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Tuesday, March 17, 2015

Practical Emergency Airway Management--human factors in response to medical emergencies

Physicians need to complete about 50 hours of some kind of continuing medical education (CME) every year. The ideal kind of class is one that we actually attend in person, with teachers who are expert in the field being taught and are somewhere near the cutting edge. CME classes are especially nice when they include something hands-on rather than just a lecture format because much of medicine is hands on and because that wakes us up and keeps us focused. There are other ways to get education, such as studying written materials or attending classes taught via video presentation, and they are an important way for physicians who don't have the leisure to leave their work to rerfresh or expand their knowledge base. I've always gotten more from the courses that were taught by actual living breathing people, though I have availed myself of lots of the distance options

One thing that physicians are often required to do, and rightly, is to remain familiar with how to deal with emergency situations, ones which thankfully don't happen very often. The hardest things to remain competent to do are the procedures that we perform only in extreme situations and can't be practiced on healthy or nearly healthy people because the procedures carry too much risk. The most perfect example of such a procedure is providing an emergency airway to a patient who is at risk of being unable to safely breathe for him or herself. In such a situation, for instance if a patient comes in who is so ill and weak that they are unable to support their need for oxygen and/or for elimination of carbon dioxide, breathing must be augmented in some way. Sometimes a pressurized mask, "bilevel positive airway pressure" or "bipap" may work, but sometimes even that in not enough and the person must be connected to a ventilator. The ventilator provides the "good air in, bad air out" that normal breathing normally does, but a tube must be placed into the trachea via the nose or mouth to connect the ventilator to the human. This is a tricky and sometimes difficult procedure. A tube stuffed blindly into the mouth will normally go down the esophagus into the stomach, which does not actually connect to the lungs in health people. In order for a person to allow a tube to go down the throat (or nose in rare cases), he or she must be heavily sedated and, ideally, entirely paralyzed in order to see the clear path for tube placement. When a person is not breathing adequately, there is still some oxygen exchange going on, but when that same person is heavily sedated and paralyzed, no breathing will happen. Artifical respiration can be performed via a mask and a bag, but that is difficult to maintain and often fills the stomach with air as well, so the endotracheal tube (tube to the lungs) needs to be placed quickly and accurately. If it accidentally goes in the esophagus and the situation is not quickly discovered, the patient will die. Most of us physicians don't often run into a situation where endotracheal tube placement is a common occurrence so, despite the fact that we need to be very adept at it, it's hard to maintain competence. Even those of us who do it pretty often were sometimes taught in a haphazard manner which we try to overcome by practice. When an endotracheal tube does not go in easily, as planned, we have the option to place a temporary puffy internal mask which fits over the trachea through the mouth, or to perform a surgical procedure to put a tube through the cricothyroid membrane in the neck. That is likewise a procedure that demands competence and one which is not possible to practice on real people who value their lives.

I just returned from a nearly perfect course in providing airways in emergency situations, taught by Dr. Richard Levitan, a self proclaimed airway geek. He taught the course in conjunction with two other airway experts, Dr. George Kovacs from Dalhousie University Medical School in Halifax, Canada and Dr. Ken Butler, and emergency physician and airway pharmacology specialist from University of Maryland. I say nearly perfect without any real concept as to what would have made it more perfect. The course started with a day of lectures, heavily sprinkled with video recordings of real situations, anecdotes and student participation. The students were primarily emergency physicians, with a smattering of medical residents and critical care and hospitalilst type of doctors. There were not very many of us, maybe 18 total which gave us all great access to the teachers. Lunch was at a Greek restaurant a few blocks from the hotel venue, and we all ate together at a large table. We were encouraged to tell an airway story (which are some of the most colorful stories in most peoples' memories) after we finished eating, which meant that we knew each other as individuals by the end of lunch the first day. That is very unusual in medical conferences where it is pretty easy to depart with no new friends. Dr. Levitan has a huge amount of practical and academic knowledge of everything to do with the airway, which despite being small geographically is huge in spectrum. He digested that to give us an uncluttered approach to placing the most appropriate kind of airway device, recognizing that the psychology of stress in times of great urgency of action limits our ability to be able to use complex, multi-branched tree charts. His co-teachers provided alternate approaches when something was controversial, which I found very helpful and reassuring. He focused on "human factors" in the procedures, a term which I have heard floating around more and more lately, often in regards to computerized documentation. "Human factor" and ergonomics are words used to describe efforts to make processes, cognitive, emotional and physical, fit real humans in such a way that they are efficient and also happier and less likely to be injured. Dr. Levitan was particularly interested in making the ways we think about performing in emergencies add to our success and reduce our tendency to fear and subsequent stupid decisions. He also taught details about holding instruments, positioning patients and breaking down complex procedures into easily accomplished bits. His presentation style was engaging and he combined media with printed data, stories and questions in a way that excellent professors do.

The second day was spent in the lab. There were about 20 relatively recently deceased people whose unselfish decision to donate their bodies made it possible for all of the students to become competent and confident by the end of the day. We gowned and gloved and viewed the epiglottises, larynges and tracheas of each of them, allowing us to become familiar with a tremendous amount of diversity of anatomy. We placed endotracheal tubes in 20 subjects, practiced use of standard, fiberoptic and video laryngoscopes, bronchoscopes and other optical gadgets. We learned exactly what twist of the wrist allows atraumatic passage of a tube. We placed tubes through cricothyroid membranes, thus de-stressing one of the most worrisome procedures in our potential practice. The bodies were softer than the embalmed bodies that I learned anatomy with in medical school, and were much like the patients we might see in this type of situation in texture. I thought it might be a little bit horrible, but it was not. I was kind of attached to our patients by the end of the class, and would have liked to have known their stories. 

Beside my profound thanks to the cadaver subjects, I am so very grateful to excellent teachers who spend years learning things of immense complexity and then present them to us, with a generous helping of humor and compassion.