Dr Dave Forster: A tough airway made easy

Welcome back!  Apologies for being away for a few weeks.  You may know that a large part of the FOAM community was attacked, hacked and disabled by malignant robots last month.

Thanks to Dr Mike Cadogan and his band of merry men we are now back online along with other awesome sites that fell victim to this pillaging ( KIDocs, St Emlyns, The RAGE podcast, etc).

In case you missed the podcast was still alive during the carnage over at the LITFL bunker… and I managed to record a little chat with my local hero and fellow Broome Doc – Dave Forster.

Dave is a man of many talents, he is a gadget guy = remote controlled airplanes etc.  He is therefore a master of the Atari and fiberoptic bronchoscope!  And many don’t know this – but if you download the free “Introduction to Bedside Ultrasound” textbook and check out the SUSSIT chapter – his is the really, really hairy chest used for still images.  (And yes, he does routinely wear a Bon Jovi T-shirt to work… overdressed for Broome some might say 😉

Dave F

What a man: sono-model and master of the airways.  You can even follow him on Twitter after a few years of arm twisting he is on there @DavidFo00088350

In this podcast he outlines his approach to a really tough, “back to the wall” case where an airway needed to be placed in a really difficult scenario.

Sure there are some great technical pearls in here, but for me it is all about the team and how a confident, communicative leader can turn a shit storm into a sleigh ride.

Have a listen HERE.  Then spend a moment thanking Mike Cadogan and his team for all this stuff that you, our fantastic audience, get for free.  Without folk like Mike we would not have FOAM… and the Medical world would be a bigger, emptier and less safe place.

Casey

Surviving Sedation 2015

It has been a busy month behind the scenes here at Broome Docs – lots of big projects and plans going on…  wait and see what we are have in the offing.

One project that I have been working on with a group of great clinicians from all over Australia.  It is called SURVIVING SEDATION 2015. Yes – that is a deliberate pun on the “Surviving Sepsis Guidelines” – and we want to install the idea that this is a high stakes situation, with lots of potential morbidity and unfortunate track record of mortality for these patients.  The goal is to use early, goal-directed sedation to maintain a safe environment for staff and allow patients to be cared for in a standardised, safe fashion.

We have been sharing ideas, data and experience around the acute sedation of patients with psychosis or other behavioural disturbance.  If you have been following the blog from the outset – then you will know that this is something that I am passionate about.  There have been a lot of changes to the way I practice when it comes to sedating Psychiatric patients.  This set of guidelines represents the vest available evidence, interpreted by front-line clinicians and presented in as simple, usable possible format.

Our lead “author” is Dr Minh le Cong – @ketaminh – the foremost Aussie researcher in Psychiatric retrieval.  Also on the panel were Dr Tim Leeuwenburg @Kangaroobeach , Dr Andy Buck @edexam and Dr George Douros.

Pre-publication peer review was also done by Dr Amit Maini @sithlord2004, Dr Peter Fritz @pzfritz & Dr Michael Downes @ToxTalks.

It is really difficult to write a set of guidelines that can be applied to all scenarios – our panel practice everywhere from major tertiary EDs to tiny remote clinics with near-zero resources for this scenario.  There is also a lot of variation in practice depending on your location. Many practitioners are working in locations that need to transfer Mental Health clients by air to a secure facility. Others work in hospitals that can provide this care immediately [though often not…]   However, as a panel we have tried to come up with a basic toolkit of medications, a strategy and logistical considerations that may be applied in any setting.

For the full detail of the rationale – pop over to Minh’s blog on the PHARM to read his thoughts.

The actual short version (2 pages – front and back) is designed to be laminated for reference in the clinic / ED / ward etc.

You can see it HERE SURVIVING SEDATION 2015

I am going to leave it up on the blog here in the permanent top menu under clinical resources.

SO – what is new in this set of guidelines?  Nothing too controversial.  The main changes are to the way we plan the sedation.

  1. Treat any Psych sedation as a “procedural sedation” – where the procedure is the safety of the patient +/- transfer to an appropriate centre.
  2. Pharmacological minimalism – using less agents in a titrated fashion
  3. There is a specific objective sedation score (SAT) – with goals of therapy clearly laid out.
  4. Ketamine is used in several potential situations: as a 2nd line IV / IMI agent in severe agitation and also as an infusion for transfer by air.
  5. There is emphasis placed on making a pre-sedation assessment of the airway / Anaesthetic / medical risk of sedation for a given patient.
  6. We have deliberately recommended that appropriate airway equipment and personnel be present.  No more dark, back room sedation supervised by the grad nurse up the far end of the ward.
  7. You will notice that midazolam does NOT feature in the mix.  This is the result of several papers showing it can be dangerous.  Diazepam is the chosen benzo – although this was largely due to its wide availability and clinical familiarity.  [Personally I will be using long-acting benzos such as clonazepam or lorazepam in my ED.]

Now it is your turn – I know that there are a lot of experts out there – and I want to hear your thoughts on this project.  So please have a read of the guidelines and the rationale on the PHARM site. Let us know what you like, don’t like or disagree with.  If you have any evidence that you feel might be incorporated – then send me the link.

Thanks

Safe sedating team

Casey

Resus Room Feng Shui

Just had to reblog this one.  My mate and fellow “madman” of rural FOAM has just posted his SMACC talk slides for you all to check out – he was a star of the SMACC stage and did a great job selling the rural scene as the place to do great Medicine .

 

So Check out his talk here: Resus Room Feng Shui

If you are a rural doc and want to know what all the FOAM noise is about – then this is a good place to start.

If you are just finding your way, and want to be better at the cold face of trauma, critical care or other medical malady – then watch this and you will have a great base to start to shape your practice.

Thanks Tim

C

O.A.S.I.S. : Optimal Airway Strategy In Situation

So you might have noticed a bit of banter in the community about airway management in the last few weeks!  What’s new?

[ I usually try to stay out of the airway stuff – as there are many brighter and more expert “airway bloggers” out there. ]

A lot of debate about cricoid pressure and the way we do this in a medico-legal system where expert opinion is not consistent or often appropriate to the setting in which we practice.

My good mate Dr Tim Leeuwenburg has been pondering this topic deeply in the last week or so and has tried to reach a consensus – a deep dive into the literature around emergency airway management with all of its dogmatic idiosyncrasies and variations.  The idea is that we need a template which we can all agree upon.  We need a set of workable guidelines as to what constitutes “best practice” in 2014.  However….

…the problem is that there are many ways to skin a cat.  There are many different situations in which one might flay a feline, many different morphs of moggy and there are a lot of varieties of domestic taxidermists out there with a range of skills, tools, preferences and training.

One might argue that writing a consensus statement around this is like trying to… herd cats.  Too many variables – prehospital, ED, in helicopter, ICU, in CT scanner or a well-lit OT.  And that is just in location, before we even consider the other variables.  Is it really appropriate to try and define a standard that covers…?

  • an occasional intubator by the roadside at night using a spoon and the reflected light off of his high-beams,
  • an ED with lots of junior trainees, supervision and plenty of resources
  • a post-op ICU with a consistently sick, difficult airway [surgically inevitable] patient population
  • a small country hospital with a heterogenous mix of practitioners working with a team that changes daily with high staff turnover.
  • an elective theatre suite with  high-volumes of fasted, well prepared and healthy patients?

In case you were wondering about my answer to this question…  “No!” in a word.  There is no single standard that we can apply.  In my opinion even recommending a basic minimum standard is unrealistic / unachievable in some settings.  Tim gave a fantastic talk at SMACC GOLD about his rural Resus room feng-shui.  But trust me, he is an exceptional Doc and an exception to the rules when it comes to remote and rural emergency airway practice.

Sure, you can argue the merits of evidence for or against a particular manoeuvre [cricoid pressure, Apnoeic oxygenation, ramping….]  and that is all OK. What we need in this debate is to have better data to replace the dogma that has little evidentiary basis.  I sense a communal breath-holding {excuse the pun} for more evidence to guide us.  However – what should we do in the meantime?

So I have been thinking about a hypothetical scenario.  Imagine that you were asked by some MDO lawyers to act as an ‘expert’ witness in the case of an airway disaster involving one of my fellow rural GPs. [ I am not likely to do this any time soon 😉 ]

The thought experiment is as follows: what would you state when asked by the judge to define the ‘standard of care’ for emergency airway management?  Could you do this in simple terms without boring the assembled legal minds to death with jargon and dogma that really is as clear as mud?  Could you make a case for the accepted variations in practice around the country / world?

Well here is how I might answer the question:

  1. At the present time there are multiple safe and reliable approaches to airway management in emergency care.
  2. There are a number of specific techniques and manoeuvres which might be utilised in differing settings
  3. One must consider the following factors in choosing the specific strategy:
    • The team’s experience / skill set
    • The patient:  premorbid state and acute problem
    • The resources and equipment available
    • The environment – geographic, lighting, access to the patient etc.
    • Alternative options – such as delaying intervention, temporising therapies or getting more support
  4. The chosen strategy should include a pre-defined set of alternate options should ‘plan A’ fail

In summary – the practitioner should be able to provide the Optimal Airway Strategy In the Situation  (O.A.S.I.S).  In many situations the OASIS will in fact be a ‘formal’ RSI with all the traditionally described drugs, gear and team set-up.  However, we must be aware that there is a range of acceptable practice patterns and that in many situations these will be preferable to what has been described traditionally. (For, example: cricoid pressure would appear to be a poor utilisation of resources in a team of 2.)

So – that is my answer.  I am introducing a new meme – the acronym OASIS.  We can use this term to describe the best airway strategy for that team, at the time in the situation they find themselves.

Now just to be clear – I do not think that this is a justification for rampant pragmatism or “fly by the seat of one’s pants” medicine.  One must understand all the evidence and have multiple tools in the cognitive and practical toolbox in order to achieve an OASIS on any given day.

So if you find yourself on the pointy end of criticism about your airway management – I would be more than happy to defend you if it were clear that you were going for the OASIS in the desert you found yourself.

And it is worth saying that at the institutional level we ought to be making our hospital, clinic, theatre (or car in Tim’s case) into a fertile OASIS.  We should have the kit & training to provide a range of OASISes for our patients.

OK enough said.  Try it out – next time that you decide to smoke the blue cigar ask yourself first – what is our OASIS?

Casey

PS: there has been a Twitter meltdown over this involving the usual airway Foamies – so we have created a Google discussion thread on the Broome Docs community page to make it more workable and leave all the nice twitter followers in peace!

Here is the link : https://plus.google.com/u/0/communities/112402831578834720667

Clinical Case 099: To Lose One’s Marbles

A quick clinical case this week – it is a classical problem with kids – the airway foreign body.  I know there are a few ways to skin the proverbial cat – so I want to hear your approach.

The setting is a small ED, no specialists – just the trusty old GP generalist plugging away over a long weekend.

A family arrive at triage in a state of panic.  The Mum is carrying a small child – about 2 years old / 15 kg.

The story:  the kids were all playing in the “other room” when the 6 year old came into the kitchen to tell Mum that Billy had started coughing and choking.  Like a mafia hit – nobody saw nothing….  the kids are all tight lipped about what happened.

Mum found the little guy sitting on the floor in a tripod position.  He was gagging and looked pale.  She tried to calm him, but noted he was breathing “like Darth Vader” – “really loud noises coming from his throat.”  The noises settled once he relaxed a bit and she gave him a cuddle.  She tried to get him to drink some water but he refused.

They all got bundled into the car as potential witnesses and rushed into ED!  On questioning there were innumerable potential objects in the play area that might have been inhaled / swallowed / eaten…

Initial Obs are all normal – no hypoxia or tachypnoea.  He has no audible stridor until…. you try to examine his mouth.

As soon as you make a movement in the direction of his face he starts crying and there is an unmistakable stridor. It sounds like a whistle.  OK – so this is for real – there is something in there!  Auscultation of the chest is clear – but that whistle is everywhere.

OK – We will stop the story there and ask a few questions.

Q1:  Is there any benefit or harm potential in persisting with examination of his throat?

Q2:  Imaging – would you get an Xray?  Will it change your management if you are pretty sure there is an upper airway FB?

Q3:  OK – lets say he is going for an attempted manual extraction in theatre.  What is your Anaesthetic plan?  Or what is the lis tot Do’s and Don’ts in this setting.