 부록 ( 설문지 ) 코드일련번호 병원전기도유지및호흡처치실태조사 안녕하십니까? 병원임상수련과정의간사를맡고있는가천의과대학교길병원의임용수입니다. 열악한근무환경과여건에서도우리나라병원전응급의료서비스를책임지시느라고생이많으십니다. 현재병원전단계에서의응급처치는여러복합적인요인으로인해많은문제점을가지고있지만그개선의노력은더디기만한것이현실입니다. 하지만현장응급처치의실태및문제점그리고교육현황에대한적절한조사도없는것이사실입니다. 따라서, 현장응급처치특히기도유지및호흡처치의실태및문제점그리고교육현황에대해조사하고해결방안과교육과정을모색하기위해 병원전기도유지및호흡처치실태조사 라는제목으로병원임상수련과정을마쳤거나시작하시는 119 구급대원을대상으로설문조사를하고있습니다. 본조사에서파악된정보는전체적인통계량을산출하는데에만사용되며, 통계는통계법제 8조에근거한일반통계이며, 응답내용은동법제 13조에따라통계목적이외는사용되지않을것이며, 개별기관이나개인의정보형태로서는유통되지않으므로사적인기밀유출에대해서는전혀걱정하지않으셔도됩니다. 귀하의답변자료는 병원전기도유지및호흡처치 의실태와문제점을파악하고개선방법을마련하는데사용할것이므로, 병원전응급처치의미래와발전에기여하신다고생각하시고성실하게답변해주시고적극적협조를해주시면감사하겠습니다. 질문의대답은해당하는 에 를해주시고주관식문답에는서술형으로써주시면감사하겠습니다. 일반적사항

10 138 / 대한응급의학회지 : 제 22 권제 2 호 2011 기도유지및호흡처치현장경험 ( 해당항목에 를하든지직접횟수를적어주세요 ) 1. 현재기도유지및호흡처치가필요한환자에서다음의처치를현장또는이송중에실제로시행하고있는빈도는? (2008 년기준으로한달에평균시행하는평균횟수 ) 예 ) 2008년도에 1년동안기관내삽관을 2번시행하였다면, 주의 : 모든항목을체크해주시면감사하겠습니다. 질문의대답은해당하는 에 를해주시고주관식문답에는서술형으로써주시면감사하겠습니다. 일반적사항

11 김재혁외 : 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 / 139 기도유지및호흡처치의문제점 ( 해당항목에 를하세요 ) 2-1. 현장의기도유지및호흡처치를방해하거나시행횟수가적은이유는? 2-2. 시간이부족하다면환자이송에걸리는평균시간은? 1 10 분이내 2 10~20 분 3 20~30 분 4 30~40 분 5 40 분이상 2-3. 전문적인기도및호흡처치를시행하기위한최소한의이송시간은? 1 10 분이내 2 10~20 분 3 20~30 분 4 30~40 분 5 40 분이상 2-4. 위의문제들이해결된다면다음의처치에대한당신의적극적시행의의지는?

12 140 / 대한응급의학회지 : 제 22 권제 2 호 2011 기도유지및호흡처치능력및수준 ( 해당항목에 를하세요 ) 3. 본인이생각하는아래의기도및호흡처치와관련된현재본인의처치능력및수준을 표시해주십시요 주의 : 모든항목을체크해주시면감사하겠습니다. 교육경험 ( 해당항목에 를하세요 ) 4. 귀하의기도및호흡처치교육경험은? ( 대학재학시교육은제외 ) ( 이론및실습강의를 1 있다 (4-1) 이동 ) 2 없다 (5. 으로이동 )

13 김재혁외 : 병원전단계에서의응급구조사에의한기도유지및호흡처치에대한시행현황에관한조사 / 에서 [ 있다 ] 로대답하신분만해당 1-1. 현재까지총교육횟수 회 1-2. 교육받은곳은? ( 중복기입가능 ) 1 소방학교 2 소방서 3 중앙응급의료센터 4 권역 / 지역응급의료센터 5 기타의료기관 6 기타 : 1-3. 교육받은계기? ( 중복기입가능 ) 1 보수 / 직무교육 2 개인적관심및필요 3 기타 : 5. 기존의교육의만족도는?

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