Day 3 of GSA HEMS induction training was devoted to prehospital procedure training, in particular around airway management.
I have run courses on prehospital airway management, have a somewhat obsessive passion for emergency airway techniques including research interests like disposable video laryngoscopes, so I was very keen to see how this service conducts its airway training.
The challenges of teaching a bunch of new doctors from various medical tribes like anaesthesia, ICU and ED, all who have a different approach/attitude to airway management, are immense for an educator.
Throw in the mix that at the same training , you need to train airway skills to paramedics, lets say its not an easy task when you add it all up.
But in my observations, I think GSA HEMS have got the recipe for success!
It all begins with the unit ethos of airway management : “There are many ways to do the airway but this is the GSA HEMS way and we want you to do it this way”
The airway kit for prehospital care is kept simple and laid out in a standard way in a custom designed bag that protects the gear and makes it easy to setup for a prehospital RSI. Direct laryngoscopy with bougie is the preferred technique for all their intubations.
You can see the intubation gear is laid out and secured by elastic loop fasteners and there is a RSI checklist directly opposite the DL gear. This was interesting to observe the use of the RSI checklist in the training. They ritualised its use in their airway training and in particular the SCAT paramedics appeared to use it almost as a cognitive stop point or mental rally point during the scenarios I witnessed. Some of the doctors not used to checklists ( i.e most of them!) seemed to struggle with the concept and appear distracted even when the checklist was being done. However with repeated practice, it seemed the checklist was able to unify the paramedic and doctor doing the prehospital RSI into a short common goal of checking all the gear and being mentally ready to proceed.
I think the other thing I observed that makes the RSI checklist effective in prehospital airway training is the fact there is the unit ethos of everyone being able to intubate i.e paramedic or doctor. The checklist levels the intubator to a minimum standard of preparation regardless and since it is ritualised, this is accepted as the norm within the service.
Some folks might find this odd, the concept that it can be either the paramedic or doctor doing the airway and intubating but it makes perfect sense to me. Cross training is another hallmark of an elite unit, that each team member is able to provide backup skills for each other.
Key to all this, is that you keep your techniques simple and the gear options even simpler. There is no fancy McCoy levering blade nor a videolaryngoscope in the prehospital kit bag. RSI drug choices are also deliberately kept simple = ketamine or thiopentone + rocuronium or suxamethonium.
The prehospital intubation kit bag shown has other sections, like pages of a book that carry the Supraglottic airway of the service, the iGel. Also there is the surgical airway kit in a small pouch in another section. More on that later but once again, its kept deliberately simple.
One very important factor I forgot to mention earlier is how the senior retrieval consultant faculty develop and refine their airway training, equipment and strategy. In fact I think this is the most powerful element of the GSA HEMS recipe for success. Cliff at the beginning of the airway training gave a brief lecture on their approach as a service to prehospital airway management and he showed several videos. Whilst there were some impressive videos of actual surgical airways done by their doctors, what impressed me the most were multiple videos of cadaver /animal lab training sessions that the faculty had attended, usually overseas, to try to practice and gain greater insight into a better way of teaching and actually doing these advanced airway skills, like surgical airway.
This is a service that prides itself on constantly improving what they do. Their clinical leaders go out and test techniques and re-assess what they teach, not just by theory but by experimenting and questioning. Another example of this is RSI kit dump bag I mentioned earlier. Previously they used kit dump sheets like this
Karel Habig told me they found these sheets too flimsy and often would blow away in wind, did not keep gear together all that well. Hence they searched and thought of a better way, resulting the in the current kit dump bags .
Now they do carry other advanced airway kit in the interhospital transfer bag. They teach and use the King Vision Video laryngoscope as well as the Ambu Ascope flexible endoscope. Here is their quick summary reference card for advanced airway techniques
Now Cliff one day decided to record a live demonstration of how they use the awake intubation technique with the Ambu Ascope. Dont copy him please for fun! He did it and was not harmed but learn from his pain rather than try to do it on yourself!
To be honest I am not a big fan of VL as some might know but it does have a role. Certainly allowing a careful awake laryngoscopy can be very helpful. As for flexible endoscope technique, its rarely been described in the prehospital literature but anecdotally I know of at least one case from Adelaide where using a flexible bronchoscope during a retrieval for an airway clot was life saving. Its got a limited role and the skills to do it well are challenging to maintain but its handy to have in certain cases like tongue swelling, Ludwigs angina etc.
For me the absolute gold of the airway training day was the surgical airway section. The GSA HEMS faculty have travelled the world, researching the best ideas and techniques. They have arrived at their current technique of “scalpel-finger-bougie”
Previously they used techniques with instruments like a tracheal hook and dilator. In animal lab testing and from recorded experiences of service doctors, they realised this was far too complex approach. The strong focus of their surgical airway teaching now is to cut till find trachea/cricothyroid membrane ( they teach both horizontal and vertical incisions depending if anatomy is easily felt or not), incise into tracheal lumen, insert a finger ( little or index whichever fits), confirm tracheal rings, slightly withdraw finger, pass bougie alongside finger, reconfirm tracheal rings, then railroad ETT over bougie.
The finger is the key to the surgical airway.
Now Cliff referenced this paper from Adelaide on this prehospital surgical airway technique they teach
Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method.
The other thing to mention was the training models used to teach surgical airway. There was the usual improvised corrugated plastic tubing used to simulate the trachea but for the first time, I saw pork belly meat cuts being used to wrap the tubing to simulate the skin and neck tissues. This was quite clever I thought and I had not come across this model!
Now the stats say GSAHEMS provides approximately 280 RSIs per annum as a service. Thats fairly busy! They maintain a meticulous airway registry and audit all their RSI cases carefully. This is how they have improved things like the RSI kit.
I cant remember from the lecture but their intubation success rate is comparable with other similar services like London HEMS, with 98% + intubation success and a strong focus on 1st pass success.
I thoroughly enjoyed this airway training with GSA HEMS!