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Airway Confidential

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Here is an intubation we prepared earlier

Sometimes when you are flying around the Australian Outback, you have a moment of reflection. You look back on the past, consider the present and dream of the future. I talk a lot about emergency airway management, both here and via Twitter. Why?

I have met and communicated with many colleagues and people in my quest to improve how we understand, train and provide airway management. My journey has been both humbling, inspiring and yet saddening. It is as much a self discovery of my own biases, arrogance and weaknesses as it is an epiphany to the whole approach of medicine/health care towards a singular issue and the culture around it.

Scott Weingart of EMCRIT  talks of the “Laryngoscope as a Murder Weapon” concept right from his earliest podcasts. I dont want to be a murderer, nor should you. One of the most sobering , humbling podcasts I ever did on the PHARM was with Martin Bromiley, a man who has a tragic story that always chills me.  He wants doctors, nurses, health care professionals, to be better. I want us to be better. So here are my thoughts on how we can be better.

We all need to own the airway. Currently our approach to airway care is siloed and divisive. The culture pits rival camps against each other in an idiotic competitive style. Anaesthesia claim expertise in all but the surgical airway. Emergency medicine have their way but lack the skills of awake intubation like anaesthesia does. No one really claims expertise in surgical airway apart from surgeons especially ENT. Non physicians feel marginalised in terms of airway training and expertise credentials and it gets political in terms of being allowed to manage emergency airways depending on technique! Everyone argues safety reasons for their own opinions about the best way to manage airways when we have lost sight of the fact that the safest strategy would be to have everyone trained to a high standard to manage all aspects of the emergency airway! Politics should not restrict us in gaining the best skills to manage the airway. We all can and should learn from each other so there is a comprehensive curriculum and training for anyone who needs to manage the airway. Why do we always have to reinvent the wheel when it comes to teaching airway? Its not like the larynx was discovered recently! Why cant there be a United Nations of Airway where we all can agree as to best approach and protect current and future patients by adopting an international standard and policy?

Its not acceptable that we have divided airway management into pockets of responsibility. We either own the airway entirely or we dont! The idea that you need to wait for someone else to come and do an emergency surgical airway, whilst seemingly practical is hardly that! The common arguement against universal airway skills is time and money. I find that deplorable! If it takes time, then start early in training! If it takes money then rethink how current funding is designed for airway training and equipment. We should spend less on airway technology and more on better training, earlier!

Technology is no panacea in airway management so we should stop hoping and believing it is! There is too much torturing of the airway with more devices and special gear being taught as essential and making things safer. I reject all of that. Airway management should be simple to do and simple to learn. Your best airway device is the one between your ears!

And let us be honest about airway skills and training. It is not a finite pursuit. It is in fact an infinite pursuit of mastery. Once you begin you can never say you have reached the end of perfecting the skill. It is frustrating to talk to anaesthesia colleagues who argue that since the risk of the need to do a surgical airway is so low in an entire career that they only superficially pay respect to the skill to perform one. Equally it is frustrating to talk to EM colleagues who disregard the need to learn awake intubation techniques or consider needle based surgical airway techniques as being unlikely to ever require them. We will never ever know the day, the hour , the moment when we will need those very skills. Those skills that the patient requires of us. Those skills that are our duty to know and provide if we assume the role of being a professional who can manage emergency airways.

Former head of Australian Army, General David Morrison once famously said : “The standard you walk past is the standard you accept” . We should not accept the current standard in airway training and the culture of it. We should not be divided as health care providers. The nurse I work with should be able to take over from me, if I am doing an emergency RSI or surgical airway. There should be no distinction in roles. The only distinctions are artificial, political constructs. Its clear to me via Twitter and direct personal contact over the years with professionals from around the globe , that emergency airway management is confidently and competently provided by many non physician providers. There should be no discrimination in this area. We can do better. We are better than this.

I call it the arrogance of the current airway culture. Its arrogant airway management. To say, you can only do it this way, or as one EM doctor claimed a few years ago ” If you dont use VL  then you are providing unsafe care” . The skill and art of airway  engenders this arrogance but it need not. The larynx does not discriminate. It doesnt care if you are a nurse, paramedic, PA, RT, anaesthesia trained, EM trained, vet trained. It is the larynx. It should be respected and we do this by not half learning things or cherry picking our skills and training. So debates abour sux vs roc, VL vs DL, scalpel bougie vs needle cric,cricoid vs no cricoid :these are all manifestations of airway arrogance. I confess I often enthusiastically argued in such debates! I have though come to the realisation that this self indulgence was exactly that : an indulgence and an unhelpful one at that! I resolve to stop this!

Our fear is what drives us in airway care. Fear of failure, fear of not doing whats expected by other folks who lived in the same fear all their careers. Being reckless and being unafraid may appear to be the same thing but they are not. The former is easy to be, the latter is a life journey often. We are not born naturally to fear. That is learnt and taught, which means it can be unlearnt and untaught. I was once afraid of the airway and my journey to cope with this as a physician lead me to the feet of one true master of our time in emergency airway management, Dr Richard Levitan. A physician who has encompassed all aspects of emergency airway care and provides teaching and a path to providing airway care without fear. It is no surprise to me and many others passionate about improving airway care that Dr Levitan has explored the areas of psychology, cognition and stress induced performance. As the famous saying goes ” it is not enough to know, one must apply”

Here he is at SMACCGOLD, explaining his philosophy about emergency airway

FOAMEd has allowed a much greater sharing of airway skills and knowledge than ever before in human history. True innovation has been demonstrated in such projects like Dr Jim Ducanto’s SALAD teachings and Dr Nicholas Chrimes/Dr Peter Fritz’s VORTEX APPROACH concept.

DuCanto MSSM SALAD Instruction Movie from reuben strayer on Vimeo.

FOAMEd airway education should be strongly encouraged and promoted

10 years on from Elaine Bromiley’s death in an operating room in England, I’d like to think such tragedies are less likely to occur and the world of airway care is a safer place. I really want to believe that. But I dont.
If you are reading this, do you believe it?
If you dont then ask yourself why not?

In the greater scheme of medicine and life, you can argue that airway care is only one aspect of health. But to end where I began, I do not want to be a murderer with a laryngoscope, either due to arrogance or apathy or both.

4 Comments Post a comment
  1. Agree with all the above mate. Similar journey, similar fears (ever since being involved in a CICO crisis over 10yrs ago as an EM teainee on anaes rotation!).

    Whilst the arguments are often fought out on SoMe (hey, you forgot pro/con checklist debate!) there is a danger of arrogance or ‘my way or highway’

    So…where are we now? I like to think SoMe and FOAMed has helped smash siloism and allow ALL those involved in airway management to reflect, to seek mastery and ensure they are ‘expert enough’

    We’ve come a long way….but there’s more to be done. System safety, #EZdrugID, meticulous training across craft groups, open disclosure and so much more work to be done…

    http://onlinelibrary.wiley.com/doi/10.1111/anae.13665/epdf

    October 8, 2016
    • Checklists suck

      October 8, 2016
      • …I could rise to the taunt, but it’s a lovely day outside and the kangaroos are bouncing

        Suffice it to say most high reliability organisations use checklists for tightly-coupled procedures such as RSI outside of OT. Most tertiary EDs, Hell, even some rural….and the prehospital mob such as London HEMS, Sydney HEMs, Careflight…even the RFDS….

        Anyhow, off to bounce the kangaroo…

        October 8, 2016
      • Oh Kangaroo

        October 8, 2016

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