Difficult airways are overestimated by academic emergency medicine

[bougiecric]

I've been out in the community for awhile now, and I continue to be fascinated by the differences I see here versus when I was in academia.

Recently it struck me that, man, I really haven't had that difficult of an airway in a long time. I'd like to think that I'm proficient at intubating (who doesn't), but it's not just me. I rarely hear about a difficult airway from my partners. I rarely get asked to assist in a tube my partner can't get. The only time I see an anesthesiologist is when I kindly request them to do a blood patch. Don't get me wrong: the ish still hits the fan, and I'm very vigilant in having plans B and C, but the vast majority of even these cases are easily solved with a bougie or glidescope. And they are very infrequent. *Knocks on wood*

This is coming from a guy who can't get enough airway. I mean, that's the ER doc's favorite. I love listening to and reading all the FOAM education on airway (see my username). I'm a huge Weingart / Levitan fan. Airway dominates the online world, and this is true of academia in general.

This will never will be and can't be studied, obviously, but I have a strong suspicion that the preponderance of emphasis on difficult airways takes place simply because they occur much more commonly in academic EDs. (And academic docs are the ones publishing and educating about them.)

In the community (depending on the hospital), intubation is a common procedure for an individual doctor. I imagine I do 8-12 per month, so maybe 120 or so per year. In an academic ER, intubations area spread thin over trainees, with attendings left to pick up the very rare scraps.

Who would you want intubating you in an academic ED? I'd go with the 3rd year resident. Hard to say after that. In academics, one year I did a total of 2(!) intubations (obviously supervising many, many more). I knew multiple attendings who had to take a few days to go to the OR and intubate to stay credentialed. I shudder to think about how far degraded some of the older academic attending's skills have become.

I honestly think that a lot of the fancier airway stuff is coming from academics who simply don't do DL enough. That's right, I said it. 99.9% of intubations can be done DL, but it has to be done repetitively and frequently to maintain mastery.

Look at the academic attending's scenario. The intern has missed, and your rockstar 3rd year can't even get it. You last intubated 8 months ago, so there's no way in hell you're getting this tube. Cue multiple episodes of desatting / bagging as everyone in the room is starting to wet themselves. Thus the impetus for a large amount of discussion regarding the "difficult airway," and the creation of airway techniques that will never actually be used (see: fiberoptic with aintree through an intubating LMA).

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[docB]

I agree with you in principle. I've been in the community for 10 years and I seem to run into a really difficult airway about twice a year.

I think the academic centers see more because of trauma and ENT stuff. I work in non trauma centers and no one in town except the big academic center has ENT so EMS diverts that stuff for the most part.

I do about 20 to 30 tubes a month. That sounds high but in my EDs the EP does all the in house tubes and codes. I usually get called to the ICU to tube at least once or twice a shift. That plus the ED tubes inflates the numbers. Many of my difficult cases over the last several years have been on patients post anterior approach cervical fusion. UG! No neck extension, lots of edema, if they're young enough to have teeth it's always a struggle.

That said I still think that for EPs any training in residency and after on airway is justified. I haven't personally experienced any more sphincter tightening moments than when fighting for the airway. Bad OB disasters are up there but I've been lucky with those so far.

 

[southerndoc]

In almost 6 years of practice, I finally had an airway I didn't feel comfortable attempting. Guy with very severe kyphosis who could not extend his neck (it was flexed and literally touching his chest without ability to move it). Called anesthesia for a fiberoptic intubation. ENT was at the bedside, but not sure if the patient could've been cric'd (probably would've had to do a side approach to get to his trachea.

Luckily we had a little time to intubate him. Heaven forbid that guy had presented in arrest. Half his face was blocked meaning you couldn't get a seal with a BVM mask.

 

[goodoldalky]

I've been out in the community for awhile now, and I continue to be fascinated by the differences I see here versus when I was in academia.

I don't know how long you have been out, but it seems to me that video laryngoscopy has become more widely used and even a difficult airway is pretty easy with a video laryngoscope.

 

[deleted109597]

I don't know how long you have been out, but it seems to me that video laryngoscopy has become more widely used and even a difficult airway is pretty easy with a video laryngoscope.

Sadly, lots of community places either won't pony up for the devices, or they're restricted to the OR and anesthesia.

That being said, while I agree that the concept of difficult airways may be a bit overplayed, there are very few other things in EM that we have to get right THIS VERY INSTANT or the patient dies. Can't go and look something up before doing it. Can't halfass it and let it fly.

I'm jealous of the number of tubes my residents graduate with. I miss having to rush up and do the airways in codes at my community shop (but I don't miss actually running the code).

 

[Arcan57]

The numbers you guys are quoting for tubes is significantly higher than any shop I've ever worked in. I work in a 60k community shop with a trauma designation and maybe intubate 2-3 times per month. My prior job was also 60k and acted as the receiving hub for a 9 hospital system including all neurosurgery pts and I'd intubate about once per week. Even in residency as the R2 (who got every airway when on shift) at the only Level 1 in the city I was probably intubating 1.8x/shift. EMS tends to have all the pre-hospital codes at my current shop intubated prior to arrival (even if it means 40+ min scene times) which factors in keeping the airways down. But 20-30/month? That's an astounding number and may be why you find failed airways so uncommon.

 

[Bostonredsox]

Obviously not EM but I would agree on the number of tubes in community practice. I have a little over a hundred tubes from floor codes/ICU pts in just over two years of residency as an IM resident at a community shop. The number that I would call truly difficult is still <10. And I have rarely intubated a pt in the ED, so if you add in all the pts that my Ed docs tube before they get to me there's literally hundreds of airways being done, very few of which are truly difficult airways. We have In house anesthesia, but its generally a CRNA. So while most all of us also have a plan b and c like you mentioned in mind, it rarely escalates to needing to go there. When I was a med student at an academic tertiary care, it seemed like every airway, Ed or ICU, was prepped as if it was a 500 pound, neck less, spinal surgery pt.
seemed like overkill then. I definitely feel it was overkill now after my training time in community medicine.

 

[Bostonredsox]

I don't know how long you have been out, but it seems to me that video laryngoscopy has become more widely used and even a difficult airway is pretty easy with a video laryngoscope.

I would agree with this in general. Almost every patient that I could not intubate with a McGrath or glide ended up trach'd. with the exception of one bad parotitis pt with laryngeal swelling and cord edema that I was able to poke around for a bit and eventually slip a bougie through ''where the cords should have been" even though I couldn't really see the cords with the glide.

 

[goodoldalky]

Sadly, lots of community places either won't pony up for the devices, or they're restricted to the OR and anesthesia.

That being said, while I agree that the concept of difficult airways may be a bit overplayed, there are very few other things in EM that we have to get right THIS VERY INSTANT or the patient dies. Can't go and look something up before doing it. Can't halfass it and let it fly.

I'm jealous of the number of tubes my residents graduate with. I miss having to rush up and do the airways in codes at my community shop (but I don't miss actually running the code).

I hear what you're saying. On the other hand, having available video laryngoscopy is essentially standard of care. There is ample literature highlighting the benefits, and to be honest, although we all learned how to intubate DL, in 10 years you're only going to find those blades in a museum.

I understand some places don't want to "pony up the dough", but would you practice somewhere without a pulse ox?

If I were in a place where they didn't make this technology available to me, I would buy one of the variety of adjunctive video laryngoscopy devices. A glidescope is about 10 grand but there are some similar handheld devices for less than $5K out there.

 

[deleted109597]

I hear what you're saying. On the other hand, having available video laryngoscopy is essentially standard of care. There is ample literature highlighting the benefits, and to be honest, although we all learned how to intubate DL, in 10 years you're only going to find those blades in a museum.

I understand some places don't want to "pony up the dough", but would you practice somewhere without a pulse ox?

If I were in a place where they didn't make this technology available to me, I would buy one of the variety of adjunctive video laryngoscopy devices. A glidescope is about 10 grand but there are some similar handheld devices for less than $5K out there.

I love the idealistic.
First, they're not standard of care anywhere. If they were, you would be using them for every intubation.
Second, sometimes you are places without power, and you can't do DL with many of the indirect devices (CMAC, cobalt you can).
Third, I would argue that you could survey the known US emergency world, and many (if not half) would not have it available in the ED. Lots of rural hospitals out there.
Pulse ox and fiberoptic aren't the same.

 

[Birdstrike]

I agree that difficult airways are overestimated in academics. That's good. I never lost an airway or a patient due to a failed airway, fortunately. The more over prepared on this one, the better, just like sick kids.

Man, a bad airway sure as h--l will clear up a bad case of doctor stool impaction though, won't it?

It's not for the faint of heart (or weak sphinctered).

 

[pseudoknot]

video laryngoscopy is essentially standard of care. There is ample literature highlighting the benefits,

There really isn't. There are a bunch of papers saying that VL improves the view especially for novice intubators. There is ONE claiming increased first pass success rate in difficult airways and that was less significant with operator experience. There is now also a prospective trial showing increased mortality in trauma patients with VL.

These devices do make it easier to see the cords, but especially with the hyperangulated ones it can still be quite challenging to deliver the tube. I've seen patients become critically hypoxic because of the seductive lure of the view on the screen...but you can't oxygenate through a glidescope screen. They are useful as a backup when DL fails but DL is still faster if you know what you're doing.

 

[Bostonredsox]

There really isn't. There are a bunch of papers saying that VL improves the view especially for novice intubators. There is ONE claiming increased first pass success rate in difficult airways and that was less significant with operator experience. There is now also a prospective trial showing increased mortality in trauma patients with VL.

These devices do make it easier to see the cords, but especially with the hyperangulated ones it can still be quite challenging to deliver the tube. I've seen patients become critically hypoxic because of the seductive lure of the view on the screen...but you can't oxygenate through a glidescope screen. They are useful as a backup when DL fails but DL is still faster if you know what you're doing.

Agree 100%. I have watched countless physicians get the most crystal clear view with a glide, then fiddle around for 3 minutes trying to get the tube to pass while the patient became significantly hypoxic. The view doesn't help if you can't quickly deliver the tube. I bring my newly acquired McGrath Mac to all of my airways. But I start every airway with a standard DL Mac 3/4. Only turn to my McGrath if DL fails. As pseudo said, VL is the backup to DL.

 

[docB]

I hear what you're saying. On the other hand, having available video laryngoscopy is essentially standard of care. There is ample literature highlighting the benefits, and to be honest, although we all learned how to intubate DL, in 10 years you're only going to find those blades in a museum.

I understand some places don't want to "pony up the dough", but would you practice somewhere without a pulse ox?

If I were in a place where they didn't make this technology available to me, I would buy one of the variety of adjunctive video laryngoscopy devices. A glidescope is about 10 grand but there are some similar handheld devices for less than $5K out there.

I definitely hear what you're saying but there are places that don't get the toys. I still don't have waveform end tidal CO2 ANYWHERE I work (6 hospitals).

I agree there is stuff I would buy and one of the new, handheld video scopes would be something I'd look at. Fortunately I have a glidescope in the 2 ERs I work at most.

A word of warning about buying your own stuff though. Sometimes group leaders don't want you to do that as it creates the precedent of the docs or the group buying DME rather than the hospital and makes the physician and the group liable for any malfunctions. Also you probably need to run it by engineering. They have to certify all electronic devices as safe for the hospital environment (even notice all those little stickers on everything?). You may also need to make sure that you're privileged to do whatever it is you plan to do. If your house has never had a video scope they may think it's a new skill that needs to be in your DOPs or worse, they may think it's restricted to anesthesia or something. Just as a surgeon can't assume they could buy a robotic surgery system and take it into the OR and start using it without clearing it with anyone you should have some conversations before you start using a personal device.

The numbers you guys are quoting for tubes is significantly higher than any shop I've ever worked in. I work in a 60k community shop with a trauma designation and maybe intubate 2-3 times per month. My prior job was also 60k and acted as the receiving hub for a 9 hospital system including all neurosurgery pts and I'd intubate about once per week. Even in residency as the R2 (who got every airway when on shift) at the only Level 1 in the city I was probably intubating 1.8x/shift. EMS tends to have all the pre-hospital codes at my current shop intubated prior to arrival (even if it means 40+ min scene times) which factors in keeping the airways down. But 20-30/month? That's an astounding number and may be why you find failed airways so uncommon.

I agree that my quoted numbers are incredible (in the true sense of the word incredible, as in unbelievable). I stand by my numbers though. Let me explain. My environment has several factors that make this happen. We are embedded in an area with many nursing homes. We receive a high volume of elderly critically ill patients (e.g. sepsis, AMS, etc.) which results in tubes. We do all the in house tubes outside of the OR. All of them. Pulmonary has given up their intubation privileges due to malpractice costs. It just wasn't worth it for them. So we do all the ICU tubes, the tube changes, the failed BiPAP and so on. EMS in Las Vegas does not have paralytics so no RSI (a long story for another time). So we get a lot of patients from EMS that would have been intubated prehospital in other locales. Finally we have pretty lean staffing. We are double physician coverage for about 14 hours a day and drop to single physician coverage for the late 10. That means there's only one or two guys around at any time to do all those previously mentioned tubes. It's kind of a perfect storm but that's how it is here.

 

[Bostonredsox]

I definitely hear what you're saying but there are places that don't get the toys. I still don't have waveform end tidal CO2 ANYWHERE I work (6 hospitals).

I agree there is stuff I would buy and one of the new, handheld video scopes would be something I'd look at. Fortunately I have a glidescope in the 2 ERs I work at most.

A word of warning about buying your own stuff though. Sometimes group leaders don't want you to do that as it creates the precedent of the docs or the group buying DME rather than the hospital and makes the physician and the group liable for any malfunctions. Also you probably need to run it by engineering. They have to certify all electronic devices as safe for the hospital environment (even notice all those little stickers on everything?). You may also need to make sure that you're privileged to do whatever it is you plan to do. If your house has never had a video scope they may think it's a new skill that needs to be in your DOPs or worse, they may think it's restricted to anesthesia or something. Just as a surgeon can't assume they could buy a robotic surgery system and take it into the OR and start using it without clearing it with anyone you should have some conversations before you start using a personal device.



I agree that my quoted numbers are incredible (in the true sense of the word incredible, as in unbelievable). I stand by my numbers though. Let me explain. My environment has several factors that make this happen. We are embedded in an area with many nursing homes. We receive a high volume of elderly critically ill patients (e.g. sepsis, AMS, etc.) which results in tubes. We do all the in house tubes outside of the OR. All of them. Pulmonary has given up their intubation privileges due to malpractice costs. It just wasn't worth it for them. So we do all the ICU tubes, the tube changes, the failed BiPAP and so on. EMS in Las Vegas does not have paralytics so no RSI (a long story for another time). So we get a lot of patients from EMS that would have been intubated prehospital in other locales. Finally we have pretty lean staffing. We are double physician coverage for about 14 hours a day and drop to single physician coverage for the late 10. That means there's only one or two guys around at any time to do all those previously mentioned tubes. It's kind of a perfect storm but that's how it is here.

Your numbers seem realistic. If the EM guys were doing the tubes on the floors and in ICU at my shop as you do at yours, they would hit those numbers. Just depends on the respiratory failure volume for a given hospital, and how many other physicians are participating in the airways. One of the places I trained as a med student was similar to you, my ED attending did all of the tubes in the floor ps and MICU. Anesthesia was or only. The hospitalist program hasn't started at that time. So he was easily 2 per shift, probably more. One night we had 6 between 2 floor codes, a MICU self extubation and 3 from our end in Ed.

 

[Arcan57]

Agree 100%. I have watched countless physicians get the most crystal clear view with a glide, then fiddle around for 3 minutes trying to get the tube to pass while the patient became significantly hypoxic. The view doesn't help if you can't quickly deliver the tube. I bring my newly acquired McGrath Mac to all of my airways. But I start every airway with a standard DL Mac 3/4. Only turn to my McGrath if DL fails. As pseudo said, VL is the backup to DL.

It's been mentioned in previous posts, but for all those that have run into this personally:

If you can see the cords close-up with a glidescope but can't pass the ETT then your scope is too deep and needs to be pulled back about 1-2 cm.

Burying the glidescope in the vallecula will give you cords that fill the screen and create an angle that is physically impossible to maneuver a tube through even with the hypercurved stylet. I've found being able to visualize at least the medial sides of the piriformis recesses seems to be the ideal depth. The cords will look a little far away but if they're in the center of the screen then the ETT will curve up and pass right into them.

 

[dotcb]

I think airway management is appropriately overemphasized in EM residency training. It's because the skill is so critical to being able to practice competently, and it only takes one airway gone bad or a dead patient for a can of badness to open.

Fortunately most airways just aren't that hard to get, and over time there are so many tools which help, such as VL, bougie, LMA, etc., that usually an airway can at least be temporized.

As an academic EM attending, I do about 2-4 ED intubations per year, usually when the residents are at their weekly teaching conference. I also spend a few mornings per year in the OR practicing intubation.

I do think that practice in academic centers compared to private hospitals tends to be more conservative. I think there's more testing, more caution in general, because trainees are doing most of the work.

I think the overemphasis on airway management in residency is appropriate. It sets you up for a career of safe practice.

 

[deleted547339]

I think airway management is appropriately overemphasized in EM residency training. It's because the skill is so critical to being able to practice competently, and it only takes one airway gone bad or a dead patient for a can of badness to open.

Fortunately most airways just aren't that hard to get, and over time there are so many tools which help, such as VL, bougie, LMA, etc., that usually an airway can at least be temporized.

As an academic EM attending, I do about 2-4 ED intubations per year, usually when the residents are at their weekly teaching conference. I also spend a few mornings per year in the OR practicing intubation.

I do think that practice in academic centers compared to private hospitals tends to be more conservative. I think there's more testing, more caution in general, because trainees are doing most of the work.

I think the overemphasis on airway management in residency is appropriate. It sets you up for a career of safe practice.

isn't that an oxymoron?

 

[substanceP]

On the other hand, having available video laryngoscopy is essentially standard of care.... in 10 years you're only going to find those blades in a museum.

I disagree with this statement. in someone with a lot of secretions, the glydescope gets fogged up and visualizing any anatomic structures is essentially impossible, even after suctioning. i've had a few cases recently where some of the recent hires (just out of residency) go straight to glydescope and fail and i've gotten it with DL.

 

[Cerberus]

It's been mentioned in previous posts, but for all those that have run into this personally:

If you can see the cords close-up with a glidescope but can't pass the ETT then your scope is too deep and needs to be pulled back about 1-2 cm.

Burying the glidescope in the vallecula will give you cords that fill the screen and create an angle that is physically impossible to maneuver a tube through even with the hypercurved stylet. I've found being able to visualize at least the medial sides of the piriformis recesses seems to be the ideal depth. The cords will look a little far away but if they're in the center of the screen then the ETT will curve up and pass right into them.

This! I've seen a lot of VL novices have trouble with a glidescope because they are way too close to the cords. Once they pull back a little they find it much easier. The other issue I see people have (especially older Attendings that didn't grow up with video games) is having a hard time maneuvering the tube when viewing it on the screen. One tip I can offer is to hold the tube near the top (like it's a manual shifter). It makes it much easier to adjust position this way.

 

[Rendar5]

This! I've seen a lot of VL novices have trouble with a glidescope because they are way too close to the cords. Once they pull back a little they find it much easier. The other issue I see people have (especially older Attendings that didn't grow up with video games) is having a hard time maneuvering the tube when viewing it on the screen. One tip I can offer is to hold the tube near the top (like it's a manual shifter). It makes it much easier to adjust position this way.

I miss VL honestly, none where I'm at. Though my only difficult intubation this year was a floor cardiac arrest with a massively obese guy, who had blood spewing from his mouth with each compression. No way VL was going to save me on that one, not that there's gonna be a VL on the floor anyway.

The above tips for moving the glidescope back though are dead on. Better a slightly worse view with good angle than a great view with a shoddy angle, especially when you have a rigid stylet.

 

[Cerberus]

I miss VL honestly, none where I'm at. Though my only difficult intubation this year was a floor cardiac arrest with a massively obese guy, who had blood spewing from his mouth with each compression. No way VL was going to save me on that one, not that there's gonna be a VL on the floor anyway.

The above tips for moving the glidescope back though are dead on. Better a slightly worse view with good angle than a great view with a shoddy angle, especially when you have a rigid stylet.

The only times I've run into problems with VL (and despite being academic, I think we do see a lot of difficult airways) is when the patient is actively vomiting, hemorrhaging, or the glidescope doesn't power on (which of course happened on the patient 3 people had already failed on - thank god for the boughie).

 

[DeadCactus]

Tangential question: When in your training did you start experimenting with new techniques and back-up devices? It seems like picking one method (probably DL or CMAC used as DL in most places) and sticking with it to build a comfortable/reliable intubation technique is a wise choice. But when do you start messing with bougies, VL, etc to build a wider repertoire?

 

[Daiphon]

Tangential question: When in your training did you start experimenting with new techniques and back-up devices? It seems like picking one method (probably DL or CMAC used as DL in most places) and sticking with it to build a comfortable/reliable intubation technique is a wise choice. But when do you start messing with bougies, VL, etc to build a wider repertoire?

When you get comfy with DL. Or when the excrement hits the rotating air circulator. Or when the handles aren't working...

I started practicing by doing a quick look with the DL on "easy" airways (mallampati 1-2, 332 good, and passed LEMON)... if I knew I could get it with DL, I'd switch to another modality & practice those - knowing the tube was gonna get in with my DL.

-d

Sent from my DROID BIONIC using Tapatalk

 

[deleted547339]

I'm only an intern, but I started playing with the bougie and I've done a several LMAs. I don't think our program is really excited about that idea, but I have. They say they don't want us to get used to using backup methods until we're good at DL because we may not end up putting enough emphasis on DL.

I'm on my airway month and I've gotten about 50 tubes so far. I had gotten maybe about a dozen tubes in med school. I feel reasonably OK with intubation, not extremely proficient, but at least where I should be for where I am in my education level.

The LMAs were all in the OR for procedures when they planned on using an LMA (i.e. not as a rescue for a failed intubation). When there aren't any patients I can tube, I look for the LMAs. The first time I used the bougie was with an anesthesia attending where it wasn't needed, but the attending said it would be good to get practice with it. He had seen me tube about a half dozen patients successfully, a couple with me using the c-mac to do DL and him looking at the screen. The other was one that was tough to intubate, but he was easy to bag. I could see aretynoids and told the attending that I couldn't see cords. He took a look, saw the same thing. He came out, I gave the patient a few breaths with the bag and then went in again and did it with the bougie.

 

[Bostonredsox]

When you get comfy with DL. Or when the excrement hits the rotating air circulator. Or when the handles aren't working...

I started practicing by doing a quick look with the DL on "easy" airways (mallampati 1-2, 332 good, and passed LEMON)... if I knew I could get it with DL, I'd switch to another modality & practice those - knowing the tube was gonna get in with my DL.

-d

Sent from my DROID BIONIC using Tapatalk

This. I started doing this in second year for people who were ventilating ok. Quick look with DL. Easy to see cords. Then swapping to McGrath Mac and practicing technique.

 

[FLTDOC1]

The greatest low tech airway device since positive pressure ventilation. I use it for ALL DL and especially VL intubations

http://www.bomimed.com/Products/Catalog/IntubationAids/Bougies/IntroesPocketBougie.html

 

[Hamhock]

VL is the future...I hate to say it, but it is true. It is the complete fututre for NP/PAs with expert MD-back up. It is the future for physicians who are not going to be the airway expert.

However, it should not be the complete future for any real EM doc (see the R Walls-kerfuffle). I suspect that soon, VL will be the first option and that DL will be the back-up device; yes, DL will be the "resuce" device. Indeeed, it should be.

Nearly every airway that I can get with VL, I can get with DL. However, there are too many airways that I can not get with VL that I can get with DL...trauma, UGIB, epistaxis, etc.

I propose that all new EM residents should spend as much time as possible mastering VL and then move on to DL.

-----------

A second point:

I COMPLETELY agree with the above posts about pulling back VL (especially the Glidescope on "anterior" airways); however, I would add that people should not just pull back, but put the cords in the upper corner of the screen, not the center.

---------

A third point:

Althogh the majority of ED airways at most community shops will be fairly easy -- and the majority of airways in the OR will be even easier -- there are many places that the ED doc is the "airway expert" in-house (especially at night) and is responsible for the ICU and floor intubations. As an EM-trianed doc who is very interested in airway and who has spent a crazy amount of time studying and practicing airway management, I have found way too many ICU airways (admittedly, I spend the majority of my time in the ICU these days) exceedingly difficult. The post-op (esp. after neuro/ENT/neck/vascular surgery) airway is probably the most difficult of all crash airways. I have found these crazy difficult airways so frequently that I find the assertion that too much time is spent on "difficult airway" during EM residency laughable.

Please, dear EM residents: DO take advantage of every bit of difficult airway training and exposure you get. You WILL save a life with this training someday. Isn't this the point of being an EM doc?...ready for the common problems, but prepared for the opportunities to safe a life?

(also: please interpret my definition of "difficulty airway" to include, not just anatomy, but also cardiovascular physiology and toxicology)

HH

 

[Hamhock]

One last bit of advice to EM residents:

Carry a scalpel. (sub rosa)

You will be made fun of, until you cric or relieve tension PTX or relieve compressive hematoma...it will happen.

HH

 

[deleted109597]

One last bit of advice to EM residents:

Carry a scalpel. (sub rosa)

You will be made fun of, until you cric or relieve tension PTX or relieve compressive hematoma...it will happen.

HH

Hell. I still carry an 11 blade everywhere. I've even carried it through airports, although accidentally.

 

[Bostonredsox]

Hell. I still carry an 11 blade everywhere. I've even carried it through airports, although accidentally.

/nod. i have an 11 blade, 14ga angiocath and bougie in coat pocket whenever im in the hospital.

 

[BLADEMDA]

Approaching any airway in the ER is fraught with the potential for a disaster. Nothing can kill a patient faster than a failed attempt at intubation. Fortunately, most airways are straightforward and easy.

However, trauma patients can have blood in their airways combined with poor positioning on the trauma table. Ths means a moderate level intubation can quickly turn into a difficult intubation. I agree having a Glidescope nearby ready to go is a good idea; but, the time to call for help (even if it is just standby) is before you need it.

Those of you unfamiliar with LMAs should become familiar with them. They may save a patient's life one day or avoid an emergency cric. Again, a colleague with experience in airway management is nice to have around when things turn ugly.

From my time in the ER as an Anesthesiologist over the past 2 decades I have seen the skills by EM Attendings vastly improve from poor to fair. A few of the new superstar Attendings are even pretty good.
Please note my comments are for my ER attending room staff only. Some of you may indeed be excellent at this skill but I still recommend backup for the anticipated difficult airway.

Finally, I had a new ER attending who was board certified in EM call me stat to the ER to assist him with an intubation. Unfortunately, I was called after the propofol and Sux were already given by this Attending. By the time I got the patient intubated he was in full cardiopulmonary arrest. The patient was a 400 pound, 6'2" male in the ER for CHF/rule out MI. He died that evening in the ER about 10 minutes after I got him intubated.

As a guy who intubates about 20-25 patients a week on a regular basis there is no substitute for experience when dealing with the unanticipated difficult airway. I've had some close calls myself including 2 crics in the ER but I've never lost a patient due to failed airway (I've had some close calls where even another 30 seconds and the patient would have likely died or suffered brain damage).

I really appreciate the job the new ER Attendings are doing now as far as airway management education is concerned; but, knowing when to call for help prior to a airway disaster is essential. When it comes to the airway leave your ego at home.

One last thing. Why don't ER Attendings rotate up to the OR and do 10-20 elective intubations a month?
This could include fiberoptic intubations, ETT through an LMA and glidescope intubations. There is no better way to stay skilled than by practicing that skill over and over again. The old saying "use it or lose it" definitely applies to airway management.

 

[deleted109597]

One last thing. Why don't ER Attendings rotate up to the OR and do 10-20 elective intubations a month?.

Some do.
Some work at places where it's discouraged.
Some work at places where they're simply not allowed to.
Some are lazy.

I think that covers everyone.

 

[BLADEMDA]

Some do.
Some work at places where it's discouraged.
Some work at places where they're simply not allowed to.
Some are lazy.

I think that covers everyone.

1. I applaud those that keep their skills sharp
2. Why would you discourage someone from maintaining solid airway skills?
3. Why would they not be allowed to intubate in the OR? Get the policy changed
4. Lazy. We all know those people and nothing can be done about it except a policy which encourages (? Forces) essential skill maintenance. Use it or lose it.

 

[deleted547339]

1. I applaud those that keep their skills sharp
2. Why would you discourage someone from maintaining solid airway skills?
3. Why would they not be allowed to intubate in the OR? Get the policy changed
4. Lazy. We all know those people and nothing can be done about it except a policy which encourages (? Forces) essential skill maintenance. Use it or lose it.

Maybe they don't want to take tubes from their anesthesia residents?

 

[BLADEMDA]

Maybe they don't want to take tubes from their anesthesia residents?

If you are getting 10-20 intubations per month in the ER then that is a sufficient number. But, this skill requires you to maintain proficiency even after you have obtained it. In academics many cases have CRNAs and not Anesthesia residents so the opportunity for intubation is present for any EM/ER attending who wishes to stay sharp. At community hospitals there are no anesthesia residents most of the time. Hence, at those ERs where intubations are infrequent there is likely ample opportunity to intubate in the OR.

My point here is that skills atrophy then whither and die. I'm simply advocating you exercise those intubation skills in the ER and the OR, preferably both.

 

[prometheus09]

Maybe they don't want to take tubes from their anesthesia residents?

I know as a med student I have seen in the OR residents and other med students be put second to CRNA students trying to make their intubation number requirements...

 

[BLADEMDA]

We are talking "Attending" level Physicians going to the OR and asking their colleagues to call them to do a few intubations or glidescope or ETT via an LMA. I for one would bend over backwards to get an attending colleague at my institution whatever he/she needed to maintain proficiency in airway management. I believe a well-trained ER physician is essential for good patient care.

 

[Birdstrike]

Approaching any airway in the ER is fraught with the potential for a disaster. Nothing can kill a patient faster than a failed attempt at intubation. Fortunately, most airways are straightforward and easy.

However, trauma patients can have blood in their airways combined with poor positioning on the trauma table. Ths means a moderate level intubation can quickly turn into a difficult intubation. I agree having a Glidescope nearby ready to go is a good idea; but, the time to call for help (even if it is just standby) is before you need it.

Those of you unfamiliar with LMAs should become familiar with them. They may save a patient's life one day or avoid an emergency cric. Again, a colleague with experience in airway management is nice to have around when things turn ugly.

From my time in the ER as an Anesthesiologist over the past 2 decades I have seen the skills by EM Attendings vastly improve from poor to fair. A few of the new superstar Attendings are even pretty good.
Please note my comments are for my ER attending room staff only. Some of you may indeed be excellent at this skill but I still recommend backup for the anticipated difficult airway.

Finally, I had a new ER attending who was board certified in EM call me stat to the ER to assist him with an intubation. Unfortunately, I was called after the propofol and Sux were already given by this Attending. By the time I got the patient intubated he was in full cardiopulmonary arrest. The patient was a 400 pound, 6'2" male in the ER for CHF/rule out MI. He died that evening in the ER about 10 minutes after I got him intubated.

As a guy who intubates about 20-25 patients a week on a regular basis there is no substitute for experience when dealing with the unanticipated difficult airway. I've had some close calls myself including 2 crics in the ER but I've never lost a patient due to failed airway (I've had some close calls where even another 30 seconds and the patient would have likely died or suffered brain damage).

I really appreciate the job the new ER Attendings are doing now as far as airway management education is concerned; but, knowing when to call for help prior to a airway disaster is essential. When it comes to the airway leave your ego at home.

One last thing. Why don't ER Attendings rotate up to the OR and do 10-20 elective intubations a month?
This could include fiberoptic intubations, ETT through an LMA and glidescope intubations. There is no better way to stay skilled than by practicing that skill over and over again. The old saying "use it or lose it" definitely applies to airway management.

Agree. You can never be "too good" or too prepared with airway. I think EM residency training in this area has improved leaps and bounds since 2 decades ago, fortunately. It's something never to get cavalier with. That goes for EM attendings and Anesthesia, just the same.

On the other hand, you can't always assume that an airway disaster in the ER was necessarily "turned into one" by the ER attending, and that if called early, you would have waltzed through it, one handed, with your eyes closed. Having the option to call plays on Monday morning as quarterback is an exquisite luxury that I've lived with and without.

Also, don't forget that some of your Anesthesia colleagues blocked advancements in airway education for EPs in the past, so that RSI could remain exclusively within the realm of Anesthesia departments. The motivations for this has been called into question, as less than pure, by many. These are the same people that were blocking EPs attempts to learn advanced airways skills such as RSI while simultaneously teaching them to non-physicians, such as nurses, to increase revenue for anesthesia groups.

Thanks for the input.

 

[deleted109597]

We are talking "Attending" level Physicians going to the OR and asking their colleagues to call them to do a few intubations or glidescope or ETT via an LMA. I for one would bend over backwards to get an attending colleague at my institution whatever he/she needed to maintain proficiency in airway management. I believe a well-trained ER physician is essential for good patient care.

I agree completely.
I also wish every anesthesia department felt the same, and I wish there weren't EPs out there that were assassins with laryngoscopes.

 

[Rendar5]

call me lazy, not gonna come in my off-days to intubate pt's. I like being married and do not want my wife to divorce me. that said, I'm taking shifts soon at our high acuity hospital to keep my skills sharp; there are alternatives to OR time on days off for keeping skills sharp.

 

[Janders]

I agree with the idea that "difficulty airways" don't come up as often as one is told they will in community practice. Likely a combination of improved training, improved adjuvant availability (glidescope, bougie, etc), and lower acuity in a community setting.

That said, even it only happens once every 6mo, a truly difficulty airway is a horrible experience. Especially when you are alone in a small hospital with no one else to even call you to bail you out. THAT is why you need to keep your skills up. And keep a #11 nearby. You'll be straight chilling, shooting the &@# with the tech watching the end of a college football game and suddenly EMS is at your door with an actively coding 400lb no-neck, huge-tongue, upper GI bleed. There will be no warning. Your glidescope will be broken. The RT won't come down from the ICU (they are off on a smoke break).

Enough drama. A few tips from me, if I may:
(1) Always have 14g angios and #11 blades in your pocket, or in a special hidden spot you know they will not wander from. Just trust me.
(2) I alternate DL and glidescope with every routine intubation, to keep my skills up in each
(3) If you can SEE it on the glidescope, you MUST learn to get the tube there. Put the cords in the upper corner of the screen. Use the real glidescope hard stilet. There are a few videos showing how to insert the tube from the side of the mouth, holding it parallel to the floor, twisting with your fingers to roll the tube in the vertical plane. This is a great rescue technique.
(4) Treat every airway like it is going to screw you. Always have your difficult / backup equipment in the room with you. Don't get cocky. Again, just trust me.

 

[FLTDOC1]

I realize this is written from the anest view but still holds for EM

Emergency surgical airway in life-threatening acute airway emergencies--why are we so reluctant to do it?

Greenland KB, Acott C, Segal R, Goulding G, Riley RH, Merry AF.
Source
Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital and Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia. [email protected]
Abstract

'Can't intubate, can't oxygenate' scenarios are rare but are often poorly managed, with potentially disastrous consequences. In our opinion, all doctors should be able to create a surgical airway if necessary. More practically, at least all anaesthetists should have this ability. There should be a change in culture to one that encourages and facilitates the performance of a life-saving emergency surgical airway when required. In this regard, an understanding of the human factors that influence the decision to perform an emergency surgical airway is as important as technical skill. Standardisation of difficult airway equipment in areas where anaesthesia is performed is a step toward ensuring that an emergency surgical airway will be performed appropriately Information on the incidence and clinical management of 'can't intubate, can't oxygenate' scenarios should be compiled through various sources, including national coronial inquest databases and anaesthetic critical incident reporting systems. A systematic approach to teaching and maintaining human factors in airway crisis management and emergency surgical airway skills to anaesthetic trainees and specialists should be developed: in our opinion participation should be mandatory. Importantly, the view that performing an emergency surgical airway is an admission of anaesthetist failure should be strongly countered.