Difficult Airway? What Kind Exactly?

crazed-nutter-sm
Mention the term ‘difficult airway’ and many of us will conjure mental images of some kind of distorted anatomy. However, airway management may be ‘difficult’ for a number of reasons, and no internationally agreed definition of the term exists. Given the wrong staff and circumstances, an ‘easy’ airway in your or my hands may indeed become very difficult. In their editorial “The myth of the difficult airway: airway management revisited” (1) Huitink & Bouwman state:

“In our opinion, the ‘difficult airway’ does not exist. It is a complex situational interplay of patient, practitioner, equipment, expertise and circumstances.”

Airways that are anatomically difficult (eg. limited mouth opening, short thyromental distance, large tongue, neck immobility, etc.) and physiologically difficult (hypoxaemia, hypotension, acidosis) are well described among FOAM resources (2-4). In addition to these, a third category of difficulty is well worth considering.

At the smaccDUB conference, intensivist and human factors legend Peter Brindley described three types of difficult airway:

  1. Anatomically difficult
  2. Physiologically difficult
  3. Situationally difficult
    brindleysm
    Brindley = Legend

This last category probably surfaces more commonly than realised, particularly outside the operating room.

Imagine attending a cardiac arrest call on a medical ward. The patient is a 70 year old 120 kg male. The nurses have flattened the bed and discarded the pillow to optimise supine position for CPR. Gobs of vomitus splash from the patient’s pharynx with each compression. The wall suction system is disconnected. There is no bougie in the crash cart’s airway drawer. The nearest capnograph is on another floor of the hospital. In this scenario, no matter how excellent the critical care practitioner’s airway skills, this is a damned difficult airway.

I think Brindley’s third category is a term that should catch on, as a way of helping analyse cases that progress suboptimally and to identify factors during pre-intubation checks that can be addressed. It is terminology that I have added to my own Resuscitese Lexicon, particularly for case discussions during morbidity & mortality and airway audit meetings.

I would like to hear the ‘Situationally Difficult Airway‘ become more widely used, as it fills a gap in how we describe this important area of resuscitation practice.

 

 

1. Huitink JM, Bouwman RA. The myth of the difficult airway: airway management revisited. Anaesthesia. 2015 Mar;70(3):244–9. (Full text)

2. LITFL: Airway Assessment

3. EMCrit: HOP Killers

4. PulmCCM: The Physiologically Difficult Airway

The Course I Made For Me

CCED2013sm

My whole career has been about finding ways to optimise resuscitation. Many others also have the bug. The ‘resuscitationist movement’ is sweeping across Europe, with Katrin Hruska and Femke Geijsel about to run amazing courses for emergency teams in Sweden and The Netherlands. I have the honour of joining Clare Richmond in helping them do that. But first Critical Care in the Emergency Department is going to be run in London one more time.

This course contains the stuff I wish someone had told me as a registrar. A synthesis of my learning points in intensive care, prehospital & retrieval medicine, paediatric critical care, and being a front line ED doc for 20 years.

I’ve been running the course for over a decade, including in London, Birmingham, Basingstoke, Dublin, Stockholm, Sydney and Maribor. Each time I try to improve it, and try to squeeze one or two more learning points in. It’s a tough day – just me and fifty or so critical care cases to talk about. But no-one goes to sleep – guaranteed! Everyone has to work – to talk, think, and interact.

It is of course primarily a clinical course, focusing on optimal clinical practice. But consistent feedback from participants is that they get far more from it: a reassurance that they’re not crazy wanting to do more for their patients, and a way forward for remaining inspired and motivated to make changes to their practice and to their departments.

If you’re able to make it to London next Friday 26th August treat yourself to a day of training you’ll never forget. There are no planned future dates for this course in the UK so get it while you still can!

You can register here or read more here

CCED-FBF-sm

 

 

Humbling Reminders of the Power of Educators

the teaching hospitalvsmI’ve always had strong feelings about education. I was an uninspired and underachieving medical student, exasperated at the fact that the preclinical course at my medical school consisted of lengthy lectures about detailed aspects of basic sciences like histology and embryology. To make it worse, the teaching was delivered by basic science PhD students who were required to teach medical students as part of their contract. They taught because they had to, not because they were good at it. In other words, the best way to summarise how I was initially taught to be a doctor is this: my medical training consisted of being taught stuff I didn’t need to know, by people who weren’t doctors, and who didn’t know how to teach.

This frustrated me enormously. It wasn’t until I hit the wards as a senior medical student and then junior doctor that I would occasionally run into enthusiastic and supportive clinicians who were keen to share what they knew. They seemed to be few and far between, but the crumbs they dropped were enough to leave a trail that led me to be determined to become a doctor who could similarly inspire and motivate others to love learning.

Throughout my training I made a consistent observation: a small amount of good education was extremely motivating. The converse was also true – being denied access to education was extremely demotivating.  In one department, teaching was continually cancelled due to patient load. When questioned on this, the clinical director stated “teaching is a privilege, not a right”. This influenced me profoundly, because I immediately adopted that phrase as a personal motto, except that I flipped the order of “right” and “privilege”.

A few events have converged this week to remind me of the power of good education. The first, and most important, was when my friend Rob Rogers, a renowned emergency medicine educator who has run courses on how to teach all over the world, tweeted a picture of an interesting ECG.

Rob and his team have inspired so many people with their brilliant education. Faced with a life-threatening ST-elevation MI, Rob chose to share his ECG with his Twitter followers. Later he shared details of his angiogram pre- and post-revascularisation. Now THAT is commitment to education!

The second event this week is that we are running our Sydney HEMS induction course in prehospital & retrieval medicine. This is about as full on as medical education can get, with hours of simulation, testing, and stress exposure. I am constantly amazed at the dedication and hard work of my colleagues who make up the course faculty, and the willingness of the participants to go the extra mile to improve their performance. We have the honour of  inviting medics from certain branches of the Australian military to attend the course, and one such armed forces ‘graduate’ of our course recently contacted me:

mil

He attached a document outlining a situation he faced which took my breath away. I’m not yet allowed to share it, but the bravery he showed was awe-inspiring. To think that he credits some of his preparation to the training we gave is truly humbling. It is also a reminder of the enormous responsibility of educators.

We can provide both negative and positive inspiration through our choices in what we say and how we say them, and in the teaching we deliver. As learners those educational experiences shape us and stay with us forever, influencing the choices we make and how we choose to pass on the teaching. 

arcticpond

We are lucky to live in an age of Free Open Access Medical Education,  when the educational ripples reach out from EMCrit, St Emlyn’s, EM IrelandscanFOAM, badEM, LifeInTheFastLane, and so many others to all parts of the world. We’re all in this together, as teachers and as learners.

The humbling feedback from my military friend along with Rob’s ongoing desire to educate in the face of life-threatening illness serve to remind us of the power of education, and the responsibility we educators have to share, to inspire, and to provide the highest quality teaching.

Something Rob already seems to be working on, less than a week post-myocardial infarction …

Hilar Twists & Human Error

This engaging scene from ‘Code Blue‘ demonstrates a Helicopter Emergency Medical Service team managing a patient with major thoracic haemorrhage. They have done a right thoracotomy and want to clamp the hilum but there’s some kit missing from the pack.

This scene has some great discussion points for prehospital professionals, even if the specific scenario is somewhat unlikely for most people’s practice:

  • Non-compressible haemorrhage is possibly the biggest single clinical challenge when you’re a long way from hospital
  • Agitated friends and family can be disruptive – allocate a rescuer to look after them
  • Having blood products to give is essential
  • Don’t rely on the memory of individuals, who are fallible, to pack your equipment. “I was sure I put them in” didn’t cut it when the team needed forceps to clamp the pulmonary hilum and stop the bleeding. Checklists are the in thing, for good reason.
  • Luckily, you don’t need to clamp the hilum (which is tricky) in massive unilateral thoracic haemorrhage. You can just twist the lung 180 degrees on the hilum so it’s upside down. This can prevent further haemorrhage and air embolism.

 

What’s a hilar twist then?

The hilar twist manoeuvre, as it’s called, is worth learning if you’re a clinician who is prepared to do resuscitative clamshell thoracotomy for penetrating traumatic cardiac arrest. The clamshell is quick and provides excellent exposure(1) and is preferred to lateral thoracotomy(2).

The primary purpose of clamshell thoracotomy in penetrating traumatic arrest is to relieve cardiac tamponade and control a cardiac wound(3). It is well described and continues to save lives in the prehospital setting(4).

However, sometimes you’ll open the chest and the pericardium will be empty (other than containing the heart of course), and there will be massive haemorrhage on one side of the chest. Although most of these patients will be unsalvageable outside a trauma centre’s operating room, it’s worth trying something once you’ve gone to all the trouble of opening the chest. The hilar twist(5) is probably the best option for the non-surgeon, especially when some muppet’s forgotten to pack a clamp.

In order to make the lung mobile enough to twist, it’s first necessary to cut through the inferior pulmonary ligament. This is also known as simply the pulmonary ligament (because there’s no superior equivalent) and sometimes the inferior hilar ligament. It’s not actually a ligament, but an extension of the parietal pleura extending downwards in a fold from the hilum. Some describe it as hanging down from the hilum like a ‘wizard’s sleeve’, which invariably gets a giggle from some of our trainees from the United Kingdom for some reason.

Hilar Twist

 

After cutting the ligament completely to the level of the inferior pulmonary vein, the lung is then twisted ‘lower lobe towards you’, ie. lower lobe is rotated anteriorly over the upper lobe until the lung is oriented ‘upside down’. The twisted vessels around the hilum become occluded and further haemorrhage from that side should be limited. Other priorities in the arrested patient will be aortic occlusion, internal cardiac massage, and blood products. Packs may be required to keep the lung from untwisting, and if return of spontaneous circulation is achieved, there is a risk of dysrhythmia, right heart failure, and refractory hypoxaemia.

I’ve only done this on pigs and human cadavers so am not speaking from any reassuring level of experience or competence. The literature is out there to read, and it’s up to you to decide how you want to expand or limit your options when you’ve cracked that chest in an arrested patient.

References

1. Flaris AN, Simms ER, Prat N, Reynard F, Caillot J-L, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg. 2015 May;39(5):1306–11.

2. Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L, Voiglio EJ. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study. World J Surg. 2013 Feb 23;37(6):1277–85.

3. Wise D. Emergency thoracotomy: “how to do it.” Emerg Med J. 2005 Jan 1;22(1):22–4.

4. Davies GE, Lockey DJ. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results. The Journal of Trauma: Injury, Infection, and Critical Care. 2011 May;70(5):E75–8.

5. Wilson A, Wall MJ Jr., Maxson R, Mattox K. The pulmonary hilum twist as a thoracic damage control procedure. The American Journal of Surgery. 2003 Jul;186(1):49–52.

Convergent Evolution in the Jungles of Critical Care

boss-of-the-mob-1400090-1279x1923By Stuart Duffin
Expat Brit, intensive care physician and anaesthetist at Karolinska University Hospital in Stockholm, Sweden. Stuart trained in the UK, and spent some time working Australian emergency departments.

One of the most striking things for me about our new/old pan-specialty of critical care, brought into focus by the world-shrinking effects of FOAM and twitter, is just how differently it falls into the domains of the established specialities in different parts of the world. This leads inevitably to comments like, “emergency physicians shouldn’t intubate”, “anaesthetists cant do sick”, “nurses cant be doing such and such”, and so on. All of these statements are clearly equally rubbish because obviously, in certain parts of the world, they do. And they do it really well. Sure there are differences between countries and continents, populations and environments, but when it comes down to it, it doesn’t matter where you are, people still get sick, infected, pregnant, run over, stabbed or hit around the head with heavy things.

All over the world, in our previously quite isolated environments, these same ‘selection pressures’ have forced healthcare providers to evolve by the process of convergent evolution. Although obviously not strictly darwinian, the undeniable effects of simultaneous evolution by survival of the fittest-to-practice can be seen.

Convergent evolution is the process by which, in different parts of the world, completely different species have evolved in parallel to fill similar roles and have similar features. It didn’t matter whether it was a deer, a wildebeest or a kangaroo, there was a vacancy for a fairly big animal who liked eating grass and moved in big groups, and someone stepped up.

Unsurprisingly, critical care resuscitationists are also a little different from country to country and from continent to continent. They have different titles and work in slightly different ways. But when you really look at a critical care doc in action, or talk to one, or follow one on Twitter, we are all cut from the same cloth. I would argue that FOAM has created a critical care zoo in which the kangaroos and antelopes, lemurs and monkeys, aardvarks and echidnas and anaesthetists and emergency physicians are all chucked into the same cage. They’re all looking at each other thinking, “you look like me, but somehow not. We seem to do the same stuff, but we’re not identical – it cant be right!”.

In The United States, the idea of an anaesthetist doing a clamshell thoracotomy would be a little strange. In Scandinavia, an emergency physician doing central lines and fiberoptic intubation in resus would be just as eyebrow raising. A Swedish intensivist and anaesthetist spent some time working in Australia as an ICU senior reg. When attending a patient in resus the emergency physician there announced “we need an airway guy”. My colleague answered “I’m the airway guy”. “No an anaesthetist” replied the emergency physican. “I am an anaesthetist!” “No an….” and so it went on.

The effects of this process are of course by no means limited to doctors. Nurses, paramedics and physiotherapists are all part of this still changing ecosystem. A colleague of mine was showing a visiting Australian emergency physician our trauma bay and describing how major trauma is managed here without the involvement of emergency physicians at all. “When it’s really urgent, it’s anaesthesia and surgery” he explained. I wonder how that went down? There is an element of truth to the statement but the words are wrong. It should have been “When it’s really urgent, it’s airway, access, transfusion, invasive procedures and resuscitation thinking”.

The job title of the person who actually holds the knife/laryngoscope/needle and has what it takes to get it done isn’t important. When the push comes to shove and the bad stuff bounces off the fan, it’s more about skillset and mindset, and less about the collection of letters under your name on your badge, or after your name on your CV.

Awesome Conference on the Sunshine Coast

The Spring Seminar on Emergency Medicine is going to Noosa in September 2016!

In case you haven’t been to an SSEM before – this is a boutique Australasian emergency conference run by a not-for-profit organisation. It is squarely aimed at EM clinicans who like to get their hands dirty. The emphasis is on practical stuff: SSEM is legendary for the quality of its workshops.

It is legendary too for its venues! The last three SSEMs have been held in the Barossa Valley, Darwin and Rotorua. The extracurricular activities are brilliant and the conference draws bright, outward-going, active clinicians from all around Australasia.

This year the academic programme has been expanded with keynotes from 3 leading EM figures, deliberately controversial panel sessions and hot topics, and six awesome workshops on Snakebite (in Australia Zoo), Wilderness Medicine (in the National Park), Difficult Ventilation, Emergency Dentistry, Focused Echocardiography and Lung Ultrasound.

Extracurricular activities include a Welcome Reception with celebrity chef Matt Golinski, early morning activities on Noosa Beach, trips to Eumundi Market and the Spirit House Cooking School and a Beach Party Conference Dinner.

The conference starts with a reception in the Boat House on Tuesday 26 September and wraps up at midday on Friday 30 September with Townsville vs Nambour Simulympics.

There are concessional rates for generalists, trainees, nurses and students. Early bird rates apply until 10 July however the workshops are booking out fast so – book now!

Declaration of interest: I have no involvement in this conference, but I wish I was going!

Why And How I Teach

the teaching hospitalsmI love education. As a trainee, I was lucky to be guided by a handful of excellent mentors along the path. The truth is however, in many places I worked inspiration and good education were hard to find.

I am driven by the desire to make my trainees and colleagues better than me. As a critical care physician, I can only save so many lives in one career. But as an educator I have an opportunity to influence patient care in regions of spacetime to which I will never have personal access.

A massive investment has gone into my medical education. My parents worked their butts off to allow me to study. State funded university education in England got me my medical degree. Taxpayers’ money paid my salary throughout my training. Most importantly, thousands of patients put their trust in me as I did my best to learn medicine by treating them, sometimes getting it right, often getting it less than optimal. I owe all of them. I owe it to them, and to myself, to make it all count as much as possible.

If I can ignite a spark in a trainee’s mind that inspires them to improve, or share a memorable clinical tip that gets recalled and applied at a critical point in a resuscitation months or years from now, then all that investment, all that sacrifice, is so much more worth it. 

Here’s a list of the principles I try to apply, especially when running courses. Underlying all of this is the goal to provide the kind of training I would have loved to have received myself.

Cliff’s Clinical Teaching Tips

Keep it case-based

This allows the nurse, the specialist, and intern to be in the same classroom. When we’re considering patients, everyone can learn something that is relevant to their professional perspective and experience.

Respect the learner

Allow everyone to question the teaching and express their opinion. Never humiliate anyone. The less threatened people feel, the more exploratory their questions will be, and the better they are able to make sense of the information discussed.

Have regular breaks, with food, water, and caffeine

If people have travelled to learn, they need to be protected from fatigue, dehydration, neuroglycopaenia and caffeine withdrawal. If they know you care about these things, they know you care about an effective learning environment, and will be more engaged.

How to make it memorable

Make it fun

Learning is great fun. We should have a good time together. If you’re bored, you won’t learn effectively. Funny or unusual stuff is more memorable, too.

Connect emotionally

Critical care is emotive. During resuscitation we have powerful interactions with ourselves and with our colleagues, sometimes negatively. Learners who are experienced clinicians have all felt pain or frustration in the resuscitation environment. Addressing these issues, by focusing on what could be done better, from a self, team, environment, or systems point of view frames the clinical teaching in more realistic and more applicable context. Sharing my own feelings about cases I’ve managed shows the learners how similar we all are inside, and I’ll be better able to convince them that they are just as capable of applying what is taught as I am. We can advise learners more effectively how to think and behave if we immerse the teaching in the reality of human experience.

Keep it simple

A quotation often misattributed to Einstein is “If you can’t explain it simply, you don’t understand it well enough”. Resuscitation and critical care concepts, certainly as applied to the initial resus room evaluation and therapies, can all be explained in uncomplicated ways. It behooves any resuscitation educator to adhere to this.

Have a framework that you continually refer back to

Knowing where to ‘store’ new information and how it relates to existing knowledge or other concepts being taught is important for understanding and retention. A classic example of such a framework is the ABCDE trauma assessment, but many more can be created. It also facilitates communication of ideas though mindmaps or note taking via sketchnotes.

Tell stories

This relates to connecting emotionally, as recommended above, but there is more to it. Humans have communicated information and ideas through storytelling since the dawn of civilisation. We are hardwired so that our attention is captured by stories.

Use mnemonics

Mnemonic tools like acronyms are helpful for information that needs to be rapidly accessed, like the one I made for possible causes of a raised lactate when you’re looking at a blood gas from a patient in the resus room with a lactate of 12 mmol/l.

I’ve been in the privileged position of being able to apply these principles in courses I’ve run in various countries for over a decade. In 2016 I get to do it again in the Netherlands, Sweden, and England. I’m one very lucky educator!

 

 

Related posts and content:

How I train our Prehospital & Retrieval Medicine Team

Resus.ME courses in the UK

Education Theory for the #MedEd Clinician

Advice To A Young Resuscitationist

Advice-to-Young-Resuscitationist

This talk was the opening plenary given at smacc Chicago. The title they gave me was ‘Advice To A Young Resuscitationist. It’s Up To Us To Save The World‘ but I ditched the last half because, as I point out later in the talk, I don’t think it is up to us to save the whole World. Some AV muppetry at the conference centre prevented the smacc team from being able to include the slides, so I’ll post those too at some point. You can hear the talk as a podcast at the ICN or on iTunes

The references for the talk are here

 

Learning To Speak Resuscitese

team-sm

In the resus room, clarity of communication between team members is critical to patient safety and effective resuscitation. We are used to following standardised clinical algorithms for cardiac arrests and many other emergency presentations, but there is no standardisation of vocabulary or communication style. Communication failures are a major source of error in resuscitation, suggesting this is an area in which we need to improve.

Defining your lexicon

A contrast with the aviation industry was drawn by neonatologist Dr Nicole Yamada, who points out that pilots and air traffic controllers use an effective, concise, standardised set of words and phrases that are universally understood, for example ‘stand by’, ‘unable’, ‘read back’, and ‘cancel'(1).  She proposed adapting a similar resuscitation-specific lexicon modelled after aviation communication which ‘would aid in streamlining communication during time-pressured clinical situations when seconds count and errors can kill.‘(2)

table3Yamadasm

Dr Yamada tested this approach in a small study of simulated neonatal resuscitation. Standardised communication techniques were associated with a trend toward decreased error rate and faster initiation of critical interventions.(3)

Avoiding the fluff

In the absence of standardised approaches to communication, humans in the resus room often choose language which indirectly acknowledges social hierarchies. For ad hoc teams, phrases may be chosen which are least likely to offend people with whom we’re unfamiliar, or may be deferential in cases of real or presumed authority and expertise gradients. The consequence of this is the use of ‘mitigating language‘. Examples might be:

“Any chance you could pop a line in?”

“Would someone mind letting me know if they can feel a pulse?”

“Do you want to have a think about setting up for intubation?”

“How about we get some bag-mask ventilation happening at some point?”

“If you could have a look at his abdomen that would be awesome”

These commands (imperatives) phrased obliquely as questions or suggestions are know as ‘whimperatives‘ and are found throughout resus room dialogue, when the team leader does not wish to convey the assumption of a power relationship over her colleagues. These whimperatives are an example of ‘mitigating speech’, which refers to language that ‘de-emphasises’ or ‘sugarcoats’ the command.

In the words of Peter Brindley:

‘The danger of mitigating language illustrates why, during medical crises, we should replace comments such as “perhaps, we need a surgeon” or “we should think about intubating” with “get me a surgeon” and “intubate the patient now.”’(4)

Conclusion

There’s nothing wrong with being polite and respectful, and mitigating language may be helpful in the team building phase. However the more critical the situation, the more an authorative/directive leadership style that clearly delegates critical tasks  is required(5). Standardised terminology (with closed loop communication) is likely to enhance clarity of the message and accelerate the sharing of a team mental model. Avoiding whimperatives and excessive mitigating phrases may further prevent ambiguity and imprecision, reducing the time to critical interventions.

These components of the content of resus room communication – unequivocal, standardised, and direct – should go hand in hand with the delivery of the words. Effective delivery requires optimal delivery speed and ‘command presence’. These factors will be discussed in a future post.

I’d be interested to hear what standard phrases or words you think should be in the resus-room lexicon.

 

1. Yamada NK, Halamek LP. Communication during resuscitation: Time for a change? Resuscitation. 2014 Dec;85(12):e191–2.

2. Yamada NK, Halamek LP. On the Need for Precise, Concise Communication during Resuscitation: A Proposed Solution. The Journal of Pediatrics. 2015 Jan;166(1):184–7.

3. Yamada NK, Fuerch JH, Halamek LP. Impact of Standardized Communication Techniques on Errors during Simulated Neonatal Resuscitation. Am J Perinatol. 2016 Mar;33(4):385–92.

4. Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. Journal of Critical Care. 2011 Apr;26(2):155–9.

5. Bristowe KK, Siassakos DD, Hambly HH, Angouri JJ, Yelland AA, Draycott TJT, et al. Teamwork for clinical emergencies: interprofessional focus group analysis and triangulation with simulation. Qual Health Res. 2012 Sep 30;22(10):1383–94.

Cutting Edge Resuscitation Medical Education