Emergency Surgical Airway

Hi, My name is Keith Greenland.
I'm a fellow of the Australian
and New Zealand College of Anaesthetists and also a fellow of the Hong Kong College of Anaesthesiologists.
I received an MD from the
University of Queensland in April 2011
on a thesis
looking at a new approach to difficult airway management.
This
film clip is one of a series I produced based on the work I've being doing over the last seven years.
This particular lecture is looking at emergency surgical airway
the facts and fiction
and really looking at focusing on the
non-technical skills
associated when
a can't intubate can't oxygenate scenario occurs.
First of all this talk, is, should not be seen as critical
of any of the teaching them methods currently
performed when teaching the can't intubate can't oxygenate scenario
the CICO.
Indeed there is a lot of good
work that is being done however I'd like to highlight possible areas for further
development
in the teaching methods. So I don't feel that the glass is half-empty
it is probably if anything
half full.
One of the highlights of what we teach is the importance to emphasise the
fact that manikin
workshops
probably
are just a first step in the
teaching of how to perform an emergency surgical airway
Afterall a manikin doesn't replicate some of the scenarios that are shown on the outside
that lead to a can't intubate can't oxygenate
situation.
However, that's not to say that the manikin workshops should be abandoned.
Indeed they shouldn't they are just simply the foundation for teaching what's
in your
emergency surgical airway kit.
It teaches you cannulaes, scalpels
bougies,
tubes,
and so forth. What's in the kit and how to use them, in what order.
It does not always obviously teach you the scenario
but simply the mechanics of doing an emergency surgical airway.
So one
needs to emphasise that if you are going to teach manikin
emergency surgical airway that there is a belief that you can do
an emeregency surgical airway in any situation.
This if anything is a lie within the belief
that we have to ourselves.
You need to be able to appreciate the fact that
a CICO
may come out of nowhere
and be very insidious
onset.
On top of that there may be issues
particularly
that may make
an emergency surgical airway very difficult.
For instance,
in this situation it should be relatively easy. And manikins if anything
replicate this type of condition. This is the lingual tonsil, this patient has actually
given permission
for her photograph to be used here.
Here we have a lingual tonsil
which can easily lead to bleeding and oedema of the airway
but her external anatomy is fairly well defined
and an emergency surgical airway should be straightforward.
So a manikin
workshop does
help with the performance
on this type of patient.
Howeever a manikin does not, workshop does not, help with these
types of patients
where a distortion of the anatomy
can be very difficult or indeed where morbid obesity is a problem.
So
really of all the manikins that are available there is only a limited number that
are any good for teaching emergency surgical airway, the bottom right.
Here
the "Bill 1"
is appropriate the others are not.
So one has to be careful about how we teach it
and recognise the limitations
we don't have a mannikin that
has a short neck or morbidly obese there are certainly manikins that
provide
degree of pharyngeal swelling, or tongue swelling
restrict neck movement
but this in the
reflection of the variety of causes of a CICO scenario
is fairly limited and needs to be explored more with the manufacturers.
Second issue is the psychological step
going from the dry
wet lab scenario to the actual clinical coalface
I often talk to trainees and if mentioned in exam process if
they have a CICO scenario they often say oh yes I would cut the neck
but as I said before
a CICO scenario may be fairly insidious in onset
and that's what I would like to explore now so the decision making process
becomes a very
important non-technical
skill that needs to be addressed along with just the technique of how to
do an emergency surgical airway.
Let's just look at
a particular scenario here.
We got a patient that's been a straightforward
grade II intubation with a
a prolonged anaesthetic of two hours
fairly tram tracking
haemodynamics
but has had a
been extubated and had a problem
with their airway
the operator here
is struggling
to maintain the airway
there is some
gas being moved
but the pulse oximeters slowing dropping.
He's not sure what needs to be done. Should the patient be further anaesthetised
reanaesthetised
should the patient be reversed
should there be CPAP provided
a Guedel airway, nasopharyngeal airway
should they put an LMA in
should that put a tube back down? These are all things that are going through
there
mind, along with
their concern of their reputation, their credibility
possibly even legal action and employment
if things go bad.
Assistance may come in various sizes. Some step forward and are very helpful in this
sort of situation to provide what assistance they can.
There are others who are more afraid of the situation and with the unclear role
that that is required of them
may feel that they need to fix on other
minor issues or
hoping that they don't get involved so the approach to a CICO
or an emergency surgical airway
should be a team approach. And training
should involve both the ancilliary staff as well as
the anesthetists at the coalface.
Indeed surgeons
may recognise there is a problem
because of what's going on with the patient
but is unsure what to do
because the anaesthetist has had little
or no communication with them
but they're standing back
aware that there seems to be some difficulties.
Other nursing staff in the situation
may be preoccupied with other tasks at hand such as
paper work or processing them for the next patient
and be unaware that there is a problem
because of their fixation on other
other issues.
Indeed it may be a very junior staff, nursing staff for example, in this scenario
is aware that there is a problem but unsure exactly what the
problem is, but still there is a problem
and goes to find
somebody to help.
Now this person enters the scenario with two clear
thought patterns in mind. First of all
they are aware that there is an emergency because they've been asked to come
in
so they are already thinking, How do I handle an emergency situation?
And secondly, and this is not to be, appear to be too blunt
but they are coming in, realised
feeling that it is not their problem that the other having to help solve
but the operators problem the first operators problem.
So they therefor have a license to provide an alternative treatments which
can be taken on by the first operator or not
because the first operator still
holds the final responsibility
so they have no previous knowledge of the case
except that there is simply an emergency going on and so they are already considering
emergency algorithms
possibly even before they enter theatre
so it's interesting that we often have a situation where there is a lot of staff
within the scenario, yet
there is actually somebody from outside.
And this is the one of the
key issues when we call for help
it's not necessarily a call for
technical skills
but it's actually a call for non-technical skills, the decision making
process, the saviour comes in and says
I think you should do a surgical airway.
At which point the first operator
thinks, yes you're right.
I should have done that I'll do it now.
I would said that this play, if you will
is so heavily scripted
that the first operator and the saviour
can even swap roles, that people can swap roles and the same play would
play out. That they first operator if they were made to be the saviour would come
in
with the same thought processes.
First there's an emergency and secondly
that they are just there to support
and they
don't have the final responsibility.
They can actually they give advice to the first operator
who is then the saviour
to actually provide the correct pathway.
The one thing that would appear to confound this, is that your if the saviour is
actually a very junior person
and the first operator is experienced. So the saviour comes in being a
junior person comes in thinking there's an emergency but looking at the
first operator and thinking well
he's very experienced I'm just here to provide
technical skill
no non-technical skills. I'm not
experienced enough
and that can lead to a very serious outcome for the patient.
A case in point Jankowski in Royal Perth Hospital 2001.
This is a report from the coroner
that's available on the internet
It's a 39 year-old father of two
for surgical drainage of a dental abscess
limited mouth opening
the patient was anaesthetised with propofol spont breathing with a nasal intubation via a
fibreoptic bronchoscope
the dental abscess was drained
and morphine, penicillin
and metronidazole were provided. No dexamethasone was provided intraoperatively
Post procedure the anesthetist and the surgeon both agreed
for extubation
and this occurred and the patient was transferred to PACU
to await a HDU bed.
Two hours later
after giving adrenaline nebuliser for stridor
the patient became restless
and the decision was to reintubate the patient and the equipment was
requested.
With loss of consciousness the bag mask led to abdominal distension
laryngoscopy was unsuccessful one insertion of a bougie was attempted.
and the tube was inserted over the bougie
and possible breath sounds and movement was noted but bradycardia
led to the request for a capnograph.
This device was turned on and waited for calibration, further
abdominal occurred
no capnograph tracing
was visible.
The request for a fibreoptic scope
was made
the light source unfortunately malfunctioned
laryngoscopy was attempted again unsuccessfully
CPR was then started
cricothyroid
cricothyroid puncture was attempted twice
but was unsuccessful, a long blade was attempted, blind nasal was attempted
LMA was inserted
and finally a scalpel
cricothyroidotomy was performed with CO2.
Unfortunately the patient
was brain dead and was transferred to ICU to die three days later.
The implications from the coroner for this case
are numbered. First of all, difficult airway equipment with CO2 detection should be
available in PACU and clinical areas.
Training in non-
surgical difficult airway
management should be
improved
and training in surgical airway management also should be improved.
Complex airway patients
should have immediate access
to skilled medical care.
So this talk really focuses not so much on the
technical skills, but the non-technical
skills that
comes out in these situations.
Elaine Bromley
is another case in point
a 37 year old woman in good health
married to an airline pilot
Martin Bromley
and mother of two.
She was booked
for an endoscopic sinus surgery and septoplasty
as a GA in March, 2005.
The anaesthetic was started at 0835
and it was going to be a flexible
reinforced LMA but that couldn't be inserted
she became cyanosed
and further attempts at bag masking was attempted,
which was
unsuccessful.
Attempted tracheal intubation took place, but that was unsuccessful. A second
anaesthetist and ENT surgeon
arrived.
No airway was still achieved at this time
and sats were down at forty percent
the nurses brought in the trachy kit
they said we have the trachy kit available
but they didn't receive any
reply back from the
medical stuff and they weren't sure whether they were heard
or were being ignored.
But the kit
was available, the equipment was available and the surgeon,
at least the level of expertise was available. Yet
laryngoscopy, supraglottic
attempts continued
further laryngoscopy was, failed including
that performed by the surgeon
the Fastrach, intubating LMA was inserted
saturations
came up to 90 but we're not stable at 90
and attempts at intubating through the
the intubating LMA was attempted but failed.
So the procedures was abandond and she was sent to
recovery
but unfortunately she was admitted to ICU and died
some 13 days later.
So we have a problem
of the decision making process where no matter what the cause in Elaine Bromley
the problem was that there was no attempt not even a single attempt
at performing
an emergency surgical airway
despite the availability
of not only the equipment
but the
expertise.
Martin Bromley has said many things in relation to his wife's death. At the inquest
they all talked about what they should have done
but none could understand why they hadn't taken the actions they themselves expected
to have taken.
This is a interesting
particular case because there was not
even an attempt at a surgical airway, so the non-technical skills are
what's very important here.
Interestingly in the sociology of the OR
we have various teams or crews
surgical, anesthetic, nursing
but there is
a lack of hierarchy overall
its crew has its own hierarchy and structure
but there is an ambiguous command
structure in the OR, especially in this sort of situation.
Interestingly if you take Elaine Bromley for a moment and hypothesise that you put her
into
a major war zone
and she has a
bomb blow-up, she has torrential bleeding from her middle third leading
to a can't intubate can't oxygenate scenario
one would postulate that it would be a lot
more acceptable to do a trachy, an emergency surgical airway in that scenario
than if she was
where she was, which was in a
private hospital undergoing an elective procedure.
So what does it take to make that decision? Why does
a patient in the war zone
have a higher chance of having a trachy
to being done at the appropriate time
than it does in an elective situation
we have a lot of information about crisis management from a variety
of different sources.
A lot of this is been crisis management from firefighers, swat
teams, ambulance and so forth.
But these people go to work expecting
that there will be a problem
there will be a crisis, they are trained in crisis management
but are we that well trained in our own
scenarios? Whether it's pilots or particularly as doctors are we trained
well enough
in how to handle the crisis.
After all
we expect that the crises will be very rare.
So the fact that they, when they do occur
is can be somewhat unexpected and therefore leads to delays
in decision making
We have a difference I feel
between pilots and ourselves
pilots are often trained in one particular
plane, but every patient that comes through
in a way is a different plane
a different scenario
so we have to expect
things they're going to be
not as mechanical as it might be
for a pilot.
When mortality does occur, it's handled at a fairly limited way
often they may occur in an M&M in a department or a hospital
or even go to a root cause analysis within a district
but they
rarely lead to reports at the state,
national,
or international levels.
For, for instance in the UK, has done
a great deal of
important work
in as far as looking at a national

collection of data.
But we need to take it even further and provide a
basis for an international collection of daughter for these fairly
rare events that end up being fairly catastrophic.
But fortunately the limited way we do it is often leads to

senior staff being
looking at the information that is being provided
and there's various
fairly nonspecific answers
such as
human error,
bad procedure, act of god
which really doesn't provide with a
solid way of providing a change to practice
that needs to occur.
The suggestion has been made
by a docotor in our department Steve Cook
for instance a monitor that has a mechanical voice for
instance that low sats below 70 for three minutes
with no CO2 would say "Perform a surgical airway now"
this is not without precedent for instance pilots have
got a
ground proximity warning system that says "Terrain terrain, pull up now"
and certainly the many
shopping centres and airports have got
automatic defibrillators that don't have a reading
doesn't have a tracing for you because you'll probably argue with the
tracing it just says shock now.
So this is not without precedent it's quite a reasonable
approach
however we have a problem
that is
we are actually taught
some
may be possible
hazardous thought patterns
the we develop a self-reliance that we can monitor the situation
without a monitor telling us what to do.
We do then over time develop various
type of
hazardous though paterns
that have been well identified in the aviation industry
anti-authority, don't tell me what to do you're not my boss,
it won't happen to me,
what's the use it's out of my hands, it's up to the surgeon,
do it quickly do anything.
The macho, I'll show you I can do it,
I can intubate the trachea on anyone.
So how do we manage it? Crisis management
in Anaesthesiology, by David Gabba
Fish and Howeard
is a good basis
this is a modification
from that book
and we're looking at the can't intubate, can't oxygenate
modification to that diagram.
So the availability of equipment
in the environement
the patient
teaching the different scenarios and the training of the operator is critical.
So
what we're trying to do at least in Asutralia is standardise the difficult airway trolley with
TG4(ANZCA professional document)
but we still need to do more research
and the application of equipment
for the CICO scenario
training we are limited, but still going ahead with manikin and animal
workshops around Australia.
but assisting in elective tracheostomy has been suggested as a way of
teaching anaesthetists how to actually handle tissues
mortality morbidity feedback is important
part of teaching and centralising coroners inquests
results from all of the states
and feeding that back to the college
should be a consideration.
Teaching situational awareness
does occur in EMAC
and various other workshops
and needs to be emphasised further though
and then finally teaching the role management during a crisis is a critical area
So really the only answer I think is
situational awareness
and that comes from specific training to the anaesthetic
trainees.
Afterall if we handle a crisis well
as in "Sully"
who managed to land
his plane on the Hudson river,

then if we can appropriately
handle the non-clinical, non-technical as well as the technical
skills
we have a good result.
But there are other situations
which have occurred, not handled well
and I think we do need as a college
and as a fraternity of
anaesthetists need to look at
how we handle, and we are responsible even for the rare deaths that occur
because after all the airway is our forte
and we need to actually
report back
on any occurrence
of deaths or morbidity
that are associated with the loss of that airway.
So we can see that there are a number of aspects
of the training of the can't intubate, can't oxygenate scenario and the emergency surgical airway
that need to be addressed now and in the future.
The idea of teaching manikin
is just the beginning
there needs to be a teaching of clinical scenarios that lead to CICO.

On top of that
is the non-technical skills that also need to be incorporated in the teaching program.
In the end the technical skills of how to do an emergency surgical airway are relatively
easy compared to the non-technical skills of how to make the decision
appropriately in a good time frame. Thankyou.