One comment from Dr Tim Leeuwenburg of KIDOCS:
Some good points Minh. Personal experience of 6/12 anaes rotation a decade ago when doing EM training, was that the exposure was lead by anaesthetists – who whilst expert did not appreciate the needs of an EM trainee. Approach to the difficult airway (then) invariably involved an AFOI. Going back to do a year of anaesthetic upskilling more recently, under the auspices of the JCCA in Oz in order to work as a rural GP-anaesthetist, I still struggled to get exposure to the necessary skill set from many anaesthetists – indeed, the only ones who ‘got’ what the needs of an isolated rural practitioner were likely to be were those who practiced retrieval medicine.
This was in 2011…and ideas like apnoeic diffusion oxygenation, RSI checklists, sux vs roc and approaches to the surgical airway, let alone iLMAs were just off the radar of the majority of FANZCAs.Speaking to FACEMs recently, they bemoan difficulty of accessing airway training for their registrars – all too often an EM trainee comes back from 6/12 of anaesthesia having mostly done elective ASA I/IIs on LMAs…plus ca change since my experience a decade ago!
We agree that the emergency airway is a very different beast. Is there scope to allow EM/ICU colleges to train in this arena? i think so. And I think core competencies need to be defined and tested. Bottomline, I think that with DAS algorithms / Vortex and the emergence of affordable, robust equipment, then we can see a fairly standardised, teachable and assessable means of approaching the emergency airway, overlaid with not just sim but translation into the resus room, incorporating team work and checklists.
Essentially a coming together of tall the airway FOAMed stuff we’ve been banging on about for past 2 years.My thoughts on this are distilled in the ‘difficult airway kit for remote/austere’ talk – basically a toolkit for intubation out of the elective OT environment…which is entirely built upon DuCanto and your work.http://kidocs.org/wp-content/uploads/2013/03/smacc2013-7-00-leeuwenburg.ppthttp://kidocs.org/wp-content/uploads/2012/09/plans-a-b-c-d-summary-ki-hospital.pdfWe need to train Docs to this sort of approach, wherever they will practice intubation – roadside, ED, ICU, rural etc
My take home message on this :
There is a balance between patient safety and training the next generation of emergency airway providers. The public expect us to not experiment on them callously or casually but are prepared to accept that training junior staff is necessary and this involves supervised practice, even in critical situations. This is one of the greatest challenges of teaching, especially in emergency airway management. This is how surgeons learn to do the life saving stuff, having an experienced mentor assist them in critical cases after they have assisted their mentors in countless similar cases. At some point that is yet poorly understood or defined, the junior provider becomes the expert . Clearly the results of the survey indicate most PHARM readers/listeners do not think a junior resident should be given opportunity to perform a likely difficult intubation on a paediatric trauma case. But some do think it is acceptable and perhaps even necessary to allow exposure of junior staff to the difficult cases.
Personally I think it should not fall onto one individual. It must be a team approach to the emergency airway and if this is done and organised properly with clear roles, a well rehearsed drill of difficult airway techniques and good experienced backup within the team, regardless of professional title, then theoretically any team member should be able to perform the intubation knowing that they have a great team backup if things go badly. When on retrieval I often offer the intubation to the rural doctor to perform with myself as backup, even if it is a potentially difficult case. To me this allows them to gain confidence in managing emergency airways in a supervised manner with backup at hand. I have done this for paramedics and nurses, to allow them opportunities to do face mask ventilation, place LMAs or perform intubation. If a remote patient needs airway management, I want the remote providers there to be confident in doing this, before any help arrives. Not everyone agrees with this approach as many regard letting novices practice on emergency cases is not reasonable as it may breach patient safety standards. My own view is that it is better to train as many providers as possible in safe and reliable techniques as we cannot rely upon individual skills to provide airway management. The more we train as a team approach using strategies like VORTEX the better the standard of airway care will be. It focusses on not relying upon one technique. Think about how we all learnt to manage difficult airway cases. It was mainly a process of trial and error with guidance and supervision along the way. After so many years of training, most of us assumed the title of Senior resident/registrar and so were promoted to managing difficult cases. How did we know we were ready? Well to be honest we did not. Would it have been better to have had greater exposure to difficult cases as a junior trainee with good supervision, rather than waiting for this to happen later on ?
Now I am not saying just open slather for all junior trainees to practice on all the difficult cases ! What I am proposing is an agreed team approach with well rehearsed drills and equipment training prior to any real cases and a standard strategy that the whole team adheres to. There must be an agreed drill as to when changing airway providers is necessary to allow progression of a difficult airway strategy. 3 best attempts of ETI, LMA and FMV, no matter how you decide or perform those 3 best attempts.
This is a paradigm shift for us in airway teaching and management. Focus on team approach, not the individual.
Love to hear your thoughts and comments!
Minh
Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds 
You have nailed it.
Goes back to the old mantra – emergency airway management is not just preserve of the anaesthetist – it includes ED, ICU, prehospital, rural, paramedic etc.
The good anaesthetists recognise this and encourage training. The silo mentality (if difficult – call anaes or if difficult do AFOI etc) ignores reality of where emergency airway management happens
So – a team approach (checklists, kit dump, Vortex and other algorithms help) – plan for 3am, junior EM reg, agency staff.
If your plan is robust enough to survive this, it will survive battle…
My flatmate has just started in ED and is absolutely terrified of anybody even remotely crook; I told her that cognitive decision making is far more important than the psychomotor skill of actually doing. Now lets be fair, you have to have some competence of actually performing what you decide to do, however, laryngoscopy and intubation are not difficult skills to learn (I argue it is only mildly more difficult than learning to competently put a drip in somebody)
While you will always that sneaky bugger who o/e appears the perfect tube and ends up an unexpected difficult airway, with the plethora of resources and fancy gadgets, (and checklists, checklists, checklists!) I have no reason to doubt that the Junior Registrar could safely tube the sick, crashing child.
What if he works at an ED where the Consultant FACEM and Anaesthetist are on call, it’s 1 am, and the roads are covered in snow? … winter is coming you know.
I think the key point here is ‘junior’ registrar. This implies inexperience and the critical paediatric trauma is probably not the best place to cut your teeth on airway management. If the term ‘junior’ was left out, I dare say you would get a lot more yes votes for te reasons Tim has outlined so well.
thanks David. this is the current cultural paradigm we work in now. the focus on individual skill.
but what defines junior vs senior vs competent vs expert vs safe provider?
is it number of intubations? years of experience?
you might easily have a senior registrar or junior consultant/attending who has never been exposed to a critical paediatric trauma case needing intubation..so are they any better qualified ? maybe..maybe not!
the cases of Gordon Ewing, Elaine Bromiley…these involved senior anaesthetic specialist doctors, not solo but in groups…and these were elective cases where there was option of not proceeding with further anaesthesia.
the paradox here is that years of experience does not always lead to expected crisis management.
the notion in emergency medicine that we keep patients safe by having experienced individuals needs to be challenged esp in field of critical airway management
Old adage
junior reg asks the senior doctor “How do you avoid mistakes?”
“Why, by gaining experience” says the senior doctor.
“How then do I get experience?” Asks the young padawan…
“By making mistakes!” laughs the master.
Is that good enough? No, not really. And Minh’s point about junior also translating to newly qualified specialists is well made – we all have anecdotes of this – how the senior reg needs supervision one wek but returns as ‘the boss’ a week later.
Some have criticsed recent changes in the UK for decreasing doctors hours and exposure to clinical medicine in training – new consultants might qualify with several thousand less hours of trainng than their predecessors. Now trainees are toicked off on “competencies” … But which may not translate into decision-making (eg they can pass the plastic on a mannikin, but not manage a dynamic airway in a resus)
I think way forward is team training and more use of cognitive aids such as Vortex…and training across silos.
Perhaps its time for ACEM to take control of teaching airway management to their trainees…rather than let the FANZCAs do it…6/12 of elective LMA and propofol-jockeying doesnt really address thier needs (I acknowledge that not all anaes placements are like this and that excellent trainers and trainees will rise far above this standard).