Along with many others, am playing around with various combinations of airway trainer, simulated vomit, pump and suction to develop a self-contained portable SALAD sim (SALAD – suction assisted laryngoscopic airway decontamination)
SALAD is of course the brainchild of James DuCanto, Milwaukee airway fanatic and well known to the FOAMed world. Instructions on the SALAD set up are here and training videos here
I’ve had the privilege of assisting Jim in airway workshops in Chicago and Dublin as part of the smacc conference series most recently assisted by UK anaesthetists Ben Shippey @rallydoc and Barbara Stanley (@theneurosim). We’ve managed to train several hundred people in the nuances of airway decontamination, under both ‘static’ (simple deposit of simulated airway contaminant) and ‘dynamic’ tests (an ongoing tsunami of vomit which threatens to overwhelm the intubator unless master the art of continuous suction whilst intubating – not as easy as it sounds!)
The future challenge will be to create a SALAD sim set up that is both compact & self-contained
Present SALAD setups rely upon an open container of ‘simulated airway contaminant’ (a heinous mix of xanthem gum, white vinegar and food colouring) which is then pumped to the oropharynx using variously
a drill-powered inline siphon pump
a submersible bilge or pond pump
a dirty water sump pump
Flow rates can be adjusted by either use of inline valves or a variable rheostat speed-controller to reduce pump speed and hence flow of vomitus.
The contaminated airway is then suctioned out, using a medical grade suction device. I struggled with this in Dublin, as the two loan units rapidly became overwhelmed…I didn’t realise that the bags within suction cannister are designed as single use and the inlet valve soon became clogged.
In contrast Jim DuCanto’s units (from SSCOR) functioned brilliantly despite multiple rounds (200 litres each I reckon) of vomit passing through.
Problem is, lugging around suction pumps, submersible pumps and the containers for vomit is quite bulky.
The purist in me wants to design a closed system, namely
bladder which can be removed, filled with vomit and then emptied at end of session
both submersible pump and suction pumps small enough to sit within Pelican case and be self-contained
suctioned contents to be automatically returned to the bladder, for further pumping to airway head
controls for pumps to be available on outside of case, once closed
variable controller built in
So the challenge will be to create something that can be carried in a Pelican case (Storm IM2500, on wheels).
It might look something like this:
I’d envisage the whole unit being self-contained, the “simulated airway contaminant” (vomit) being cycled from bladder to oropharynx and back via the two pumps.
Bladder needs to be removable for filling/emptying at start/finish of session and able to tolerate periods where inflow < outflow (suction out < pump in to oropharynx).
Ideally the whole unit should function with lid of Pelican case closed, with control switches for pumps accessible on outside. Marine rocker switches are ideal, as would a variable control rheostat panel control, flush with case.
A simple mains socket could be mounted in the Pelican case, such that the SALAD Pelican case can be plugged into mains power.
Really interested to hear from anyone with ideas on how to make this happen…preferably on a budget!
Next year smacc continues in the Northern Hemisphere – the Teutonic DASsmacc will be held over four days in Berlin from 26-29 June 2017.
This will be the fifth smacc event…and as other conferences slowly begin to adopt the smacc-format of engaging TEDx style talks, powerful presentations and engaging speakers, it’s anticipated that DASsmacc will again break the mould.
In part I reckon the venue will force some changes; the Tempodrom is really designed as a concert venue – one stage, surrounded by seating. Which means, I think, that there will be scant place for concurrent sessions – rather the WHOLE of the smacc content is potentially going to be played out in the one arena.
A challenge? Perhaps – but in many ways the single stage may make it easier. This opens up opportunities – wouldn’t it be fantastic if, instead of having several thousand critical care afficianados come together to hear a select few speak, the conference concept was ‘flipped’ such that every attendee was also a participant?
Attendees as Particpants?
How? Well of course there will be the usual finely-crafted talks across a range of topics (more on that later)…but there’s opportunity to mix it up. Have panel discussions, have real-time simulation, have competitions and challenges. The 2016 smaccDUB showcased wrist bracelets that attendees wore as part of the opening ceremony light show and gala dinner; how easy would it be to use the same technology to select audience members – perhaps select attendees to participate as the ‘on call team’ for a sim session? Or to use colour bracelets to indicate audience polling on a controversial subject?
Creating immersive audience participation, such that all attendees contribute to the smacc content is one thing….how about the content itself?
One of my beefs with much FOAMed content is that we often emphasise critical care from a tertiary perspective, more often than not as practiced in a developed critical care system. As such, the talks may be focussed on the 1% of the 1% – on prehospital REBOA, on ECMO etc.
Let’s step back and consider critical illness as a spectrum
As a rural primary care practitioner, I am privileged to be involved in all aspects of my patient’s journey. On occasions I am called to the roadside to assist the (mostly volunteer) ambulance crews for a vehicle trauma. It’s easy to talk about the immediate care – the technical challenges of extrication facilitated by placement of an IO and an aliquot of ketamine…the roadside RSI followed by bilateral finger thoracostomies…the use of prehospital blood products….the use of POCUS in flight to confirm free fluid in abdomen and fast-track straight to OT in the haemodynamically unstable.
Many weeks after that same patient returns to their home, their pelvic and spinal fractures healed, their lung empyema drained….then the HARD work in primary care starts…managing their chonic pain, sorting out the skin grafts from their decubitus ulcers picked up in ICU, dealing with their depression, their weight gain and loss of function that impact in lost QALYs etc. This is the grind of primary care..dealing with downstream consequences and is important to understand how this enmeshes with the work in resus.
As well as the role of clinicians in prevention and rehablitation, we also don’t talk about prevention – the mundane stuff of seat belts, of crash helmets, of driver education, of designing out human error by use of crash barriers, airbags and so on. But this is important. And that’s just for trauma. Where is our preventative care for other aspects of critical illness?
So for DASsmacc I think there are two angles to consider.
First, that is we are serious about making a difference in critical illness, then we need to consider other aspects of the critical care journey. I recall Karim Brohi speaking in Melbourne at the ATS Trauma 2007 conference, reminding us that it is “more important to be the fence at the top of the cliff than the ambulance at the bottom”
We need to talk about other aspects – preventative care…organ donation…the longterm morbidity, whether it be physical or psychological. Primary care…
It would be awesome to explore these aspects for a variety of patients in a system….whether it be the trauma patient (prevention, rehabilitation), the unsalvageable (advanced care directives in primary care, the nitty-gritty of organ donation). I would love to hear more from those experts in prevention, in rehabilitation, in primary care….in how we can make a difference to critical illness. I’d also like to hear more from the administrators – the people who manage the systems within which we work…how do they see incremental improvement in this arena?
Critical Care – Everywhere!
Second up, we need to acknowledge that critical illness is a global phenomenon for which many do not have the same resources as the typical audience at smacc. As such, we can make an awful lot of difference by both understanding the dynamics of global critical illness and also contributing to effective knowledge translation. prehospital REBOA is for a very few…access to contextually-relevant knowledge and skills is likely to give more bag for buck.
A conversation with BAD-EM’sRoss Hofmeyer after the airway workshop brought this home; I had no idea that access to bougies in South Africa is problematic. Ross told me that bougies tend to be re-used for up to two years in Cape Town. I shudder to think how many bougies I’ve used, whether in theatre or ED..or on airway courses. I;d love to start a scheme whereby used bougies can be collected and sent on to Ross and colleagues at BAD-EM….
…and if Cape Town needs this sort of stuff, then how about clinicians in South America, sub-Saharan Africa, Pakistan etc? I have no idea….but the potential for the critical care community to make a difference to global care is huge.
On that note, smacc was held during Ramadan. Does that impact on the ability of some clinicians to attend? Perhaps, I honestly don’t know. But where are the talks on the burden of trauma & critical care from the Middle East, South Asia etc?
Whatever #DASsmacc holds, I do hope that it has an appreciation of the global burden of critical illness and helps advocate for effective knowledge translation back from the conference to those places that are currently not part of the smacc community.
100% conference audience involvement, attendees as participants
longitudinal progress of a variety of patients through a system of critical care (from prevention, resus and critical care through to rehabilitation, with inout from primary care, psychology, health admin and systems engineers)
the usual format of engaging speakers, panel discussions intermixed with short ‘blast’ talks, rants (as at #smaccFORCE) and audience participation through polls, challenges, sim etc
appreciation of the context of critical illness, with discussion of applicability on a global scale, ensuring effective knowledge translation..not just of the ‘sexy’ minutiae, but through ensuring broad-brush applicability to humanity.
Because if we are serious about making a difference in critical care, we need to think outside the confines of Western tertiary care…let’s make #DASsmacc be all about ‘critical care, everywhere’
Rural trauma – a high-speed vehicle roll over, a farming accident with a chainsaw, a gas BBQ explosion at the family picnic. These are all scenarios that may affect individuals & families…and the rural community. Occasionally a multi-agency event such as a bushfire, extreme weather event or other natural disaster will cause traumatic injuries and impact on not just community but State resources.
Whilst it is true that each State has well-developed retrieval services, whether land, fixed or rotary-wing, the reality is that the help they can offer is usually distant to rural folk; response times are measured in hours, not in minutes or seconds.
For all practical purposes these services might as well be on the moon in the face of truly urgent care (catastrophic haemorrhage, impact brain apnoea, compromised airway, delivery of effective analgesia etc).
The first link in the trauma chain of survival is invariably the first responder – he or she may be a rural volunteer in a service such as ambulance, fire, SES , coastguard…or may respond as part of their job role (eg: Parks officer, tour guide)…or may be a lay member of the public who comes across an incident and is thrust into the maw of trauma care..is This impromtu response what Christina Hernon defined as the ‘immediate responder’ in her excellent talk on ‘the disaster gap’ at smaccDUB.
The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better.
Of course many organisations insist on their members having an advanced first aid qualification; whilst these are useful, their proscribed content often lags behind current trauma care delivery. First responders are the initial link in the ‘trauma chain’ and there is no reason not to equip them with appropriate skills, knowledge and equipment – regardless of agency!
Whilst most interagency training is focussed on ‘mass incident’ exercises as a learning exercise, the reality is that these rarely, if ever, happen. Most of the work is in the usual business – a vehicle rollover or crash, an injured bushwalker, a farm accident, a patient needing medical care but unable to use the stairs, requiring SES and Ambulance teams etc – and yet do we ever train as a team for such circumstances?
This week we were privileged to have a visit from the Careflight MediSim team, to deliver the Trauma Care Workshop on Kangaroo Island, SA.
Launched in 2011, this innovative program from the Careflight organisation (mostly charity funded) delivers a world class trauma education system designed for rural first responders.
Despite the session having to be rescheduled, willing first responders from Parks, CFS and SA Ambulance were able to come together for an interactive day of lectures, task-training and sim sessions under the credible instruction of the approachable MediSim facilitators.
I’ve been banging on about the need for effective interagency training in rural communities for some time now. My involvement in trauma nowadays is mostly limited to involvement via the SA RERN system (a doctor responding only when needed by volunteer ambulance officers, with the goal of value-adding by performing certain interventions), in the hospital when oncall for emergency or anaesthesia and of course in trauma education through ETMcourse and EMST etc.
Whilst RERN, SAAS and of course RFDS and SAAS-MedSTAR Retrieval have a role to play, the initial care is invariably provided by a first responder. If lucky he or she may be a part of an emergency system…or they may be in another capacity (CFS, SES, Police, Parks etc). Most prehospital incidents will require input from several agencies.
At a typical vehicle crash, there will be representatives from Road Crash Rescue (CFS or SES), Ambulance – typically these are unpaid volunteers in rural. Add to that Police, then RERN, and Retrieval…it can be hard to both know ‘who is who in the zoo‘ and more importantly what they can do!
Training together has clear advantages – it emphasises the need for simple interventions to make a difference and that such interventions can be performed by appropriately trained and equipped individuals regardless of agency. It also allows discussion of current protocols and equipment (such as the value of first responders, whether ambulance, fire or SES having access to tourniquets, and a suitable haemorrhage control device).
Understanding and sharing of each other’s treatment priorities (scene control & safety, patient extrication and medical needs) can be practiced by scenario training, allowing effective communication, a shared mental model and planning for ‘the real thing’
It’s time to ditch the notion of each agency training in silos and instead practice regular ‘real life’ multiagency scenarios
The MediSim team provided local Kangaroo Island first responders with a solid foundation to develop further local community resilience. Lectures covered the concept of a ‘zero survey’, triage. effective handover and of course the nuts & bolts of trauma care.
The day involved practical, hands on task-training sessions on triage, on helmet removal and immobilisation, on haemorrhage control and basic airway management.
Skills learned in the workshop were reinforced by scenario-based training on managing a casualty, involving scene awareness, leadership, role allocation and the delivery of basic care in an effective manner (simultaneous extrication, treatment and packaging of the patient) underpinned by clear communication both on-scene and with central comms.
All in all, a wonderful effort by the CareFlight MediSIm team and by the local Kangaroo Island volunteers who gave up their own time to attend this trauma workshop.
I am hopeful that we can run similar exercises in the future using local expertise. To my mind the benefits of team members who are aware of each other’s roles and operational capabilities, who have trained together and share a common goal offer immediate tangible benefits to victims of trauma.
Moreover we live in a small community – the more first responders who are trained and equipped, the more resilient our response can be – whether for an accident at home, at the roadside or in the case of a community-wide catastrophe.
A Kangaroo Island Resilience Model, akin to those overseas, is achievable if we work together.
Thanks again Careflight for visiting Kangaroo Island – come again next year!
Learn about how the Isle of Arran (Scotland) has developed a local resilience model for multi-agency training and trauma care
Principles of trauma care are taught on many courses; I recommend
Emergency Trauma Management (ETM) course – etmcourse.com(COI I instruct on ETM)
Anaesthesia, Trauma & Critical Care (ATACC) course – atacc.co.uk(COI am trying to persuade Mark Forrest to bring this course ‘down under’)
The Holmatro Rescue Experience(COI have facilitated with Holmatro extrication guru, Ian Dunbar on this in Australia, mostly teaching SES and CFS volunteers)
Many clinicians worldwide share knowledge and skills – regardless of whether background in emergency, anaesthesia, rural medicine, critical care or whether involved as doctor, nurse, paramedic or volunteer. By sharing such knowledge we can all become better.
Full credit for this goes to Dr James DuCanto, airway geek and innovator from Milwaukee, USA. It’s been my great privilege (and crazy pleasure) to facilitate with Jim at smacc airway workshops in Chicago and Dublin, using the SALAD sim (suction assisted laryngoscopic airway decontamination).
This is a great setup to teach techniques to manage the contaminated airway and tends to put even experienced operators under a degree of stress. Check out more on SALAD here or make your own…
But DuCanto is also notorious for innovative education – who can forget the ‘laryng-o-beer’ task trainer from smacc Chicago – a laryngoscope blade attached to a full beer bottle, with the challenge to see if could perform gently epiglottoscopy without inadvertently detaching the lid and losing the beer…
Meducation – in the Pub!
After a hectic full day of meducation at the smaccDUB airway workshop, we de-camped to the EMS Wolfpack ‘pop up’ session. This was one of many satellite get-togethers that happen at a conference like smacc, wherever there are like-minded people around. Walking into a small Irish pub, we were warmly greeted by prehospital colleagues…and with a few minutes drinks were poured, ultrasound gel was applied and the meducation (ultrasound & airway) began.
The Dublin folk, bless them, seemed to take this in their stride, calmly sipping on Guinness whilst around all around them live demos of sonography and intubation took place!
Difficult Airway Training with Chewie
A stand out success was the ‘Chewbacca mask’ challenge. If you haven’t already seen them, the Chewbacca mask emits a wookie roar when the mouth is opened. It is, quite simply, one of the silliest things on the market and has become a bit of an internet sensation. Of course, the roaring of a wookie is just what is needed when practicing difficult intubation….
Now this is idea is definitely DuCanto’s baby…but I have to share my impressions after making my own Chewbacca Difficult Airway Trainer post-smacc. It is great fun – not only to hear Chewie roar, but also to practice…
The premise is simple – take a Chewbacca mask and add it to the Laerdal airway trainer oropharynx; you can pick both up from eBay with relative ease (although needless to say the Chewbacca mask is easier to source)
The next step is to drill a couple of small holes in the Chewbacca mask and attach the oropharynx model; there is also a chin plate inside the mask – use fine picture hanging wire or fishing line to invisibly anchor the oropharynx to this pate within the mask (there are a couple of small screws on the oropharynx model that can be removed, wire threaded and then replaced)
I mounted the whole ensemble on some wood offcuts from the shed – the mask straps allow it to be slipped on/off with ease. Raising the mask allows the oropharynx to be placed in different positions, markedly changing the difficulty of this airway trainer….
Shades of Difficulty?
Now I am no expert at Wookie anatomy, so it took some experimentation to work out what was happening. With the oropharynx dropped distally, the intubation became a lot easier
But dropping the entire oropharynx lower (a degree of retrognathia), the intubation became incredibly gnarly…
In fact, at one point the ONLY view I could get of the cords was via the orbit…
…and of course airway geeks will be familiar with the ‘trans-orbital intubation technique’ – it’s in the literature and kind of makes sense…provided the eye is enucleated completely along with the orbital floor (see Fernando et al Anaesthesiology 2014 121 654 doi:10.1097/ALN.0b013e31829b36af)
What else is great about this trainer?
Well, it’s cheap and easy to make
It encourages you NOT to put their hands in the mouth when placing supraglottic devices (else Wookie may bite)
Allows move from Grade I to IV view (and all stages in-between) depending on positioning of the oropharynx
Can compare DL and VL views with a variety of devices (I will post some views of the C-Mac and D-blade soon)
Can practice the art of gentle epiglottoscopy & limited mouth-opening, lest unleash the Wookie roar!
It’s stupidly fun.
Thanks to the mad genius of Dr James DuCanto for this idea
There’s a fair chance that you may not be able to get passed the EMA ‘pay-per-view’ firewall, unless you have institutional access or can blag a copy off the author (thanks guys). So what did I like about this paper?
“Two is one, one is none”
First up, it’s a simple piece of research – a retrospective review of missions (2566 total; 848 prehospital, 1662 interhospital & 56 mixed) and the medications used. The first author was a medical student at the time. The paper provides a useful summary of commonly used medications for both primary and secondary retrievals….more importantly, it also informs which medications are perhaps unnecessary to carry.
Why does this matter? Well a retrieval service needs to be able to function autonomously. Kit space is limited and cost/weight considerations need to be made, especially for kit infrequently used. Cost and stability need to be factored in.
The maxim ‘two is one, one is none‘ is often applied in retrieval – place two IVs in case one is ripped out, carry spare batteries in case power fails, have redundancy in clinician skills and training….
WARNING <RANT MODE ON> Why some retrieval services don’t use a model that allows alternating RSI by doctor and RN/paramedic escapes me – better to have redundancy in airway management IMHO providing clinicians are trained to appropriate standard and operate under an agreed SOP <RANT MODE OFF>
Whilst the contents of kit packs are often determined by historical and expert opinion, as well as driven by SOPs, a retrospective audit of actual use can inform future stocking – more so if additional information from other services is shared.
Of course, the majority of cases reviewed in this paper were inter-hospital missions; it would be interesting to see how many of the medications were available at the referring institution (ie source of medication used in this retrospective analysis of case cards) as there may be scope to avoid carrying medications that are commonly available either on roadside (ambulance) or hospital eg: ipratropium, metoclopramide etc
Relevance to Rural?
Unlike the UK & NZ, only a very few rural doctors are involved in the prehospital space in Australia (a 2012 survey showed that over 50% of rural GP-anaesthetists had responded to a prehospital incident in the previous 12 months). Worryingly such responses were informal – typically activated by ambulance comms; the clinicians attending had no formal agreement for call out criteria, equipment, training nor ongoing CPD.
Of course in South Australia we have the RERN system, designed to ‘value add’ in specific cases, typically where local (mostly volunteer) ambulance officer responders cannot offer the appropriate intervention and when State-based retrieval services are not available in a timely fashion. The tyranny of distance in Australia dictates that reliance purely on metropolitan-based retrieval services and volunteer-based ambulance responders represents a potential therapeutic vacuum, where appropriately trained and equipped rural doctors with ongoing skills in emergency care/anaesthesia could value add – akin to UK BASICS.
I will certainly be re-assessing the contents of my RERN prehospital packs based on this paper, although I suspect not much will change. Similarly the results of this sort of publication may help inform the stocking of small rural hospitals.
More importantly, the published experience of Sydney HEMS in regard to post-intubation sedation protocols has immediate applicability to rural hospitals (if you can’t access the paper, my recommendation based on reading would be to use fentanyl>morphine and propofol>midazolam). Whilst my practice may not have changed, it MAY change the practice of other rural hospitals where M&M (morph/midaz) sedation may be the default. Development of a post intubation sedation SOP is one of the recommendations from this paper.
The real value is knowledge-sharing
Another thing I liked about this paper is that I know most of the authors! Luke Regan, John Glasheen and Brian Burns have all, at various times, supplied me with copies of their talks, their research and their ideas. This is because of the commonality that comes from the FOAMed community. The commitment to share.
More than that, the service within which these individuals work also has a demonstrated commitment to sharing their experience, skills and knowledge – not only by publishing such low-hanging fruit as this (and let’s face it, reproducing such a paper is an easy ‘gimme’ for any service), but also by their commitment to sharing protocols and information through other channels.
Sydney HEMS use of Twitter, Blogs and even a YouTube channel is well-established. The outcomes of their Clinical Governance Days are blogged online, along with relevant resources. Despite the potential for concerns (often expressed by health administration), sharing such information has had little disadvantage and instead offered significant advantages to the quality of the service!
Why is this important? Because I think many of the lessons from prehospital are applicable not just to those in the prehospital space, but also the rural doctor cadre and of course the wider community working in ED. We all benefit when such knowledge is shared.
We’ve seen this with lessons on safety (human factors, sim training, resus room management, action cards, checklists) and in the commitment to excellence (metacognition, measurement and refinement of training to lead to incremental change). And these lessons are now shared on a global stage.
In short, there’s no point in any organisation planning and practicing excellence, unless also reflect and learn – and most importantly, to share this information with others.
This is where Sydney HEMS have set the lead for others to follow – by enot just a commitment to clinical excellence, but also by committing to share this information widely – their engagement in use of social media, at both an individual level and institutional, has reaped significant benefits to both sharers and recipients.
By sharing they not only raise the bar for others – they raise the bar for themselves by benchmarking
Globally, clinicians looking to attend a ‘finishing school’ in prehospital care will no doubt be applying to work at Sydney HEMS as a first choice, and rightly so.
In short, this paper (although very simple research) demonstrates a useful overview of appropriate medications in the PHARM environment.
However for me it also reflects as a demonstration of the value of SoMe and FOAMed at an institutional level.
Leeuwenburg T & Hall J (2015) Tyranny of distance and rural prehospital care: Is there potential for a national rural respnder network? Emerg Med Australasia. 2015 Oct;27(5):481-4. doi: 10.1111/1742-6723.12432. Epub 2015 Jun 24.