donkoski

10+ Year Member
Feb 24, 2008
17
0
Status
The fat chick with lido allergy thread talks about the need to have a surgeon nearby for airway help via crichothyroidotomy. This begs the question: why don't WE do the start teaching residents to do the trachs in such a situation? It's great if you have an ENT or otherwise capable surgeon on hand, but let's be honest: this is unlikely to be found at a community hospital, or most university hospitals for that matter.

If the airway is of vital importance to us, we really should be able to master the surgical airway. I admit that I would rather have someone who cuts people for a living doing this, but in many situations, especially a crash c-section on a patient who's been hastily brought to the floor without properly being admitted, this might not be available.
 

rsgillmd

ASA Member
10+ Year Member
7+ Year Member
Nov 24, 2007
696
4
Status
Attending Physician
The fat chick with lido allergy thread talks about the need to have a surgeon nearby for airway help via crichothyroidotomy. This begs the question: why don't WE do the start teaching residents to do the trachs in such a situation? It's great if you have an ENT or otherwise capable surgeon on hand, but let's be honest: this is unlikely to be found at a community hospital, or most university hospitals for that matter.

If the airway is of vital importance to us, we really should be able to master the surgical airway. I admit that I would rather have someone who cuts people for a living doing this, but in many situations, especially a crash c-section on a patient who's been hastily brought to the floor without properly being admitted, this might not be available.
There are plenty of non-surgical (i.e. Seldinger technique type) cricothyroidotomy kits out there. I'm sure people are familiar with how to use the kits at their institution. If they are not they should find out. After all, there's no point in having equipment on a difficult airway cart if you don't know how to use it.

BTW at my institution the two OB ORs are adjacent to each other. We keep a difficult airway cart in one of them, in addition to having one available 3 floors up in the main OR. Both have cric kits on them.
 

rsgillmd

ASA Member
10+ Year Member
7+ Year Member
Nov 24, 2007
696
4
Status
Attending Physician
Additionally, if all you need to do is oxygenate, I'm sure a simple needle cric will suffice in an emergency.
 
OP
D

donkoski

10+ Year Member
Feb 24, 2008
17
0
Status
Needle cric is a jet vent technique that you use to temporize while awaiting a more definitive airway, like a crich. In the situation I described, we have no surgeon available, just you and the OB.

As for the retrograde intubation mentioned, there are people who've used them and they'll readily admit that they're not easy and have a pretty high failure rate. In this case, you've got the sow and her little piglet to worry about, so I would be looking for something a little easier than this approach.
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
110
level at FL210
Status
The fat chick with lido allergy thread talks about the need to have a surgeon nearby for airway help via crichothyroidotomy. This begs the question: why don't WE do the start teaching residents to do the trachs in such a situation? It's great if you have an ENT or otherwise capable surgeon on hand, but let's be honest: this is unlikely to be found at a community hospital, or most university hospitals for that matter.

If the airway is of vital importance to us, we really should be able to master the surgical airway. I admit that I would rather have someone who cuts people for a living doing this, but in many situations, especially a crash c-section on a patient who's been hastily brought to the floor without properly being admitted, this might not be available.
You bring up a very good point.

Wonder how residents could get adequate exposure to the training.

An ENT rotation, maybe?
 

Winged Scapula

Cougariffic!
Staff member
Administrator
Lifetime Donor
15+ Year Member
Apr 9, 2000
39,439
27,982
forums.studentdoctor.net
Status
Attending Physician
You bring up a very good point.

Wonder how residents could get adequate exposure to the training.

An ENT rotation, maybe?
Depends on the institution.

Our ENT residents certainly did a lot of trachs, but they were formal open ones in the OR for H&N cases.

Emergency surgical airways are thankfully uncommon in most places. However, planned percutaneous and bedside open ones, at my institutions, were the job of the trauma service who did *way* more than ENT given all the PEG and PET cases in the SICU. Emergent calls for surgical airways went to the trauma service. So I'd vote for a trauma rotation to get the most exposure to doing trachs esp perc ones.

I'd be wary of training open trachs/definitive surgical airways because of the lack of opportunities to keep your skills fresh and the major complications that can result from same. Using the perc kits in an emergency is a useful skill that anyone working in the field should have.
 

rsgillmd

ASA Member
10+ Year Member
7+ Year Member
Nov 24, 2007
696
4
Status
Attending Physician
Needle cric is a jet vent technique that you use to temporize while awaiting a more definitive airway, like a crich. In the situation I described, we have no surgeon available, just you and the OB.

As for the retrograde intubation mentioned, there are people who've used them and they'll readily admit that they're not easy and have a pretty high failure rate. In this case, you've got the sow and her little piglet to worry about, so I would be looking for something a little easier than this approach.
I think I was misunderstood. I wasn't talking about retrograde. I agree with you about that. I was just mentioning there are quick cricothyroidotomy kits out there. I had a chance to play with them on pig tracheas at an airway course I took a couple of months ago. I found them fairly easy to use.

I am not against advanced training. I don't think anybody can have too many skill sets. However, I also think you need to practice a skill in order to maintain it. It's going to be difficult to maintain a surgical skill. Non-surgical techniques lend themselves to easier practice in simulated sessions.
 
OP
D

donkoski

10+ Year Member
Feb 24, 2008
17
0
Status
That would be a great way to do it, although getting the department to cut you loose for the month might be tough.

Perhaps a "crash-course" in trachs would be given by a surgical service comfortable in doing them. The anesthesia resident would at least know the basics, enough to get a patient through the thing in a pinch.

The resident who's losing the airway of this fat patient is going to be scared to slice that neck if he has never tried it before. Give it a few shots, at least on cadavers or whatever, and you have *some* idea what you're doing.

As the ENTs here say, it ain't a tough thing to do.

But the fear of ****ing up is the big problem that needs to be overcome. Taking a pair of scissors and jabbing into the neck, then spreading the wound a bit, shoving a tube in and ventilating the patient doesn't sound that tough.


But the idea of doing it for the first time in such a situation freaks most people out. They'd probably grab their favorite airway tool--the one that already failed--than slice that neck.

Residents need to learn it, though. Screaming for surgical help for an AIRWAY ISSUE seems to make us unnecessarily reliant upon the surgeons.

Again, I'm not trying to make the procedure sound any easier than it really is, but this, along with chest tubes after the occasional PTX resulting from a subclavian we place, needs to be part of our armamentarium.
 

Winged Scapula

Cougariffic!
Staff member
Administrator
Lifetime Donor
15+ Year Member
Apr 9, 2000
39,439
27,982
forums.studentdoctor.net
Status
Attending Physician
Screaming for surgical help for an AIRWAY ISSUE seems to make us unnecessarily reliant upon the surgeons.
But no man or physician is an island.

You are making it sound easier than it is and ignoring the very real complications. That said, I have no objections to anesthesiologists learning the skill because it may come in handy in those rare instances when a surgeon is not available.

We are not "unnecessarily" reliant on each other. I can intubate someone using RSI and can certainly sedate them and give them local (the latter of which is what I use for most of my cases), but I prefer to have my anesthesiologists do it because that's what you guys are trained to do (and much more) and can much better handle any possible problems related to the airway than I. You need surgeons because you want someone who has spent at least 5 years learning surgical technique doing a surgical procedure.

I need you guys, medical oncologists and radiation oncologists, and so on. Gastroenterologists need general surgeons, Cards need CT, FM needs Cards, etc.

Its ok to need each other unless you want to get into a discussion of whether or not anyone should do any procedure that they cannot handle the possible compliations.
 
OP
D

donkoski

10+ Year Member
Feb 24, 2008
17
0
Status
"You are making it sound easier than it is and ignoring the very real complications. That said, I have no objections to anesthesiologists learning the skill because it may come in handy in those rare instances when a surgeon is not available."

I disagree. I mentioned:

"I admit that I would rather have someone who cuts people for a living doing this, but in many situations, especially a crash c-section on a patient who's been hastily brought to the floor without properly being admitted, this might not be available."

Let's face it: it's not that hard a procedure to become proficient in this, although if I were the patient I would rather have a surgeon or CCM anesthesiologist do it if the option existed.

In the situation I described above, it's just the anesthesiologist and the OB.

The tube aint' going in and the kid and mom are going south fast.

The gas doc or the OB will need to do it.

Shouldn't we (the anesthesiologist) know how to access the airway in this situation?
 

Winged Scapula

Cougariffic!
Staff member
Administrator
Lifetime Donor
15+ Year Member
Apr 9, 2000
39,439
27,982
forums.studentdoctor.net
Status
Attending Physician
"You are making it sound easier than it is and ignoring the very real complications. That said, I have no objections to anesthesiologists learning the skill because it may come in handy in those rare instances when a surgeon is not available."

I disagree. I mentioned:

"I admit that I would rather have someone who cuts people for a living doing this, but in many situations, especially a crash c-section on a patient who's been hastily brought to the floor without properly being admitted, this might not be available."

Let's face it: it's not that hard a procedure to become proficient in this, although if I were the patient I would rather have a surgeon or CCM anesthesiologist do it if the option existed.
Fair enough and that's why I agreed that it would be a valuable skill to have in an emergency. I understood you to be advocating it being done at all times when a surgical airway is needed.

There are a lot of procedures that are relatively easy to do but its the managing of the complications that are not so easy. This is why I have a problem with places like the Shouldice Clinic training PAs and FMs to do surgery. A hernia repair can be taught, but if you make a mistake and tie off the femoral vessels or open them, it can be a disaster and not within the realm of training to fix. It is the realization that even the most routine, technically easy procedure can lead to major problems, that is the hallmark of a senior resident or attending. Believe me, I hear medical students all the time talk about how easy it looks to do a lap chole or appy. Its lots of fun to watch them in the Sim Lab and realize its not as easy as it looks, and that's with a computer model (who cares if it bleeds out or you tie off the CBD)?

But I am off topic...

In the situation I described above, it's just the anesthesiologist and the OB.

The tube aint' going in and the kid and mom are going south fast.

The gas doc or the OB will need to do it.

Shouldn't we (the anesthesiologist) know how to access the airway in this situation?
Of course you should and that's why I advocated it (as you'll see from my posts above). Frankly, I'd rather the anesthesiologist learn how to do it than an Ob-Gyn and it should be within your scope of practice.

It was your comment about being overreliant on surgeons that made me think you were advocating doing it in all cases, even when a surgeon is available. I'm not sure that is in the best interest of everyone involved because these are not common events and it would behoove everyone involved to have a person who has done it most frequently there. Hence my comments about we all need each other, no physician being able to do it all.

But in the hospital without emergent surgeon coverage? Sure, I think you guys should have privileges to do it.
 
OP
D

donkoski

10+ Year Member
Feb 24, 2008
17
0
Status
"It was your comment about being overreliant on surgeons that made me think you were advocating doing it in all cases, even when a surgeon is available."

If you or any other surgeon is in-house and can assist, you better believe I'll be happy to call for help and to step aside and help you in any way I can to do the job.
 

2win

10+ Year Member
Apr 25, 2008
1,177
32
Status
Attending Physician
You bring up a very good point.

Wonder how residents could get adequate exposure to the training.

An ENT rotation, maybe?
First congrats for the new position! I read some of your posts and are great. Finnaly somebody is steping in the mess...ENT rotation is a must. I wonder how come was not introduced so far in the programs ( actually I know - better keep the res, in OR...).
glty
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
110
level at FL210
Status
First congrats for the new position! I read some of your posts and are great. Finnaly somebody is steping in the mess...ENT rotation is a must. I wonder how come was not introduced so far in the programs ( actually I know - better keep the res, in OR...).
glty
Uhhhh....Dude....put the CONBUD down....you're about to fall asleep.....you're gonna burn down your waterfront condo with that BIG BLUNT....:lol:
 

Magnus67

Lord of Sleepytime
10+ Year Member
Jan 29, 2006
167
12
Status
Fellow [Any Field]
Interesting posts, so as was mentioned above, how many resident/attendings here could throw in a chest tube in a pinch?, seems like it would be a handy skill similiar to the emergency/surgical airway. Do residents commonly get exposure to these procedures in residency? Even 20 years from residency it would prolly be better to say "hey i did a couple of these in residency" if you were in a tight spot.
 

2win

10+ Year Member
Apr 25, 2008
1,177
32
Status
Attending Physician
Good - I used again the hydroponic...Send me a private one to mail you same seeds..take care
 

proman

Member
Moderator Emeritus
15+ Year Member
Mar 5, 2002
1,858
11
Status
Attending Physician
What exactly is a 'quick trach'? I just attended a workshop where we learned the 4 step method of doing an emergency cricothyrotomy. It's quick and really all that we need to establish an airway. I have no intention of learning how to do a trach.
 

lfesiam

Regional Guy for Hire!
10+ Year Member
Feb 2, 2005
956
3
Status
Resident [Any Field]
Needle cric is a jet vent technique that you use to temporize while awaiting a more definitive airway, like a crich. In the situation I described, we have no surgeon available, just you and the OB.

As for the retrograde intubation mentioned, there are people who've used them and they'll readily admit that they're not easy and have a pretty high failure rate. In this case, you've got the sow and her little piglet to worry about, so I would be looking for something a little easier than this approach.
Donkoski, I agree with your views. As a prospective resident...I think surgical airways should be a part of the training!

boy...Percutaneous transtracheal jet ventilation is awesome though... eventhough not definitive. wonder if a machine or an adaptor can be invented for an automated prolonged PTJV hook up...

Large Bore angiocath thru the cricothyroid membrane. A private attending trained at UAB showed me once. It is similar to manually pumping a tire on high PPi. (50 lb per square inch!!!!!) Lots of finesse involve. You can easily pop a lobe.

:thumbup::thumbup::thumbup::thumbup:







 

surg

15+ Year Member
Dec 16, 2001
501
39
Visit site
Status
Attending Physician
I definitely think this should be part of the training, even if it is only to do something related in an elective setting. Things are never as scary if you at least know the anatomy. Few surgical residents ever do an emergency cricothyroidotomy any more since the number of failed intubations is not too high at most places. I've done at least 3 I remember. 2 in ICU's after a non-anesthesiologist/non-CRNA resident tried in intubate and failed in a hospital with no anesthesia back up, and 1 in an OR for a lost airway on induction for a neck case when the anesthesiologist induced and then found he was unable to intubate and then couldn't bag him up either. The first one was nerve-racking, since I did it on my own with no help other then an RT (unless you count the IM resident staring at me in horror as I saved the patient he had been trying to intubate for over an hour).

As a senior resident on our trauma service, I always tried to make sure that our anesthesia residents that rotated with us and our ED residents that rotated with us scrubbed at least one elective trach just to know the anatomy. I would take them through it. All through the case, we would discuss the techniques for emergency cric's/trach's. Uniformly, they all felt a lot better about what they might need to do someday if ever caught with their proverbial pants down. Not sure they can do it or can't, but at least they won't ever let someone die for lack of trying to get an airway in.

FYI: emergency cric is part of the Advanced Trauma Life Support (ATLS) course as is chest tubes, so maybe all anesthesia folks should have to do that course. It's only 2 days and is probably offered close by since virtually every surgery resident nationwide and many general surgeons that take trauma call takes it every 2 years or so. It should include an animal lab that includes both procedures (As well as saphenous cut down, central line practice, and the like).