Prehospital and Retrieval Medicine – THE PHARM dedicated to the memory of Dr John Hinds

This was written in response to a question by a United States Paramedic on how to construct the SALAD recirculation system without utilizing an electric drill pump. I’m sharing it now with the remarkable innovators across the globe who have shared interest in the simulation method in the past.
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Thanks for asking, and thanks for your greeting and encouragement.
Here it is—you gave me the ‘push’ I needed to finally write this down and share it.
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I THINK that the tubing used to join the pump system to the head is 1/2 inch internal diameter tubing to connect the pump to the mannequin. I’m a bit of a tinker-er, so I change it up on occasion. You’ll need to fit this tubing to a part that is around 22 mm diameter to allow a zip tie to secure to the mannequin’s esophagus. You’ll want to plug the mainstream bronchi on the mannequin, or you’ll lose excessive amounts of the simulated airway contaminant (although I have a way to to attach lungs for BLS SALAD stimulation).
I just made a ‘fresh’ SALAD lecture that is heavy on literature, and what I have found is that in essence, this technique is a missing link from the original description of RSI by Stept and Safari in 1970. Safar and Elam created “CPR” in 1960 by bundling mouth-to-mouth rescue breathing and sternal chest compressions and they are the ones who worked with Asmund Laerdal to create the Resusci-Anne in order to teach the technique.
Stept and Safar bundled 15 distinct steps in this description of the technique, which were taught to the Anesthesiology Resident trainees that he oversaw as chairman of the department of Anesthesia at the University of Pennsylvania in Pittsburgh. They created this to give their residents the knowledge and skill to practice safely. The biggest modern ‘controversy’ of this article was that Stept and Safar mandated the administration of d-tubocurare several minutes before the succinylcholine, as the literature in the 1960’s all but proved that succinylcholine without defasciculation dose of d-tubocurare CAUSED regurgitation—due to the fasciculation. And by golly I have actually SEEN this happen when I was an intern. You can substitute 1 ml rocuronium (10 mg) for the d-tubocurare BTW, but better yet, just use an appropriate dose—of rocuronium.
What I discovered as a consequence of creating the SALAD simulation and ‘deep diving’ the topic of the management of the contaminated airway was that there was not a stepwise, progressive and comprehensive plan to manage the airway contaminant, other than a vague description of repositioning the patient head-down to allow the airway contaminant to drain out of the mouth and away from the larynx.
The Hi-D large bore suction catheter was created circa 1987 by the founder of the SSCOR, Inc. Corporation , followed by the “Big Yank” in the 1990’s. The medical marketplace had the physical solution to the problem, but did not possess a unified approach to utilize them effectively. It was by ‘cooperative play’ with EMS professionals and Emergency Medicine professionals that the techniques were created. We developed permutations on how to manage the contaminated airway, and—this is important—this simulation can help you bring many of your disparate airway management skills together, in very short order, as the separate skills we practice need to come together when the ‘heat is on’.
Richard Pilbery has authored a wikipedia page on SALAD with my assistance, view it here https://en.wikipedia.org/wiki/Suction_Assisted_Laryngoscopy_Airway_Decontamination
Richard is a UK paramedic who authored the SATIATED Trial—a study of SALAD in simulation with the Yorkshire Ambulance Service (British Paramedic Journal, 2018) [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706768/}
We now have 2 case reports in the peer-reviewed literature on SALAD, one from Korea (from an Anesthesiologist) and one from the Midwestern United States (from an Emergency Physician). What this technique needs is a larger collection of case reports, especially from EMS.
Thanks,
JIm DuCanto, M.D.

Below is the pdf with instructions to make the system:

recirculating-salad-simulation-system.pdf