In its 4th iteration at SMACC this year, the airway workshop was held twice – in the morning and afternoon. It was essentially a masterclass in what is being developed and implemented regarding airway simulation and skill around the world.
Each workshop was divided into four sessions – intubation, surgical cricothyroidotomy, nasendoscopy, and scenario simulation. These were led by expert faculty, with help from the SMACC Juniors to make things run smoothly!
I attended the afternoon session. Here is a review of what went on for those of you who went elsewhere, with some links to extra materials that you can look at to feel like you were there all along!
It will come as no surprise to hear that Scott Weingart headlined the surgical cric station. He has become renowned for his podcasts and lectures on the topic, and gave a talk entitled “Cut to Cure” at the RCEM Scientific Conference, held in Manchester, UK late last year. You can see all of his resources and listen to the podcast on his website – EMCrit.
Scott went through a concise version of his presentation and facilitated practice on some fantastic foam and plastic models. He then showed videos of both cadaveric and real crics to reinforce the practical skills, and points he had made in his talk, namely surrounding safety issues of aerosolised blood. A video of a failed cric supported a discussion on why surgical airways fail, and how it is important to recognise when things aren’t going well and have the confidence to say so and start again from the beginning.
Finger guided cric with #SmaccAIRWAY #smaccDUB where’s @emcrit? #smaccjunior pic.twitter.com/N3vz0MrKOC
— Alyxandra Presler (@zanurban) June 13, 2016
His take home message was that every airway could turn into an emergency surgical airway. It may be that you only do one surgical airway in your lifetime, so practice is key. Visualise the process once a month, practise it. If you can practise on a model, even better, but if not, then wave your hands around and go through the steps in your head. Maybe do it whilst you’re alone though or you might draw some funny looks.
On starting the session, we were almost immediately granted full view of Richard Levitan‘s vocal cords, moving around as he sang the Scooby-Doo theme tune. A great introduction, and really got us all excited for what we were about to do, even though it meant sticking weird tubes down our noses!
@airwaycam demonstrating his beautiful larynx by nasoendoscopy. #smaccDUB #smaccairway pic.twitter.com/PYSO7SH7qJ
— Bryan Feinstein (@bfeinste) June 13, 2016
After a brief talk from Rich, Georgie Harris (an ENT surgeon from Sydney) took us on a tour of the nose, its anatomy, dangers, and pitfalls. We learnt about septal spurs and avoiding the turbinates, and tips to improve the size of the nasal space to make it easier for us to navigate. We all experienced the bitterness of co-phenylcaine (some lucky punters had it squirted in both nostrils!), divided into pairs, and Rich guided us through working the scope to see first down to our partner’s cords, and then scoping ourselves as well. It was a great experience, and we had endless fun taking photos of our own cords, and with a scope hanging out of our noses. If you don’t want to see these, maybe scroll quickly past!
Welcome to #SmaccAIRWAY pic.twitter.com/SpRUs641jU
— Andywebster (@Andywebster) June 13, 2016
Finally, Jorge Cabrera showed us the long scope and how to exchange a supraglottic device for an endotracheal tube using the scope and a pair of McGill’s forceps to hold the tube in place from the top end whilst sliding the LMA/iGel far enough over to secure the tube from the bottom.
Check out these great videos from The Sharp End on nasendoscopy, and see Rich Levitan for yourself!
Does your ED have a nasendoscope? Do you use it? If so, what for?
The scenarios took the form of fun, team based airway challenges. With people we had never met before, we managed an inevitable surgical airway situation, where tomato ketchup replaced blood and despite any intervention we tried, nothing was going to help but a cut to the neck. The other scenario took place inside a simulated ambulance, where coming across a major RTC during a transfer left a lone provider in the back whilst his crewmate was dragged out to help. I’m not going to give too much away regarding the scenarios themselves, but the main theme for this part was the human factors side, with team working and crew resource management playing a huge role. Shared mental modelling was emphasised in feedback sessions, and this is crucial in difficult situations, and more so given we’d never worked together. The ambulance isolation scenario was a great lesson in how going back to basics, and doing those well, can get you out of a tight spot.
There was also a “stuck in the lift” scenario for the other group, which we got to listen to from afar, and continued to reinforce non-technical skills through leaderships and teamwork in a dark, small environment, with a patient to care for as well.
It’s hot, dark, noisy and dangerous the #smaccairway lift of doom pic.twitter.com/y7BGeNpg38
— John McKenna (@DrJEMcK) June 13, 2016
Our intubation station was a round-robin with quick rotation through several skills. First up we looked at direct and video laryngoscopy on complicated airway models. Some had small mouth openings, one an impaled metal bar through the cheek and lip that we had to navigate. One memorable manikin, created by Jim DuCanto, had a Chewbacca mask which was fantastic, as it roared when you tried to intubate it. Not many people can say they’ve intubated a wookie!
Intubated a wookie today! #smaccDUB #smaccairway @jducanto pic.twitter.com/sIw03Lk5iH
— Chris Gray (@cgraydoc) June 13, 2016
The next skills involved airway exchange using supraglottic devices, including a new device being trialled in South Africa which is an intubating video supraglottic device called the TotalTrack, with a video scope attached directly to a working LMA. There is a summary of how it works here (PDF). We also used fibreoptic intubating scopes both to perform primary intubation, and also to exchange airways. There were some great tips on how to use adjuncts to maintain oxygenation whilst exchanging devices.
Fiberoptic intubation through I-gel. ETT cuffed to allow ventilation while scoping. #smaccDUB #smaccairway pic.twitter.com/NAKXe31qgj
— Oskar Sandqvist (@OskarS4ND) June 13, 2016
We also got to play with vomit on Jim DuCanto’s SALAD simulator. SALAD stands for Suction Assisted Laryngoscopy Airway Decontamination, and was as messy as it sounds. Jim and Tim Leeuwenberg took us through several techniques for intubating the airway made difficult by constant regurgitation, and we had great fun practising these whilst blue vinegary liquid flooded the mouth of the manikin. You can see Jim’s video again on The Sharp End, and if you fancy making your own SALAD simulator, all of the instructions are on his Twitter page.
Overall a fantastic workshop, with lots of great technical and non-technical tips from a highly experienced faculty. Please check out some of the links above, and see how you can incorporate some of this advice into your daily practice.
- The Sharp End, as already stated above, has some great resources relating to the smaccDUB airway workshop.
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