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

PODCAST: Dr Airell Hodgkinson

Gday and welcome back to the podcast after a short hiatus as I checked out the fish in Fiji…  Ahhh.

Today’s podcast is a conversation I had with my former colleague and mentor Dr Airell Hodgkinson.  Airell is a rural GP Anesthetist based in Albany – the southern end of WA.

He is a real thinker and has similar interests in trying to ensure our rural patients get the best quality care which they deserve.  Airell has recently concluded an audit of the local Albany cohort of “fractured NOF” patients.  He has collected the data to see how this group of high risk patients fare in Albany and compared it to those whom were transferred to a metropolitan hospital for surgery / anaesthesia etc.

The data is quite interesting – but not yet published… so watch this space.

Although it is an audit of older people with NOFs – there is a lot we can learn from this review – particualry when it comes to the decsion-making around transferring rural patients to tertiary care for serious illness.  Although it seems like a good idea on first thought – one has to consider a lot of factors when making these decisions with our patients.  As there are a lot of problems associated with transfer – especially for conditions with a time-critical course and where the rate of bad outcomes can be high.

From the outset – the Broome Docs motto has been: “delivering great care, out there!”  And it is something that I think about a lot – are we doing the best thing by this patient by keeping them in a small rural cetre – or could they get better care in the city?  This is a really tough call – especially when the patient wants to stay in the bush and for you to do “your best”.

In Broome, our capacity to provide great care has increased in recent years for conditions like sepsis, mental health clients, trauma and other medical emergencies.  As such the lines have moved in terms of who we keep or whom we send “south” (or east!)  Most of my practice is shaped by anecdote and receny bias – so it is really nice to see Airell has managed to collect some hard data around a group of patients where there is no good answer often.  This is a dynamic and wicked problem – one where there are many unknowns. BUt now we have a bit of data to have htat important discussion with our patients before deciding on the best place for their care.

OK – onto the podcast!
DOWNLOAD HERE

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.

Clinical Case 096: Abdominal Ambiguity

Gday. Another quick case from the surgical files!  This is a diagnostic case that plays out intra-operatively. Put your thinking caps on – when does your “penny drop”?

This is probably more for the Anaesthesia types, but there is plenty in here for the ED docs and even surgeons out there.  Here we go:

46 year old man, a traveller – on his way around the north of Australia.  Usually fit and well, working miscellaneous manual-labour jobs to pay his way.

This chap had hitched a ride into town the day prior from a remote camping spot. He had noticed some “crampy belly pain” overnight – so thought he would pop into town for a check up….

At triage he reports: intermittent, central abdo pain that has become more right-sided and severe over the past 12 hours.  He is feeling “full”, not wanting to eat, vomited once en route this AM.  He gets a “cat 3” score, a bed and an IVC.  The triage note simply says: “46yo M, ?appendix

The trusty RMO gets the history – thin, well smoker.  Not much PMHx, had an inguinal hernia repair 20 years ago – otherwise a virgin abdo. No meds, no other chronic problems.

Obs:  T = 37.6, pulse = 100,  BP = 120/60  RR = 18/min  He is reporting a pain score of 7/10.   His pain settles with 10 mg of IV morphine.

On exam: tender over much of the lower abdo, right-side more than left.  Percussion tenderness at McBurnie’s point.

I heard about this case when the phone rang in theatre – I was doing an Anaesthesia list for the local Gynae.  The ED team were pretty sure he would get a look in OT and it was nearly sundown – so they wanted to let us know not to close up shop for the day!  The surgeon had been called to review in ED….

Ten minutes later we got a call form the Surgeon – he wanted to get this chap on the table tonight.  Now this was an old school surgeon – one that was happy to call it clinically.  No imaging or bloods required.  The story and exam did fit nicely with Appy, he was sore enough to suggest it was progressive and needed something doing.  So off to OT…

Yes hard to believe, I know! There are still places where surgeons operate without definitive imaging – they are fun places to work!

My Anaesthetic assessment was pretty dull – same as the ED notes.  Thin, fit, normal airway, looked like a dream tube.  Was still breathing up with a bit of pain in the holding bay.  The plan was for a “quick open appendix”.  Love the old school surgeons – no laparosopic adventuring when it is keeping us all out of bed!

Induction went well on 100 mcg fentanyl, 100 mg sux and enough propofol to do the trick.  Tube fell in easy and onto the vent….   now our first clue that something is awry.   The end-tidal CO2 on the first few vent cycles  comes back at 23 mmHg.

What does it mean?  We love the ET CO2 in Anesthesia-land.  You get A, B and C in a single squiggly line!

Airway is good – tube was easy, position check is OK, and we are seeing regular rise & fall of the CO2

Breathing seems OK – chest is moving well, the vent is happy with nice, skinny low pressures and we are reaching target volumes and a sensible MV.  SpO2 is 100% for what it is worth.  He was not bagged in the 25 seconds of apnoea…

Circulation – is the CO2 low because he has crappy output?    Nope – the BP is still 120/60,  pulse is 75 – hasn’t gone brady.  Looks like he is well perfused.  The volatile is washing in and he is peripherally flushed & pink.

So – why is the CO2 so low?  Sure he was breathing up pre-op… thought that was pain – nothing a slug of fentanyl shouldn’t fix???

Anyway – onwards – the Surgeon is true to form – he has cracked open the gridiron incision.  However, as he opens the peritoneum he starts to mutter…..  Occasionally we gas docs do wonder what it is that is going on down that end.  So I lean over the drapes for a gander – hmmm.  There is a good volume of haemoserous fluid pouring out of the incision – the scrub nurse is sucking it up, we are up to 300 mls before it starts to slow.  That is a bit odd – not the norm for an appendix – no pus, just lots of bloody serous fluid.

To make conversation (and try work out what the heck is going on) I ask: “Have you ever seen that before in appendicitis?”   There is no answer, just some brow furrowing.  Our surgeon is clearly deep in thought and is now looking for the offending appendage.

Meanwhile at the brain end of the room – the ET CO2 is falling now with relatively low volume ventilation – it is now 22 mmHg… and the BP is not looking so hot – that is down to 80/40 with a tachycardia developing 110/min.  So I do what Anesthetic folk do – a few boluses of metaraminol.  This seems to help the numbers.  Odd – he didn’t seem that sick or septic pre-op, yet he is behaving like one of those really nasty, peritoneal sepsis type appendix disasters on the table.  Reassured by a good heart and ‘young’ physiology I decide to wait & see what happens.

5 minutes later I peek over the drapes again.  Expecting to see an appendix with a few loops cast about it – I am disappointed to find the team preparing to open the midline.  A bigger cut, something is not right….
“Ahhemm! How is it going?”  I wonder.

The reply is along the lines of – well this is not appendicitis.  In true surgical form I am assured that we will know the diagnosis in a few minutes once the belly is properly opened.   Off I go looking for some longer acting paralytic – this is going to take a while!

OK.  SPOILER – I am about to reveal the diagnosis.  So take a moment to ponder your thoughts.  What else could be going on.  Not much to go on admittedly – as Vonnegut would say… “So it goes.”

About 4 metres of dead small boweldead gut.
 Suddenly the numbers all became clear – this was a seriously sick patient, compensating remarkably, but truly on the brink of collapse.

Time to change into the brown scrubs!  There is work to be done.

The CO2 was right all along – this is a guy with a good going metabolic acidosis, and a faltering cardiac output now thanks to my “routine RSI GA”.

First move – crank the ventilator.  We need to return the CO2 from whence it came – get that pH up ASAP.  But too much volume might kill the venous return – so I opted for a brisk RR and maintained ~ 6 ml/kg Vt.

Next – a big IVC, bolus of crystalloid.  I am a Hartman’s man when I am flying blind like this.  IS this the right thing to do?

I am not sure – the recent literature on fluid Resus and discussion in the FOAMed world has been controversial to say the least.  Is giving a big bolus going to do damage to this man’s fragile glycocalyx and lead to horrible organ failure win ICU in a few days?  Or is the Sevoflurane I am using going to protect his endothelium?  Should I use exogenous fluid bolus or use some pressors to squeeze the venous side and achieve the same ends?

I grab a VBG at the same time.  

pH = 7.05,  pO2 =40, pCO2 = 27, HCO3 = 10 BE = -12 Lactate = 7.7 Gluc = 8.0

It was at about this point I was recalling all the times I had derided the ED junior Docs for ordering all those “unnecessary” bloods and X-rays in the work up of belly pain.  Clearly this was the exception that proves the rule??

After a few litres of fluid – the BP is still pretty crappy and I have backed off on the volatile as much as I was comfortable.  I have used an amp of metaraminol by this stage – time to change plans.  I need to know what the heart is doing.  Is this an under filled heaving, healthy heart, or a sluggish poisoned pump?

So how does one go about making this call mid-operation.  Access is limited by the surgical drapes.  I can put a CVC into the IJ – but we all know that the CVP is a really silly number.  Still – it will be handy to run some pressors, and lets face it – this man is very likely going to a better place soon where he will certainly get one anyway!

Urine output…. a good thought.. but… there is no IDC in the bladder – this was going to be a quick in/out case.

So my plan of course involved ultrasound.  Instead of asking for the usual machine that lives in OT I really wanted the ECHO probe as well.

We do not have any fancy Cardiac Output monitoring devices – no oesophageal Doppler or USCOM etc.  However, in a thin guy on the table – a couple of parasternal ECHO views are usually achievable.  I reckon we can get an idea of the heart’s status with some reliability.  I am not suggesting we all do VTI and calculate the CO to 3 decimal places!  I just have an eyeball and say – is this heart hyperdynamic or underfilled, or is it hypodynamic.

Some information was forthcoming from my learned friend on the cutting side of the drapes – he noted that the ischemic bowel was full of haemoserous fluid – the mythical “3rd space”? There must have been 3 or 4 litres in what he was removing.

Unsurprisingly then the ECHO pics showed –  a really hyper dynamic heart with a collapsing LV – the EF was nearing 110%!  Ah – young patients – they can compensate so well without much to show on the surface!

OK – by the time the surgery was finished we had a 46 yo guy with a nasty ischemic gut.  He had lost about 75% of his small intestine.  An ileostomy was formed.

The metabolic acidosis had improved and I was able to wind back the vent a bit.  But the settings were :  RR 24, Vt = 440 ml with 5 of PEEP.  This was giving an ET CO2 of 33 and the latest ABG showed a pH of 7.25, lactate down to 3.1 and other numbers returning to normal.

He was loaded with opiates and ketamine and all the usual adjuncts for pain and nausea.

My question to you.  It is now 10 PM.  You are in a smallish hospital with no ICU.  The retrieval team have advised they won’t be there until after sunrise at best.

This is the dilemma – do you keep him tubed, ventilated and transfer to ICU tomorrow?  Or do you wake him up – run the risk he might hypoventilate and decompensate his acidosis in recovery… but free him from the potential downside of prolonged intubation etc.  Transferring him awake is much safer from the flight team’s perspective.

Oh – and why did he get dead gut.  Well I could tell you, but it would be more fun if you guessed – let me know your thoughts on the comments below!

Lots to discuss on this case.  Break your comments down into: Diagnostic, Biases / errors, Critique of my approach and Disposition.

Casey