Surgical Airways

[Willamette]

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If motivated to do so, are there usually any impediments to gas residents becoming adept at definitive emergency airway techniques?

(A serious question, but man...the way I worded it sure sounds nerdy...)

Willamette

 

[UTSouthwestern]

Emergency airways will likely be percutaneous crics, not true surgical tracheostomies. There are many courses offered for this type of experience on pig trachs and cadavers at the ASA, SAMBA, etc.

 

[cchoukal]

At U of Chicago, we spend a month on the ENT service, ostensibly to get experience with doing crichothyrotomies and tracheotomies. Not sure yet how many we'll actually get to do or whether it will be enough to feel like we could actually do them on our own if needed. This was the only program at which I interviewed that offered this in their curriculum, but I suspect there are others.

 

[UTSouthwestern]

At U of Chicago, we spend a month on the ENT service, ostensibly to get experience with doing crichothyrotomies and tracheotomies. Not sure yet how many we'll actually get to do or whether it will be enough to feel like we could actually do them on our own if needed. This was the only program at which I interviewed that offered this in their curriculum, but I suspect there are others.

You can get that experience especially at county hospitals like Parkland, but the utility of knowing how to do a formal trach is likely minimal. I've done 5 emergency cric's and two would be cric's that were by positional definition, trach's, and there was nothing pretty, controlled, or neat about them. You just pop a scalpel down through the anterior wall of the trachea and shove whatever you have available down it. Usually a 5 or 6.0 ETT unless you have a Melker cric kit.

 

[Tenesma]

surgical management of the airway can be learned at some anesthesia programs.... there are quite a few anesthesia departments, where the anesthesia team does bedside trachs throughout the hospital with percutaneous kits and bronchoscopy assistance (with surgery doing redo's, difficult patients (obese, short necks), etc... [In fact, there are several VA studies that show that the complication rate is the same] you can take ATLS and do emergency cric's.... there are great emergency cric kits that are pretty straightforward (heck, if ER dudes can do it - so can you)

becoming adept is another issue....if you talk to most ENT or Gen Surg residents they barely have done a handful of emergency crics by the time they graduate (and if they tell you otherwise then they are either lying or have a very, very dark cloud).... and whenever there is an airway disaster I always call for my surgical buddies to be on standby next to the patient (by airway disaster I mean: I show up, see a mess with a patient who looks like he/she will be a monster to intubate)

 

[Willamette]

You can get that experience especially at county hospitals like Parkland, but the utility of knowing how to do a formal trach is likely minimal. I've done 5 emergency cric's and two would be cric's that were by positional definition, trach's, and there was nothing pretty, controlled, or neat about them. You just pop a scalpel down through the anterior wall of the trachea and shove whatever you have available down it. Usually a 5 or 6.0 ETT unless you have a Melker cric kit.

Yeah, I don't imagine that it's too pretty. I was just trying to get a feel for if anesthesiologists were considered the "Masters of the Airway," even when you find yourself up the proverbial body of water without the proper means of locomotion.


Willamette

 

[Tenesma]

We are the masters of the non-surgical airway.... that is where the true expertise ends.... Trust me, when there is a BAD airway problem we want the surgeons next to us, and the surgeons want us next to them... There is no better airway team than an anesthesiologist and an ENT/Thoracic Surgeon.

 

[bell412]

Tenesma
Is there anywhere in the country dog labs are still being used for learning surgical airway?

 

[jwk]

We are the masters of the non-surgical airway.... that is where the true expertise ends....

Amen brother and hallelujah. Tell it like it is!

I have seen two emergent surgical airways in 25 years of anesthesia, one a cricothyrotomy with a Melker-type kit on a post-op thyroid that bled (done on the floor with anesthesia and a surgeon), and one a trach for a hematoma from an inadvertent placement of an introducer into the carotid (by the surgeon with anesthesia pointing to the severely shifted trachea.) The few I've seen come to the OR have been done by paramedics in the field who couldn't get an intubation after a couple tries and panicked. (They like to brag about how many they've done, and I like to brag that I haven't had to do any.) Sure, there will be the occasional trauma case where that's the only way to secure an airway, but those are few and far between.

Anesthesia does VERY FEW surgical airways because as Tenesma says, we are the masters of the non-surgical airway. We have so many tools available besides a straight ETT and laryngoscope. LMA's, fast track LMA's, FOB's, lightwands, GlideScopes, etc., etc. Get really really good with those since you can practice them on pretty much any patient on any day. Though you've got to know them, you'll rarely need the more invasive skills (crics, retrogrades, etc.) and those can be easily practiced on a decent mannequin.

We have an annual review and check-off for difficult airways for all our MD's and anesthetists. It includes a couple of different cric sets, retrogrades, combitubes, GlideScope, etc. So at least once a year, everyone gets a good review of everything that is kept in our difficult airway carts and how to use them.