I have no problem declaring that I am an occasional intubator. Although I’m an Emergency Physician working in a busy Metropolitan Emergency Department, most patients don’t require intubation. I’m also surrounded by extremely eager registrars who are always vying with each other, let alone the consultants, for airway experience when the need to intubate arises. So it comes as no surprise that there have been periods over the past 10 years where I have probably performed less than one intubation per month. That is not to say that my airway experience during this time has always been this limited and, of course, I have supervised many other airway procedures performed by my trainees which all counts in some way – as airway management isn’t just about getting the tube in!
“airway management isn’t just about getting the tube in!”
During my registrar training I noticed that there were a few consultants who were less interested in airway management and probably shied away from performing airway procedures. I began to realise that this was probably because they were becoming less and less comfortable with airway management and avoidance seemed to be their solution. I never wanted to end up like that. I also realised that as an ED consultant the day would come where I would be faced with the inevitable CICO scenario and I would have to step up to the plate. After all that’s why I was getting paid the ‘big bucks’!
My solution to maintaining my skills was multifaceted. I became a simulation instructor and developed interprofessional courses based around teaching airway emergencies for ED staff. These meant that I was reviewing and thinking about airway topics regularly, as I was teaching them at least once a month. These included safe rapid sequence induction (RSI), surgical airway techniques, can’t intubate, can’t oxygenate (CICO) scenarios and importantly the teamwork and Clinical Resource Management (CRM) aspects of carrying out safe airway procedures.
Recently there has been a proliferation of medical blogs and websites that are either solely dedicated to airway or have a significant proportion of their content interested in it. On top of this there are interesting debates and case discussions on Twitter and Google+ which are moderated by experts such as Minh Le Cong and Scott Weingart. There are probably not enough hours in a week to keep up with the information solely dedicated to airway.
This proliferation of information came at a good time for me, when I was starting to do retrievals for Adult Retrieval Victoria about 2-3 years ago. That’s when my attitude to airway changed even further and I really needed to use the new concepts such as NODESAT, “Ketamine for most RSI’s” and delayed sequence induction (DSI). I was now going to places where I was the best-qualified airway proceduralist as opposed to my Public hospital experience where I could and would call anaesthetics down if it looked like it would be difficult. I had to be better prepared, have better plan Bs and Cs and be concrete in communicating with makeshift teams about these things. There’s nothing like knowing that you are your own back up plan to motivate you to make sure you’ve got everything planned well. There are lots of places in country Victoria where no one can hear you scream!
“There’s nothing like knowing that you are your own back up plan to motivate you to make sure you’ve got everything planned well”
All of this information and teaching experience has been fantastic in keeping me ready psychologically and physically (or so I thought) for my next difficult airway. However I recently spent half a day in the operating theatres moving from theatre to theatre just managing the airway for a number of cases. As soon as the ETT/LMA was in I moved onto the next theatre. Luckily I wasn’t obliged to sit around during the case and listen to the anaesthetist talk about Sevo or BIS monitors (I’m an ED doc, its really not relevant to me) as the concept of why I was there, how it was going to work and what I was expecting to achieve was introduced to them at the start of the day.
It worked perfectly. I placed 5 LMA’s and 3 ETT’s which was great but most importantly I spent a lot of time Face Mask ventilating and it was practicing this skill which made the day truly worthwhile. Why do I say this? As an ED/retrieval doc I don’t really Face Mask ventilate that much. Most patients are still breathing somewhat prior to intubation and usually just need some assistance. But here I was in theatre Face Mask ventilating for minutes at a time and it wasn’t that easy on occasion. I was shown different techniques and small tricks for improving my seal and it made a big difference. It was a fantastic 5 hours purely for this: I now feel more confident in my ability to Face Mask ventilate. Now I know that doesn’t sound very ‘sexy’ from an airway management point of view but it may well be thing that saves my next patient when I can’t get the ETT/LMA in.
We spend a lot of time in airway discussions and practical sessions talking about and practicing for events that are rarely going to happen. What we really need to do as well is make sure we are all doing the basics correctly. So what can you do? Simulation is great but not really the complete answer. While its great for practicing some skills and drills and is excellent for team training it really doesn’t give you the finely nuanced fidelity required for getting the feel of techniques such as face mask ventilation, laryngeal mask insertion and intubation. Approach your friendly anaesthetic department and ask if you can spend some time doing what I did this week following the model I described above. It may be met with some resistance but it’s really in their interests that staff in the other critcare areas are as well trained in the basics of airway management as they are. There is also the chance that you may be able to pass on some knowledge from the critcare blogs and websites you’ve been reading.
“We spend a lot of time in airway discussions and practical sessions talking about and practicing for events that are rarely going to happen. What we really need to do as well is make sure we are all doing the basics correctly”
Many thanks to Nicholas Chrimes (@nicholaschrimes) for organising the day in theatre for me.