Make way for the airway ... management

[Music] Well ladies and gentlemen here it is once again it's time to go inside the MS I am your host Chris Subilaro and with me is the guy the man my buddy my good friend the one we call Kelly Grayson how you doing KG? I'm good bud I'm good saving lives stamping out disease and pestilence just got announced a a really substantial pay raise and I don't top of that we're gonna be getting our hazard pay retroactive to January on top of that so life is life is pretty good awesome man to be able to help you with that bathroom how's that going? Oh my god it's it should be done but it's cosmetic stuff and then yesterday I discovered a leak in the toilet water supply line so I've got to cut out a section of drywall and and investigate and repair that and then reinstall the toilet and that's just it's just one thing after the other but hey man it getting you know almost a eleven thousand dollar a year pay raise you're in a couple days pretty nice yeah very nice it's really good when you're able to put your hands on more money and my financial sense says all that you go into your retirement account but we'll talk about finances later but Kelly you know I missed it but you did a webinar you did an airway management webinar for EMS one and I did want to check it out but I had some other business that day and I haven't got a record it I know I haven't gotten around to the recording let me finish let me finish my thought before you jump all over me and but I thought we should talk about it I mean because airway management is an important concept when it comes to EMS and maybe something we don't do very very well overall is a career field but maybe just give us the premise what was the what was the webinar about? It was it's called plan C navigating the difficult airway and and EMS one and Zoll approached me about doing this to to go through some of the nuts and bolts of managing the difficult airway and how to escalate beyond your BLS airway maneuvers and went to give up and cry uncle and some of a more educated or or experience provider to to assist with the airway and that sort of thing because I think that one of the I think they recognize that that's one of the the deficiencies or one of the weak areas that we we feel we have in this in this profession and they're they're trying to come up with educational opportunities to address those areas and airway management finally we're recognizing how much we suck at it. You know one point of the things that you talk about is this the focus of the of this webinar is really you know advanced airway management but before we get into that discussion how are we doing with basic airway management? It seems that the the challenge is that we automatically want to go to the big guns and as a career field we may not have the best practice of what a basic airway management should be about. I mean what's your feel for that? Well I think that that as as far as ALS providers go we we we kind of overlook BLS airway management and I think the way we need to approach this is is just from that aspect airway management there is no ALS airway there is no BLS airway there is a spectrum of airway maneuvers and many of which are our BLS in nature and and and don't really need a paramedic even if a paramedic is performing them so one of the the myths that we foster in emergency medical services and in health here in general is is this myth of the gold standard of airway management and I know you were taught it I was taught it we were taught that the the gold standard of airway management is an intertracial to meaning the very best we can do to manage an airway is the most invasive device that we have and that's not true and that's something I learned in taking and in teaching the slams street level airway management courses early on was that airway management is a continuum of care and interventions and that the gold standard of airway management is whatever achieves effective oxygenation ventilation and you should only go as far as you need to to achieve effective oxygenation and ventilation so I think we all need to and in my lectures at airway management lectures around the country I talk about this this concept of an airway continuum and that's something I also talk about in the in webinar as well during define that airway continuum giving credit work credit is to this was this idea was born of a conversation between myself and Wes Ogleby and Wes approach me Monday and he's a killer wise at that that most ALS providers just look at BLS airway management something is beneath them or something that you delegate to their partners and they only intervene when it requires an ALS intervention and so we you know you have an excellent point there that that is a bias that many of us have he said we ought to have something like the like the police officers use a force continuum for airway management and he left it there and I fleshed it out from there and develop the airway continuum and and its analogy the thing was based off of was the police officers use a force continuum which is a thought exercise or a concept that they teach to law enforcement officers from from the early days of the police academy to teach them the most effective way to or the most appropriate means of exercising force and it's a continuum to teach these people the the appropriate level of force for a given situation so that they can respond appropriately and not be subject to excessive use of force lawsuits and that's the that's the the concept behind the airway continuum as well as that we only need to go as invasive as we must to manage the airway like any any continuum model that there's there's also instances where we need to jump to the end of the continuum and the same way with the use of force continuum you don't speak nicely when some of this drawn a gun and shooting after you jump all the way to lethal force and the same thing there are a few things in in airway management where we need to move straight to into tracheal intubation but the rest of the time we need to start non-invasive and and get progressively more invasive as the situation demands and that's the concept we teach with the airway continuum go only as invasive as you need to to manage the airway effectively because invasive airways in and of themselves pose their own set of risks and complications for the patient they up the stakes of the patient's care significantly and and the risk complications as well so that's one of the first things we talk about in this webinar is escalating along the airway continuum so when you think about that though we're in the heat of the battle right we're dealing with somebody that's having respiratory depression or we're having somebody that's you know just having difficulty breathing I mean how do you teach this in the sense of working through this algorithm or this continuum to say all right well this isn't so bad I can get by with this I I don't have to go right to BVM or I don't have to go right to a non-rebreed or I said so so when you think about this from the teaching standpoint what's the best way to teach someone this continuum of care I I lay out the theoretical model from the from the very beginning and it's a it's a conceptual model for airway management and and there are six steps along the continuum the same as there are with the use of force continuum level one and level two are are intended to make sure that you don't have to use an airway at all level one is positioning and supplemental oxygen level two is suctioning and inhaled beta agonists the idea being is that the more you maximize airflow in the patient's ease of breathing the less likely are to have to resort to a airway adjunct in the first place level three is along the same lines that's a non-evasive positive pressure ventilation the use of CPAP and and we know that you know in in in the last 10 15 years that CPAP is really it's a double-edged source is revolutionized the way we treat severe respiratory distress in the field and it is resulted in far fewer of our patients needing to be intubated and placed on a ventilator but the the other side of that sort is is this is also resulted in less opportunities for advanced airway management in the field and God knows we need to practice and then level four is BLS airway adjunct level five is superglotic airways and level six is your your intracural intubation so I teach people to start with first of all how well is the patient maintaining their airway on their own and what can you do to help them maintain it better on their own and when it gets to the point where they can no longer maintain it on their own what devices can we choose that will manage the problem at hand. And it's all about the old saying, the family tool you have in your toolbox is a hammer. Every problem gets treated like a nail. I teach them to be proficient with a number of different airway adjuncts so that they can most appropriately choose the one for the situation. And that's kind of the way it goes. So you have to talk about it in the heat of the moment. The more you train and the more you exercise this conceptual model, the less likely your actions are going to be instinctual. And there will be more reason to the more you ingrain this, the less likely you'll already get television go straight to your endotracheal tube and forget to pre-oxygenate and post-oxygenate and suction your patient, and all that kind of stuff. You'll be more measured and the more measured and step wise and methodical you are at airway management. Generally, the more successful you're going to be. So I want to go ahead and talk about this advanced airway management because I think that this is important. And one of the things that you mentioned is, you know, CPAP in the field and using it and it's now the double-edged sword that it's making the patient have a little bit better outcome. But then again, we're not getting the use of our skills when it comes to innovation. But the question that I thought about as soon as you said that was, well, is innovation becoming obsolete? You and I have had the discussion about, you know, multiple times. Is it time that we move to just superglotic airways and forget about intubation? I mean, there are some systems where you've got a longer transport where maybe putting them on a ventilator via an ET tube is necessary. But in a system that's got a 5, 6, 10, 15 minute transport time, are superglotic airways enough. So when we think about this from a CPAP standpoint, you mentioned it. I mean, it's doing good for the patient, but it's not doing good for our skills. Do we really need to take it to level six? Number two is, do we stay with superglotic airways instead of going to that intubation? And then, you know, with that on top of that, is the fact of that a lot of our first responders are getting unseen before us? And if they recognize the need for an advanced airway, shouldn't they be the ones to be able to place that supergodic airway before our arrival? And this way, we've got a better airway, hopefully, when we get there. So, I mean, a lot of different things to unpack there, Kelly, but what do you give us? I think personally that superglotic airways need to be wholesale moved within the realm and the scope of practice of BLS providers. I think it's unconscionable that EMTs in some states cannot insert a blind superglotic airway. It's ridiculous. And the reason that they don't, you know, it's obvious that the regulatory bodies and the medical directors don't trust them. The problem with that is, when you don't trust your EMTs, they tend to lower their performance to your low expectations. You hit the goals that you aimed at. And I know that in Louisiana, any superglotic airway is within the scope of practice for a BLS provider for an EMT. And we are proficient at it. We do a good job at it. So, it's not like this is some foreign concept. It's simply the fact that people have low expectations of the skills and knowledge of BLS providers and those BLS providers tend to meet those expectations because that's all people require and expect of them. I think if we raise the bar a little bit, the superglotic airways should be part and parcel of the EMT scope of practice. And yes, I think that BLS, I think that intertracial intubation is going away and that's a darn shame. I don't think it should go away. I think it should be a useful tool in our arsenal. We should not have to take another tool out of our toolbox because some of us are not adept at it or even competent at it. What we should do is raise the bar profession wide and make sure that we are better at intertracial intubation than we have been in the past. We've been believing our own press clippings and believing our -- and being self-congratulatory attic for far too long. And there's nothing to be proud about anymore. We've all -- we've doing the same job as doctors at 3am at 70 miles an hour or you intubate in a nice well lit operation, surgical suite with plenty of help and I do it at 3am upside down and a ditch with some flash light. We need to stop pumping our chest about that and admit what Dr. Henry Wein has been pointing out for years is that generally the EMS profession sucks at advanced airway management and get better at it. There are agencies and systems around the country that do a good job at it. So we need to start modeling them instead of convincing ourselves that, "Oh, we're just as good as Boston EMS or some other Seattle Kings County, Medaq 1." We can intubate with the best of them. Show me your numbers and then we'll decide if that's true or not. Until then, you need to be copying what those guys do, training and oversight wise to make sure that you're bringing your people up to that level. Call them the numbers, say otherwise. Yeah, very interesting stuff. I got a really great question for you. But before we do that, I want to just go ahead and send a shout out to our listeners. Are you enjoying the show? Please take a moment to rate and review us on Apple Podcasts. Contact the inside EMS team at [email protected]. Share ideas, suggestions for shows and feedback or if you just like to be able to join as a guest and don't forget, we want to be able to send a shout out to the people that are in our field that need to be recognized. So if you got a shout out, go ahead and send us that at [email protected]. You know, Kelly, as you were talking about that, you don't think that intubation needs to come out of our toolbox. I agree with that, but here's my question to you. As you talk about this continuum of care, and as you go up that process of using CPAP, of using superglotic airways, of getting to intubation, aren't we really taking it out anyway because we should be able to find something that should work before we get to the definitive end all beetle, and maybe that's not intubation. Well, I disagree because the care we're providing, at least the stabilization, is not fundamentally different than the care provided in the emergency department. And in the emergency department, they're still intubating people and for the most part, proficient at it, we should be able to, you know, the whole concept of VMS has always been to bring the emergency department to you. So there are agencies that should have superglotic airway as their primary airway device, simply because they're not practice enough at it. They don't get enough opportunities to become proficient at it. And for those people, superglotic airways should be your first choice. But for the agencies and the EMS systems that do get adequate practice at advanced airway management, they need to make sure that they are proficient enough. The first option, intracurial intubation, is in that 90 plus percent range on the first pass. You should be able to pass 90 percent of your tubes or better on the first pass. And really start looking hard at your numbers, even if you're successful. A great example of this is Jeff Jarvis, Dr. Jarvis, and his work as medical director at Williamson County EMS. This whole idea of their concept of resuscitate and then intubate is something that I've discussed in the webinar. They do a good job at intracurial intubation and airway management at Williamson County EMS. Their success rates are good. There's something to be proud of. However, Dr. Jarvis was looking at their outcomes and he noted that they had some less than ideal outcomes on patients who were intubated and he wanted to know why. They start crunching the numbers and they realized that first blush, you think, "Well, these people did poorly because it was a difficult airway." That turned out not to be the case. It turned out that a number of their patients with poor outcomes or higher mortality, those patients were intubated on the first pass and they were graded by the medics as easy or relatively easy airway. There's some other reason for their higher mortality rate. He hit upon the problem of peri-intubation hypoxia and started requiring that his medics preoxygenate adequately using apneoxygenation and good formal preoxygenation techniques and get the patients oxygenation. Their hypoxia managed before you intubate them. In the webinar, some of the other points after you also need to meet their fluid needs as well. You need to treat shock before you insert an invasive airway if you at all can. also significant number of your patients with higher shock indices are going to code when you try to tube them as well. And that's a good point, but it all it goes back to this broader concept that that Jarvis espouses resuscitate then intubate. You don't correct hypoxia with an intratracheal tube. You correct hypoxia with good BLS airway management of BVM positioning and high flow oxygen and peep and maybe and maybe apnea coxygenation added to the mix. And once the hypoxia is corrected in the patients you reassess, does my patient still need advanced airway management? If so, tube them and you've got a big wide window before hypoxia sets in again to get that tube successfully. If not, well then you might stop at a lower run on the airway continuum and manage them with a superglot of airway or just simple positioning it in and of itself. And I think that's the way we need to go, but we don't need to do it away with intratracheal intubation. But I tell you what, if a lot of systems don't start looking hard at their numbers and being kind of self-aware, it's going to get taken away from us. And that's what I hope to do with webinars like this is is kind of make people aware that we have a problem and give them some tools for dealing with it because their initial education for a number of years now has been severely lacking in the realm of invasive airway management. So let's go ahead and go to the far end of the spectrum, right? When we think about advanced airway management and I want to take you to the far end and a lot of systems, you know, some systems have it, some systems don't. But when we talk about things like trans-tratial jet ventilation or retrograde intubation or even going to the top of the line of having to conduct a surgical airway, how does this fit into our airway management toolbox? Well, I think that trans-tratial jets and surgical crycotheratomy kits are useful addjuncts. There are another tool to put in the box. I do think that retrograde wire-guided intubation is an interesting trick, parlor trick, but it doesn't really have a whole lot of application in advanced airway management. I think the vast majority of me, if you're going to make a stick in the crycotheraoid membrane, it's a relatively simple matter to insert a dilator and a cannula in and intubate the patient through that opening you just created rather than fishing around in the mouth for a J-wire with a pair of McGill four-sips and then doing this roof goldberg thing. But I think that if you are if surgical crycotheraoid is going to be an option, then we need to have the tools to do that effectively and not improvise because you don't want to be improvising in jury rig and in McGyvering a crycotheraoidomy rig while a patient is rapidly getting hypoxic and tipping toward death. So if you have to do this with scalpel and set a curved four-sips and rig it along the way, I think it's much better if they have a crycotheraoid otomy kit with a made for the purpose device, a quick traker, a perch raker, or something along those lines that you don't have to improvise. You know, we're not fashioning chest seals out of a Vaseline Gaul's anymore. We're using made for the purpose chest seals because when someone can't breathe, this is not the time to be improvising the appropriate dressing for it. The same wholestero for crycotheraoid otomy. But I do make the note in the webinar that it should be an option that is exercised. Don't move your way. You don't put a patient, send a patient to the morgue with the failed airwave. They don't have a hole in their neck. We've seen some providers that probably utilize surgical crycotheraoid otomy a lot more than they should. Brian Blitzow and I were talking to a flight medic at Texas CMS conference one time and he's doing his recruiting spiel and and he says, you know, I I did six surgical crycotheraoid otomies in my in the last quarter, you know, in by way of bragging about their patient acuity level and how challenging it was. And and we both nodded politely and as we walked away, Brian kind of kind of whispered to me, you know, how many surgical cryocytes I've done in 28 years in EMS and medicine? Less than six. You know, if you had to do six surgical crycotheraoid otomies in one quarter, you're either the worst black cloud in the world or you need to go back and relearn how to use a little ringescoaps on and and that's that kind of thing. It needs to be one of those options that we have, but it needs to be an option that we we rightfully recognize as the last resort. All right. Well, it sounds like it was a good webinar, man. I can't wait to take a peek at it and one thing that it sounds like a great resource for people to get into, but you know, give us your closing thought on it, Kelly. If you're going to, you know, give one pearl of wisdom, one kind of closing thought or tip to the audience when it comes to advanced airway management. What do you leave them with? Well, the the the overall concept is right there in the title, plan C, navigating difficult airway and it's it's all about planning and being methodical and having a plan and a backup plan and an aircraft plan. And and I make the quote from that noted philosopher Admiral Joshua painter and hunt for red October. Russes don't tell you dumps on without a plan. You need to have a plan in place. You need to follow that plan because that's going to help you focus and help you do a better job for your patient. Not time to wing it. But hey, that's what I think we'd like to hear what you think. What are your tips and tricks for managing a difficult airway? Have you seen the webinar and if so give us some feedback on it. We'd love to hear your thoughts at the show at ms1.com and for myself and coho's Chris several arrow those sloucher airway management himself. Thanks for tuning in inside of EMS. We're going to catch you guys next week. (upbeat music)