Mike and Matt of the awesome ULTRASOUNDPODCAST have released Volume 2 of their brilliant Introduction to Ultrasound iBook.

Whats in it? There is prehospital section by none other than Cliff Reid

There is section by Casey Parker of BROOMEDOCS and James Rippey of the ULTRASOUNDVILLAGE
on using ultrasound in the secondary trauma survey

Okay its not free but hey not everything in life is free. I highly recommend both volumes. I have used Volume 1 as a teaching aid whilst flying out to a prehospital patient with a colleague to help supervise him doing a nerve block and reducing a dislocation.

This excellent FOAMEd blogsite is the genius work of Dr Nicholas Chrimes, Dr Peter Fritz and Dr Anoushka Perera.
It has great stuff for anaesthesia and emergency doctors but really anyone interested in resuscitation and critical care will get valuable insights and information from this high quality free educational site. The authors are keen educators and it shows.

THis is the birth place of the VORTEX

There are always great insights into areas of emergency and elective anaesthesia, airway management and education.

Get Some Cred now!
Follow em on Facebook and Twitter too!

It has a ripping hard podcast with short and sweet interviews of rural doctors, retrieval professionals, anaesthetists, animals…ok maybe not animals.;-)

And the clinical practice and training resources are of the highest quality! look at the sections and whats in them! Anaesthesia, obstetrics, emergency …more good stuff under each menu.

So go to RURALDOCTORSNET, follow and enjoy.

Tim has a cracking sense of satire and clean family friendly humour ( NOT!)
Be educated but also be entertained.

This article is by no means an official endorsement of his jokes! and there are plenty of them!

Here is the link to the article
Long term mood response to repeat dose IMI ketamine

Here is the article link ( full text free!)
Prehospital intranasal S Ketamine analgesia case series

This adds to previous case reports like this one from Cliff Reid and colleagues
Case report: prehospital use of intranasal ketamine for paediatric burn injury

And a recent Victorian ED study of intranasal ketamine for paediatric limb injuries, reported here on ResusMe
Intranasal ketamine for kids – 1mg/kg?

Here is the article

“Use of rapid sequence intubation predicts improved survival among patients intubated after out of hospital cardiac arrest”

What was the objective of the authors ? : To examine the relationship between advanced airway management and survival in a prehospital care system with RSI capability. Their hypothesis was that those patients who required RSI for prehospital intubation would be more likely to survive than those intubated without RSI drugs because of an underlying better prognosis.

How did they do this ? : Retrospective cohort analysis of a single large metropolitan EMS system in Seattle, between 2007-2011 using cardiac arrest registry and a separate advanced airway registry.

What did they find ?:  Those who did not get intubated had the best survival rates (71% left hospital). Those who got intubated with prehospital RSI did next best (48% left hospital). Those who got intubated without RSI did worse ( 11% left hospital)

What on earth does this all mean? :

Why do you need RSI to intubate a clinically dead person you ask? Good question..well this paper found that sometimes..in fact not infrequently you DO need RSI drugs to intubate someone in cardiac arrest! Why? Well think about it…it all depends on how long a person is in cardiac arrest for. Its not like the heart suddenly stops flow and everything stops working right? The paper notes that in almost half of arrest victims, there is still agonal gasping  soon after collapse as a result of ongoing brainstem activity. And if you start CPR immediately and restore some flow to the brainstem, then its not inconceivable that airway reflexes can be maintained even in full cardiac arrest. And here is where this paper makes sense…immediate CPR, restored brain perfusion..these are all things that likely contribute to better outcomes in cardiac arrest. So paradoxically the need to use RSI drugs to intubate is an associated factor that predicts those who are going to do better.

Now why does anyone care about this at all….well there have been prior prehospital studies ( notably this one by Hasegawa et al) to suggest that intubation was making things worse for cardiac arrest patients..not better as we all thought for years!

This paper refutes that assertion, saying that its not the intubation itself that is causing the worse outcomes, its the fact that if you can intubated a dead person without RSI drugs, they are of course going to do badly regardless!

Limitations of study : No supraglottic airway use employed during study period. Self reported airway registry data. Not easily extrapolated to other prehospital/EMS systems who do not have RSI capability.

Australia is a big place…huge. Training doctors in rural and remote locations is tricky

Enter remote education..enter Remote Vocational Training Scheme..remote training of rural doctors using cutting edge technology and web based delivery.

Riding the FOAM!

http://www.onqconferences.com.au/rmec13/index.html

RMEC Website (http://www.onqconferences.com.au/rmec13/index.html)

http://www.facebook.com/RMEConference?fref=ts

Facebook (http://www.facebook.com/RMEConference?fref=ts)

https://twitter.com/RMEConference

Twitter (https://twitter.com/RMEConference)

Conference Powered By:

http://www.rvts.org.au/

NEXT REMOTE MEDICAL EDUCATION CONFERENCE 28-29TH JUNE 2013, SOFITEL, BRISBANE, QUEENSLAND!

REGISTRATIONS OPEN

PROGRAM AVAILABLE

SEE YOU THERE!

hi folks. Today’s podcast is taken from a G+ Hangout I did with Dr Yen Chow(Canada), Paramedics Matt Fults and JD Graziano (Iowa, US). Lets be honest the audio quality is not great! But it was a great discussion despite not being able to record it satisfactorily!

Folks, if you ever try to do this at home…use microphones!

What did we discuss?

1. Prehospital airway training for doctors vs paramedics..does your professional background make a difference?
2. How to stay current in emergency airway skills
3. EMS Standing orders blog and podcast
4. Yen’s vimeo channel and collaborative work with Jim Du Canto
5. We demonstrate how a short Youtube video of a difficult intubation can be used to teach simple but important technique points

Here is the video of the hangout. But be prepared for poor audio quality in parts!

Show note references:

1. EMSSTANDING ORDERS BLOG AND PODCAST
2. YEN CHOW VIMEO CHANNEL
3. AIRWAYNAUTICS VIMEO CHANNEL

Below is the difficult intubation video I play during the hangout 

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

SMACC 2013 Opening ceremony Directors Cut

Stay calm and use your scalpel

Hi folks! Meet Dr Keith Greenland, a senior consultant anaesthetist at Royal Brisbane and Women’s Hospital.

This is a great 23 minute lecture on dealing with the ” Cannot Intubate Cannot Oxygenate” situation. Well worth your study time!

The awesome welcome from Dr Oli Flower and Dr Roger Harris of the Intensive Care Network site

SMACC 2013 Opening ceremony

Hi folks, on this episode we study 3 intubation videos which involved failed first pass attempts. We study each in some detail to try to learn what we can to improve our intubation technique ( VL or DL) and tactics. Thankyou to Dr Larry Mellick from Georgia, USA for making the video and allowing it to be posted to YouTube by Jo Paul Valles.

FIRST WATCH THE ORIGINAL VIDEO HERE

NOW WATCH THE VIDEO WITH A VOICE OVER OF MYSELF COMMENTING ON KEY LEARNING POINTS

ETT loaded “d” grip bougie first intubation by direct laryngoscopy from Yen Chow on Vimeo.

Thanks Fayaz!

Frova Bougie in D Grip configuration

Frova Bougie released from D Grip

Dr James Du Canto ( Wisconsin, USA) and Dr Yen Chow ( Ontario, Canada) have been collaborating via FOAMEd ( Twitter and email and Google +) in the last 2-3 weeks on the concept of modifying the Kiwi and Pistol Grips.

What they have come up with is called the D Grip.

Jim was generous to donate his time to record a quick hangout to further elaborate on the modification. Please excuse some missing sound..I think you will get the idea. Along the way Jim discussed the mechanics behind his Paleo grip modification as well to holding the laryngoscope

Now Yen also recorded a demo video of the D Grip so here it is!

Try it out on a mannikin first. I think you will like it!

Advantages:

1. Single operator technique
2. Bougie already preloaded with ETT – faster, smoother
3. still retain advantage of using bougie tip to intubate trachea
4. no extra cost
5. works with VL and DL

Disadvantages:

1. May damage Murphy eye of ETT
2. ??

Here is what it looks like on the BomiMed Pocket Bougie

Pocket Bougie D grip configuration

Pocket Bougie released from D Grip

First we brought you Burr holes in the Bush, from master FOAMEd director , Dr Tim Leeuwenberg & Dt Mark Wilson.

Now from Twitter (@StephenHearns1)

,Dr Stephen Hearns giving the shout out to this awesome FOAMEd article

ENJOY AND BE AMAZED …

CHEWING GUM FOR EXTRADURAL HAEMORRHAGE

Stay calm and use your scalpel

[View the story "Permissive hypotension : a Twitter story" on Storify]

Hi folks

Got this in the email bag last week. Lets see if the PHARM community out there can help out our Peruvian colleague!

Name: Jose Portugal
Email: jportugal18@hotmail.com
Comment: Hi, my name is Jose, and I am a 2nd year emergency medicine resident in Lima Peru. I work at a III-1 level hospital (high complexity), located in a poor county in Lima. It is the only high complexity hospital in a 6 county area, with a total population of a little over 2 million people. We in the emergency department are trying to organize a system to allow us triage the patient before it arrives, so only the sickest patients arrive to our ED (as of right now we receive every single patient that crosses the hospital doors, for example minor cuts, contusion, a flu, mild dehydration). A you can see there is no filter, to direct this not so ill patients to other centers with the capacity to solve this patients problems. The problem we are having with this is, there is no communication whatsoever between the hospital, and the EMS service (the EMS service in Peru is provided by the fire department. Fire fighters in Peru are volunteers with different professions, with little or no knowledge on healthcare). So I was wondering if you could provide some inside on how your pre-hospital system is organized, if you could provide with any documents that could help us set this system we are trying to put in place (in the local area) how hospital manage patients brought in by EMS services, is there any form of registration. who handles the communication between the field EMS providers and the hospital. Anything that you could consider important for us to set this up please send it to me, I’m sure it will be of enormous help. Thank you so much, and keep up the good work with the blog.

Folks, they said it could not be done. Then Dr Yen Chow showed them it could be. And now JD Ggraziano and his paramedic buddies show you too..it can be done. And for those wondering..thats a MAC4 bladed laryngoscope JD is wielding in the video

What’s that? Endotracheal intubation with a great big Supraglottic airway in situ.

Thank these folks here!

Standing Orders Contributors: JD Graziano, BA, NREMT-P, FP-C Matt Fults, NREMT-P, CCEMT-P Brad Buck, NREMT-P, CCEMT-P

http://emsstandingorders.com

 http://roguemedic.emsstandingorders.com

Intubation over SGA in Situ (IOSIS or ISIS) simulation from Yen Chow on Vimeo.

Okay without further ado, results of the PHARM reader survey on blade choice in direct laryngoscopy. 68 of you responded. THANKYOU

ITS THE OVERWHELMING MAJORITY CHOICE OF PHARM READERS FOR INTUBATION WITH DIRECT LARYNGOSCOPY

MACINTOSH 4 BLADE – ACCEPT NO SUBSTITUTES!

Dr Alasdair Corfield (image from EMRS official website)

hi folks.

I interview Dr Alasdair Corfield, a consultant emergency physician and retrieval doctor with Emergency medical Retrieval Service of Scotland.

Him and his colleagues in Scotland, such as Dr Stephen Hearns, put on an annual Retrieval medicine conference.

I chat to him about the 2013 highlights and the promise of 2014 conference!

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

RURAL DOCTOR UPDATE – BURR HOLES IN THE BUSH from Tim Leeuwenburg on Vimeo.

hi folks.

I interview Dr John HInds, a consultant anaesthetist/ICU doctor, prehospital doctor and motorsports medico in Ireland. We had a fun chat on a couple of prehospital articles, anaesthesia and airway management.

Show note references:

1. Introduction of the i-gel supraglottic airway device for prehospital airway management in a UK ambulance service
2. Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients : a 10 yr retrospective study
3. Issues of critical airway management (Which anesthesia; Which surgical airway?)

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

Cliff Reid with my favourite talk of the conference: how to be a hero

Dr Brian Burns and need to carry a scalpel

Retrieval docs Cliff Reid and Brian Burns of Greater Sydney Area HEMS have a chat with me on pearls and tips in preparing the critical patient for retrieval/transport.

Show note references:

1. Interhospital patient assessment
2. Rural Doctors Net

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

Dr Darren Braude of New Mexico, USA once told me quite sagely : ” Minh, if you gave me all the time in the world, I could intubate just about anyone..the problem is that when you render someone apneic, the oxygenation starts to fall and you dont have all the time in the world.”

Now most of our readers would be familiar with the NODESAT strategy advocated by Dr Levitan, right?

I always find it strange talking to colleagues from anaesthesia or residents who are spending time in an anaesthesia rotation, and they tell me that anaesthetic doctors often respond with the suggestion of NODESAT for an emergency RSI with surprise, confusion and often disdain/scorn.

This is incredible as the concept of NODESAT or apneic oxygenation was first described by the anaesthetic community

And this latest 2013 paper in Otolaryngology – Head and Neck surgery journal describes apneic oxygenation once again!

USE OF APNEIC OXYGENATION FOR PERFORMANCE OF PAN-ENDOSCOPY

Tips from the article :

1. If you get a catheter down near the carina, within the trachea and deliver 0.5l/min oxygen flow , adequate apneic oxygenation can occur. Caveat is adequate denitrogenation prior to initiation of apneic oxygenation. Not so useful concept in EM/CCM but good to know this is not just a crazy idea dreamt up by EM/CCM doctors!
2. Extreme Obesity and pulmonary restrictive conditions may be unsuitable for apneic oxygenation
3. Maximum apnea time in this study was 45 min!
4. maximum ETCO2 level recorded was 89, so CO2 will rise with apnea time . Beware patients with elevated ICP!

Hi folks

IN an Australian ED pilot study, investigators used intranasal ketamine as analgesia for paediatric limb injuries

Here is a LINK TO THE STORY

Take home messages : 1mg/kg intranasal ketamine dose appears to be safe and effective for paediatric limb injury analgesia. Why is this any better than previously studied intranasal fentanyl? For now , its not better as its only a pilot study but it does add to evidence of benefit and safety . The only other case report in the literature is this by Dr Cliff Reid himself, with co-authors on a case of paediatric burn, in which 5mg/kg intranasal ketamine was used effectively.

CASE REPORT : Prehospital use of intranasal ketamine for paediatric burn injury

Hey folks?

Ever have a bad day at work? You know. When the waiting room is full all day & you miss your lunch break. When the ED beds are all gone and 12 ambulances outside waiting to off load more? When the ICU beds are all occupied and your urine output has been less than all of your patients’ ? Or when the OT lounge espresso machine is broken and your favourite sushi bar has run out of your special tofu rolls?

Lets face it many of us work and feel safe behind four walls and a roof. Walls are good. They protect us from the weather. This makes work a happier place.

But what if your work day was not only outside a hospital but somewhere , where the walls were falling apart or about to…where the roof was gone or going to fall right on top of you..and your patient?

Thats a bad day! And only getting worse…

And what if that day was not even a work day..but a holiday for you..you are not even supposed to be at work?

Imagine that day…well read on for the real case..

A conference of urologists. cue the unlikely heroine & prehospital surgeon..Dr Lydia Johns Putra, urologist.

off duty anaesthetist Dr Bryce Curran, at home when earthquake struck. Cue the second prehospital medical hero to the story.

Then the patient, Brian Corker, trapped by both legs from fallen masonry in a stairwell.

HERE IS THEIR STORY Pgs10-11.

Hi folks.
This happened a few years ago now. I dont know the details of the patient nor family. I cant even remember the day nor month anymore. Perhaps with the telling of the case, you will understand why I have little hard details in my memory.

I was at a major airport. On my way home after spending a week or so relieving at a remote RFDS base. It was mid afternoon, I think. It was certainly daytime. I had just come off one flight and was making my way to board my final flight home.

I was walking past some escalators when noticed a small group huddled at the base of one of them. I immediately recognised some were wearing firefighters uniforms. Some were kneeling

As I walked close past the group I could see what was happening.

There was an infant lying on the ground, actively convulsing with its head grossly extended, arcing its back. One of the firefighters had an portable oxygen cylinder out and a woman was holding the mask to the infant’s face which was pale blue. There was a man who must have been the infant’s father, crying and holding onto child’s legs. I walked up , introduced myself as a flying doctor and put my carryon bag down. I had no medical gear with me at all.
The woman with the oxygen mask told me she was a general practitioner who had found the father with the convulsing child at the bottom of the escalators. They called for help and the airport security called the firefighter first responders who came with oxygen gear and a portable automatic defibrillator. Ambulance were called and evidently were stuck in evening traffic.

“How long has the fitting lasted ?” I asked.
“About 30 minutes..” replied the female GP.

I felt helpless. No drugs, no airway gear, no monitoring. In fact I felt naked!
Then the female doctor passed me the oxygen mask and said ” I need to catch my flight, can you take over ?”
What was I going to say but “Yes of course”, but felt like saying ” So do I!”
Anyway this infant was about same age as one of my own at the time and I sympathised with the crying father. The history was that the 8 month old had been febrile a few hours prior and during the flight here, had become increasingly unwell with vomiting. Then she started fitting and had not stopped for 30 minutes now. This was no simple febrile seizure!
No obvious significant past medical history.

Off went the female GP. The wait for the ambulance was agonisingly slow. Believe it or not, a couple of other doctors stopped and asked what was going on. When I told them they both promptly said ” good luck” and left!

I asked the firefighters if there was any other emergency medical gear at the airport. NO! NOTHING! I did not have the presence of mind to ask if any of the onboard medical kits on the several airplanes parked outside could be brought!

I did my best to position her airway and keep it patent but in reality needed to know the priority was to stop the fitting.

Finally the ambulance crew arrived..a man and woman pushing a stretcher with gear !

I quickly told them the situation and asked if they had midazolam. We calculated a dose and I managed to get an IV in. After the first dose the fitting stopped, they loaded her onto stretcher and then asked ” Hey Doc, do you mind coming with us ? sure could use your help in the back of the ambulance , in case we get caught in traffic!”

What would you do?

Despite knowing I would miss my plane, I did not hesitate to say yes. The father was looking desperate, so were the paramedics who looked scared having never treated an 8month old with severe status epilepticus before. So I grabbed my bag, and got into the back of the ambulance.

As often happens in prehospital care, we lost the IV soon after setting off, lights and sirens . The patient started fitting again, so I ordered a second IMI dose of midazolam. This did nothing.
I tried to get another IV in but have you ever tried to do that in the back of a speeding ambulance?
We had some monitoring on at least and the pulse oximetry of 88% was not reassuring but better than 44%. I asked the paramedic if they had any airway gear and he told me they only had oral, nasal airways and LMAs. We inserted an oral airway and gave a third IMI dose of midazolam which seemed to stop the fitting. Now the infant was not breathing too well! Oh great!
The paramedic and I gave face mask ventilation and all of a sudden the doors opened and we were at an ED!

I was met by a paediatric EM consultant who basically grabbed the infant in her arms and ran back into the resus area. I quickly followed to give my handover.
They tubed the girl and you know what ? I still to this day do not know the outcome..if it was good or bad. Is she all grown up now and wants to be a doctor? Or is she disabled from hypoxic brain injury? Or is she dead ?

I walked back out to get my bag from the ambulance. The paramedics were cleaning up and I asked them for a ride back to airport. I still had 20 minutes to catch my flight!
You know what?
They refused, claiming service protocol to not provide free rides!
So I caught a taxi and guess what, never made it to my flight. I stayed in a hotel that night and got home the next day.

So you know what? THis case to me was the essence of prehospital care and why I do what I do.
If you have no gear, the wrong drugs, no bed, no monitoring, you dont give up. You use your mind, knowledge, your hands, all your senses. If there is no resus team, you form one. Think one step ahead. Keep trying to get the result that you know needs to happen.

because at the end of it all, everyone deserves the chance to make it home safe and sound.

Hi folks

A couple of useful articles on Twitter in last 24 hrs. Check em out. Good information on prehospital cervical spine care and issues on airway management

PREHOSPITAL CERVICAL SPINE IMMOBILIZATION AFTER TRAUMA MARCH 2013

SPINAL CORD INJURY AND DIRECT LARYNGOSCOPY – THE LEGEND LIVES ON

Thanks to @socalexmd ( Alex Sammel) and @STHJournalClub for those tweeted articles!

Also Mr EmCrit just posted a new podcast on his Practical Evidence blog on new ATLS guidelines on spinal cord injury.

Attributed to some joker on Twitter

[View the story "Cricoid Pressure - You decide" on Storify]

Whilst this twitter debate is mainly in light hearted humour, there is some controversy that is relevant to clinical practice.

My concern is that a lot of EM trainees go to anaesthesia rotations to learn basic safe airway techniques and RSI , and in the main as standard of care, cricoid pressure is taught there . Now there is a growing near majority of EM /CC providers who do not teach , use or advocate cricoid pressure at all as part of standard RSI. This causes confusion and silos of practice.

I have seen nurses become quite confused over this, with some wanting to apply cricoid pressure as that is traditional and then getting rebuked for doing so. I think it is important to have a general idea of what expert bodies, guidelines and our peers think on this. the recent PHARM survey on cricoid pressure revealed a narrow majority of respondents still advocated for application of cricoid pressure, with removal of it if any airway difficulty encountered. The main reason to do this cited was for medicolegal reasons as it is considered the standard of care. The Difficult Airway Society of UK recommends application of cricoid pressure in RSI. A recent personal communication from an Australian state commision on anaesthetic related morbidity/mortality reiterated the importance of cricoid pressure as part of RSI to reduce risk of fatal aspiration.

Here are useful resources to further explore the issue for readers.

Cricoid pressure for emergency department rapid sequence tracheal intubations : A risk/benefit analysis

Cricoid pressure : indications and complications

Cricoid pressure : are we doing it right?

The last reference on a clinical trial on training cricoid pressure technique is important in that it points to the issue in why past studies have found little good evidence of proven benefit of CP in reducing aspiration risk. The technique has been poorly taught and standardised in RSI training. You cannot say that one person’s application of cricoid pressure is the same across 100 providers. The force applied varies and so the issues arise with obstruction and poor airway views.

The best practice compromise for now is to train CP appropriately using recommended guidelines and technique, apply it for RSI as standard and remove it as needed. Alternatively ( and this is my own approach currently) is to select its use for high risk aspiration cases e.g trauma cases, UGIB, bowel obstruction, acute abdomens, late pregnancy

Missed SMACC 2013 and kicking yourself?

Well from the makers of SMACC 2013 and Bedside Critical Care series, comes Bedside Critical care 2013 in my hometown of Cairns!

BEDSIDE CRITICAL CARE 2013

It will be just as awesome! I am sure @TheTopEnd will be there doing his JellyBean podcast series of interviews. I am turning up. Many of the ICN and SMACC committee will be there I am sure, like Oli Flower, Roger Harris, McPartlin.

Book your leave and get ready to register!

Amit holding McGrath VL, Andy does not need one!

Hi folks

Exciting new trauma course created by two great blokes Amit Maini and Andy Buck, both emergency physicians based in Melbourne.

You had enough of EMST/ATLS, right? Does it seem all the same every time? Seen the same trauma lectures every time?

Well the EMERGENCY TRAUMA COURSE will be fresh, innovative and educationally novel. Its designed by emergency physicians for emergency physicians.

Course Description (quoted from their website)

Survey results : Would you let the junior registrar/resident intubate the critical paediatric trauma patient?

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

Nice article by an upcoming blogger, Dr Brent Thoma. Keep an eye out for him..he is going places

Recently a twitter discussion on Rapid sequence airway and ketamine sparked an email conversation between myself, Dr Nicholas Chrimes and Dr Reuben Strayer. With their permission and my thanks to them, I will detail what we discussed by reproduction of the email content.

Reuben:

Nic I don’t totally understand your concern here. Ketamine is used constantly in dissociative doses on non-fasted (not that that matters) patients for procedures of widely variable lengths. There are no reports of clinically significant aspiration that I am aware of. I’m sure it has happened, but it is certainly exceedingly rare, and I’m confused as to why you would be concerned about it during DSI. During a 4-hour operation without an anesthesiologist, that would be a concern, but they do that all the time with ketamine monotherapy in resource-poor environments. But for 10 minutes of DSI?

I have a hard time following twitter conversations so maybe I’m missing something?

Dr Levitan delivering a lecture at RFDS Airway skills workshop 2009

Dr Richard Levitan has been running a world famous cadaver airway skills course in Philadelphia for years. Its called the Practical Emergency Airway management course. Here is what my mate, Dr Cliff Reid has to recommend about Dr Levitan’s teachings/resources on emergency airway management

With the support of the awesome Dr John Vassiliadis (@johnrachelv) and the Sydney Clinical Skills and Simulation centre

this premier airway skills training course is coming to Australia for the first time ever.

Please give it lots of support either by enrolling or spreading the word to colleagues. Its a unique experience in airway education using specially prepared cadavers to practice multiple airway techniques, combined with Dr Levitan’s encyclopaedic knowledge, experience and research into the area of emergency airway management.

HERE IS 2013 COURSE FLYER

Share it via your networks. Support this course so it can become a regular event for our colleagues and trainees to enjoy and learn. Previously we would have to travel to USA to undertake this course. Brilliant work by John Vassiliadis to make this happen, thanks!

There are more courses scheduled for January 2014 so spread the word, book early. Get your name on the wait list! You do not want to miss this!

(I have no financial relationships with the Sydney Clinical Skills and Simulation centre, Dr Vassiliadis nor Dr Levitan)

Scott Weingart gave a talk on Essence of Critical care : Upstairs care, Anywhere. Dont give up , he said.

So here is a quick 6 minute podcast on two personal pieces of writing on airway management. I meant them to be somewhat tongue in cheek but also to point towards improving our attitudes towards resuscitation tasks. A commitment to physical and mental preparation for critical tasks.

Show note references:

1. Intubator’s creed
2. RSI safety briefing

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

Karel explains need in prehospital medicine to be flexible

There is an old saying in anaesthetics : “In the predicted difficult airway, get the most experienced intubator to perform the procedure”

An eternal dilemma for clinical supervisors and educators, consultants/attendings in charge of junior doctors and trainees, is how to provide adequate training for management of the difficult airway ( predicted or unexpected).

Does simulation training prepare staff adequately? What role is there for allowing supervised practice on real patients expected to be a difficult airway?

To answer these questions, let us examine what is the current paradigm for training competency for the difficult airway : how does an emergency consultant, anaesthetist or intensivist achieve a base line competency in managing the predicted difficult airway?

Well, believe it or not there is no agreed standard curriculum. Each college in each country in each discipline has their own curriculum for managing the difficult airway. How is baseline competency assessed? Some espouse logbooks to track number of intubations, rapid sequence inductions etc. Some curricula recommend minimum supervised training terms of , say 6 months of elective anaesthesia etc. North American EM curricula recommend some anaesthesia terms but minimum time periods may be as low as 1 month.

But this is not really addressing the issue specifically. Just because you spend elective anaesthesia time in supervised teaching does not necessarily mean you will undertake difficult airway cases, predicted or not. In all likelihood the junior trainee will not be given exposure to manage a predicted difficult airway case in the OT/OR.

So what is the current paradigm? Basically, time and experience will hopefully allow the consultant/attending to gain enough practice in managing difficult airway cases. Problem is that we know that many may never gain experience in an actual emergency surgical airway for example, in their entire careers. How do we know that a newly graduated consultant /attending in EM, ICU or anaesthesia, is able to adequately manage a difficult airway? The frank answer , is that we do not know for sure!

Why not? Because we cannot adequately test it in the real world. How do we know the new anaesthetic consultant will be able to perform an emergency surgical airway if they have never done one? How do we know if the new EM consultant can perform an awake orotracheal intubation if that is needed, despite never having done one? The ICU consultant who has never done a paediatric RSI in training, how can they be sure that their adult based training can be used successfully in a predicted paediatric difficult airway like epiglottitis for example?

Now to be practical we make assumptions that base specialist training should deliver baseline competency for all curriculum requirements. Thats an assumption and extrapolation of many factors. For example, 6 months of anaesthesia term, will provide adequate practice and exposure for gaining competency in emergency airway management including surgical airway techniques. Big assumption.

Which returns us to the original dilemma. If a supervising consultant/attending has little or no real experience of difficult airway cases, how are they able to supervise and teach juniors/trainees and feel confident to allow their junior staff to practise on real cases?

And really is it ethical to allow an inexperienced provider to practice managing a clearly difficult airway case, even under supervision by someone who themselves have little or no experience of managing that difficult airway situation?

Lets try to use a hypothetical case to illustrate the issue better.

You are in the emergency department as a new consultant. its your first shift and a new rotation of junior residents/trainees. They dont know you and you dont know them. The ambulance brings in a road accident victim, a 4 yo child who has been run over. He has multiple injuries to head,chest, pelvis and limbs. He has obvious facial and mandible fractures with epistaxis and oral bleeding. Combative and crying, he is hypoxic and tachypnoeic.

The junior registrar who is allocated to the Airway role in the trauma resuscitation protocol, starts getting airway equipment ready. She asks your advice. What would you do? Allow her to continue setting up for airway management or suggest that yourself take over for this case?

Lets for arguments sake, say that the junior registrar has done 6 months of anaesthetics.

Who would allow her to proceed and manage a predicted difficult airway?

Intensive Care Medicine journal , online early access articles March 2013

Predicting non invasive ventilation failure in children from the SpO2/FiO2 ratio

Brief summary and comments:

- Spanish and Portuguese paediatric ICU study, 390 episodes over 12 months.
- goal was to validate use of SpO2/FiO2 ratio as NIV outcome predictor & develop a NIV failure prediction model.
-NIV was defined as CPAP, BiPAP, via face mask, nasal devices with initial settings EPAP( expiratory positive airway pressure ) 5cm H2O, IPAP(inspiratory pressure) 6-8cm, FiO2 variable but target SpO2 93-98%.
-Interesting point in that sedation was used as deemed necessary and in fact was given in 49.2% of cases. Midazolam was the sedation most often given. Why not ketamine? The authors do not comment on that but write that it was deemed non of the NIV failures were due to sedation. AS far as I can tell this was a clinician’s opinion alone.
- Most common indication for NIV was bronchiolitis
- NIV was successful in about 80% of cases
-NIV failure was defined as clinician’s opinion , SpO2 65mmHg , with maximal NIV settings of IPAP >25cm, EPAP>12cm
- What did they find ? Sp02/FiO2 ratio ( SF ratio) at 1 hr after NIV initiation was predictive of failure. The authors suggest the SF cutoff value of 193 at 1 hr of NIV.

HOW DO YOU CALCULATE THE SF RATIO?
SPO2 % VALUE / FIO2 DECIMAL = SF RATIO

EXAMPLE : SpO2 88% / FiO2 0.6 = 146

MY TAKE HOME MESSAGE FROM THIS STUDY :
SF ratio is simple to calculate when using NIV on a child. At 1 hr mark this study gives SOME validity into using SF ratio to highlight children who will likely fail NIV. Useful potentially in the prehospital and retrieval setting. Arterial blood gases are not fun in anyone , especially children. VBGs can give you the indicator of PCO2 and pH but they do not always correlate with NIV success or failure dependinng on when they are done in relation to NIV initiation. NIV was 80% successful in this study so its a useful modality in sick kids with acute respiratory failure. Identifying those who will be in the 20% who fail NIV early is potentially helpful information!
Nice work from our Spanish and Portuguese colleagues! Still not sure why they did not try ketamine sedation for the NIV..

PREHOSPITAL CHARCOAL : THE WAY FORWARD

THE INDICATIONS FOR SINGLE DOSE ACTIVATED CHARCOAL ADMIN IN ACUTE OVERDOSE