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Sunday, August 5, 2012

The Stanford Advanced Airway Management and Fiberoptics Course--learning to put tubes down peoples' throats to help them breathe

The actual secret to long life is continuing to breathe. The body has many amazing processes that go on all the time, little tiny molecular ones and microscopic cellular ones, organs that digest, produce hormones, pump blood, big juicy custard-like organs that think thoughts, stringy nerves and muscles that propel us, reproductive organs that beget poetry and children. It would be hard to judge any of them as being the most necessary, but the process of breathing would be a top contender.

People stop breathing for all kinds of reasons, most commonly because they have lived out their span of years and are done. When everything else ceases to work and the brain no longer gives adequate signal to the muscles of respiration to defy the elastic recoil of the diaphragm, chest wall and lungs, breathing stops. But sometimes breathing ceases or becomes ineffective because of a drug overdose, a lung inflammation or infection, morbid obesity, fluid overload, tumors, trauma, a reversible cardiac problem, a hot dog gone down the wrong way. In such situations it can be life saving to place a tube through the mouth or nose to provide oxygen and get rid of carbon dioxide. 

I suspect that was an excessively long explanation of the obvious for just about everyone who has watched any of the doctor shows on TV or had anything to do with health care. So I shall be done now with explaining. Except a few more things since it won't take long and not everybody knows all the terms. When  tube is placed anywhere in a person, the process would be accurately described as "intubating" the person, but practically we only use that term to mean putting a tube into the airway to provide support for breathing. A ventilator is the machine that hooks up to the tube to do the breathing, though a person with a bag who did the same job would also be a ventilator. But that would sound really funny. 

All that to say that I just attended Stanford University's class in managing the difficult airway (actually the person with a difficult airway, to be picky.) It was taught almost entirely by anesthesiologists, the doctors whose job it is to maintain a person alive and ideally pain free during surgical procedures and operations. They intubate patients many times daily to support their breathing while they are so deeply anesthetized that they can't breathe for themselves. Because they are so good at it, they often help us intubate patients who are reversibly dying for other reasons. They are not always available, though. 

Most of the students were anesthesiologists, too, and the tricks taught in the course were really clever. A tube does not just naturally want to go down the trachea and into the lungs. If I stuck one down my own throat, past my gag reflex, chances are pretty good it would go into my esophagus, and if that tube were hooked up to a ventilator, my stomach would blow up with air, which wouldn't be very helpful. A metal laryngoscope with a light can help the tube go in the right place, but sometimes there is no straight shot to see to the trachea, guarded by the vocal cords, and more toys are needed. There are fiberoptic scopes that can be introduced into the right place, and the tube advanced over them. There are video laryngoscopes and introducers of various sorts. There are balloon type devices called laryngeal mask airways that can fit over the airway to provide a soft seal and be hooked up to a ventilator. There are ways to convert these to endotracheal tubes under direct vision using exchange catheters. And, if all else fails, a tube can be placed through a membrane above the thyroid cartilage after a hole is made with a scalpel. This is gory but life saving if we decide to do it soon enough. There are many different companies that produce the clever and expensive tools that make all of this possible, and because we are the US and money is pretty much no object when it comes to the things that save lives, these tools are INCREDIBLY COOL. There is even a video laryngoscope that makes introducing a tube really easy that, despite its great optics and excellent functionality, is entirely disposable and costs the hospital $80 per unit. It probably gets billed out at 5-10 times that, but that $80 number is still pretty impressive. It's also kind of horrible that we can't wash it and reuse it.

Beyond the cool toys (which included both mannikins, new and old tubing technology and actual pig tracheas on which to practice cricothyrodotomy skills) the major message of the course was that in something as important and time sensitive as supporting breathing the physician must always make a well thought out plan, taking into consideration everything that is known about the patient. One way to get a very uncomfortable plastic tube into someone's trachea is to give them adequate sedation and then use a medication to completely paralyze all of their muscles. Once this is done there will be no breathing unless it is done for the patient by the health care provider. In tricky situations it is sometimes possible to leave the patient awake and thus able to breathe albeit poorly or temporarily for themselves, and simply numb the airway passages. This doesn't always work. When the patient is sedated and paralyzed or unconscious and near death, a breathing device must go in, and the choice of which one depends on what we know about which one goes in most quickly, most successfully and with the least harm to the particular patient. When stakes are high and everyone is a bit twitchy, the operator must have rock solid backup plans should the initial procedure not be successful, must know the equipment and have excellent communication skills that include calling for help.

I now feel entirely comfortable intubating plastic torsos in all of the most dire situations they might find themselves, especially when I am at Stanford where I can easily lay my hands on the most advanced technology. It will be interesting going back to my own hospital and scoping out what is available when real people are counting on being intubated. It will, of course, be different, but the hands on experience from 15 hours of being around airway gods and placing tubes in fake tracheas will probably serve me well.

Stanford's faculty did an excellent job of teaching. The course was co-lead by Drs. Vladimir Nekhendzy and Jeremy Collins, whose knowledge and background in management of the sickest patients was vast. They were experienced, passionate about what they did, collegial and respectful of our different backgrounds. There was a perfect mix of lectures and hands on demonstrations and practice. The food was superb and the weather was ideal.

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