I recently ran another of our Advanced Airway Workshops at ACEM’s 2011 ASM and invited the guys from Verathon, to bring in the Glidescope and let people have a play with it. I hope they will be at our June Airway workshop in 2012 as part of the EM CORE Conference. ( I have no financial interest in this product and I am not sponsored, nor have been in any way.)
I have not trained with a Glidescope, but picked it up and intubated within 5-6 seconds, simple easy and straightforward. I was impressed. So I don’t understand why we don’t have this equipment in our emergency departments. I don’t know why we have to have things be more difficult than they need to in the front line, where the tubes are all emergent? Can someone please explain this? I recently had a trauma patient that we needed to intubate. This was going to be a tough tube. As we prepared, I spoke with our anaesthetic colleagues and asked if they could be there. I would tube, but wondered if they could be another set of experienced hands. Before I knew it, they were down with a Glidescope, a McGrath Video Laryngoscope and a few other goodies. $30,000 plus of equipment! They asked”Pete, what have you got down here that you’re going to use?” I held up a limp bougie. Hmm… The inequality struck me. Here I was working in a major trauma centre and we didn’t have any of this stuff in the Emergency Department. Is this because anaesthetics denies us? Surely not. Is it because administration can’t be convinced that this is essential equipment for the ED? Is it that some amongst our own ranks, love the brow-sweat-generating, hair-on-end, adrenaline soaked, open-shirted hairy-chested thrill of potentially not being able to intubate, and the unavoidable litigation following this? Do we believe that we will lose our skill set? The anaesthetists don’t lose theirs! In an already charged and stressful environment, that is the resuscitation cubicle, this is one less stressor I’d like us all to have! Perhaps we should ask the patient or their attorney. “You are very unwell and we need to control your airway. You have two choices, this state of the art, video laryngoscope that allows us to visualise your vocal chords and lets us see the tube as it passes into the trachea, or this curved piece of metal that was invented sometime during the first world war?” Hmm…
I believe we need to look at the evidence. The evidence points to video laryngoscopy replacing direct laryngoscopy in the future. Not just yet maybe, but not far away! Think about it. A cardiac resuscitation with chest compressions. You don’t have to stop to intubate, video assisted intubation is there. The difficult airway, that is potentially there in all traumas, due to loss of neck movement, a little less concerning, just look inside and see the cords. Plus, what a cool teaching tool! Don’t get me wrong, I love the adrenaline, that’s why I’m an emergency physician, but there are somethings that should be straightforward, almost automatic. Passing a tube, should be matter-of-fact. Caring for the critical patient, should be the buzz! Now I’m not saying there is no place for direct laryngoscopy, but lets make sure we know what it’s place is.
Let’s look at the literature. In a meta-analysis of 11 randomised trials comparing video laryngoscopes with direct laryngoscopy (Su et al. European Journal of Anaesthesiology, Nov 2011), three important things were discovered:
1. The view provided with the video laryngoscope was superior.
2. The success rate was similar for both video laryngoscopy and direct laryngoscopy.
3. The time to intubation was the same for both.
This is important as previously, the data was leaning towards longer times to intubate with the video laryngoscope. More importantly, the time taken for difficult intubations was shortened. This is where they come into their own. In a new study by Sakles in the J Emerg Medicine June 2011 compared the video laryngoscope to direct laryngoscopy in 822 patients and found video laryngoscopy to have a high first intubation success rate as well as a decreased rate of oesophageal intubation. Not really surprising. What was surprising is that direct laryngoscopy became the rescue technique, if they needed more than one attempt. Hmmm. I think it’s time to raise our voices and get the equipment we need to provide the level of patient care expected in our Emergency Departments.