I think there’s a better way. This comes after talking to people who’ve done ton’s of surgical airway. When you work in Australia and don’t get the volume of patients that have the trauma and other conditions that will lead more often to the surgical airway, you define your technique to suit what you do and this is what we’ve done in the past.

But now we ask, is there even a better way?

What better way to learn than to ask Emergency Physicians in the country where surgical airways are more common than corn chips - OK maybe that’s not quite true, but you know I’m talking about the US of A.

Many of you have attended my airway workshop. Given that its one of the only workshops of its kind in Australasia, where do I go if I want to see if I can get challenged? Yes sir, “I saddled up the truck and moved to Beverly”(most of you younger guys won’t know this quote, but the older and more arthritically challenged amongst you, like me, will know that line is from an old series,’The Beverley Hillbillies’.

Anyway, I was taking an airway workshop and talking to the guys from USC and we had a discussion on airway and especially surgical airway.

I showed them my horizontal technique and discussed the issues related to it.

Now let me put this in context for you, and a little bit of a rant will follow! This rant is about the way anaesthetics or ICU or anyone else reacts when the ED does a surgical airway. It should be supportive and create an environment for learning. It many cases, it creates a hostile environment. That saddens me.

A few years ago I was working at a trauma centre down South in the land of OZ and there was a case where one of the emergency physicians had to perform a surgical airway. The details aren’t important. What is important is that after this, the anaesthetics department were up in arms and even had MRI’s done on this patient, to prove that the airway was in the wrong place! Why?! Why is there this desire to prove the ED wrong?  The Emergency Airway is our domain and we should deal with it. What we should have is the understanding and support of colleagues.

Anyway, after all the MRI’s, the tube was in the right place, in the cricothyroid membrane. The patient went home two weeks later.

In this same department, our anaesthetics colleagues were then trying to stop the ED from using propofol - what’s going on here?

More recently, I heard in another ED, that  there was another issue related to surgical airway, where there was a complaint made about a surgical airway being done by the ED consultant and again all the doodoo hit the fan. Again, all was done correctly with tube in the right place.

When I recounted these stories to our US colleagues they were a little taken aback. The emergent airway is the domain of the ED. Full STOP, Period, END OF STORY!

So, hopefully as we all do these airway and procedures workshops and improve our skills, the hostile approach will give way to mutual understanding. Now I’m not saying that all anaesthetists are like that. Its just that some circumstances bring out strange behaviour.

My thoughts on all of this was, how can we even make it better? How can we minimise the chances of missing? If we get better at what we do, and believe me when I say, that knowledge is power, then these ‘misunderstandings’ will occur less and less.

As most of you who have done the airway workshop know, I favour locating the cricothyroid membrane)( and we go into the anatomy of this) and then:

-make a horizontal cut

-put something in the hole, either suture, holders, or a clamp(someone recently recommended, a bougie)

-remove the scalpel

-then feed the size 6 tube, or a small ’shiley’ trachy over this.

BUT the thing I’ve noticed is that the big issue that others have is; ‘are you at the right level?’ Have we in fact not cut at the level of the cricothyroid membrane and cut at some other level and then what do you do? You either don’t realise it and put the tube in where you are, or you have to make another cut! This is a real issue, so how can we make sure we remove this type of error as best as possible?

THE NEW TECHNIQUE

Make a vertical cut - A GENEROUS VERTICAL CUT- this can be 5cm long. You need to get through all the skin with this.

Then with your finger feel down until you find the anatomy- this is where the pig’s trachea that we use in the workshops, comes into its own, as it feels like it.

Once you’ve found the cricothyroid membrane, then put a horizontal cut in it and then feed in your tube as per the method we already use.

That’s it! A simple change, but with a potentially massive result.

I’ll be showing this at the airway workshop - in May and in July at RESUS 2010.

Have fun, enjoy your work and remember that the knowledge you take into your shift DOES matter!

Peter Kas

Thanks to Alex Swain Director of Wodonga Emergency for inviting us up to Albury Wodonga to give an Advanced Airway Workshop. It was a great day and everyone played all out. It was a real treat to see the layered approach of teaching kick in and by the end of the day everyone could tube every manikin repeatedly…..even the famous manikin(dubbed this over several workshops) ‘Mr Evil’. This is even after I had changed all the anatomy ie., tongue up and larynx partly swollen and vocal cords slammed shut!

What was also great was the discovery, as we called it, of the ‘Swain technique’. Alex thought about surgical airway and his solution was to make the cut in the cricothyroid membrane and then put a bougie in there, and railroad the tube over it. I LIKE IT!

Thanks again everyone. Airway is not difficult. It’s essential and with the right teaching you can learn how to establish an airway every time!!! You don’t need the fancy gadgets. You don’t need the thousands of dollars of equipment if you cant afford it. All you need is:

-a curved blade laryngoscope(#3)

-a stylet in the endotracheal tube bent at 35 degrees ie ‘hockey stick’

-a bougie

If all else fails, then simple things  should be available, such as an intubating laryngeal mask or an ‘airtraq’ and have on standby  a 14# cannula and some tubing for jet insufflation or just a scalpel for the definitive surgical airway. Remember, the most difficult thing about the surgical airway, is the decision to perform the surgical airway. As I’ve shown you, the technique takes only 20 seconds.

REMEMBER TO HAVE A PLAN. When will you decide to go to the next step. The definition of a failed intubation is 3 failed attempts at passing a tube by an experienced operator, OR sats < 90%. Know when you must make the decision to go to surgical airway. The most important thing about intubating is position and putting the blade in the right place ie., the tip of the blade in the vallecula and  then pulling up in the direction of axis of the handle.

Make sure your basic techniques are sound. Practice those bag-valve-mask techniques as they may be what saves your patient in the end.

Well done guys and I look forward to catching up with the bunch that registered for RESUS 2010 at the conference in July.

Again thank you all for your committment to learning.

Peter Kas

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