Affordable Difficult Airway Kit

Well, this week I’ve been playing with some AirQ II blocker intubating LMAs (iLMAs) sent to me from a rep.

For those of you not familiar with an iLMA, the device is designed to allow ‘blind’ intubation of the airway, using the laryngeal mask airway (LMA) as a conduit.

The progenitor, with which most rural doctors and anaesthetists will be aware of, is the FastTrach LMA. It’s reported to allow up to 73% ‘first pass’ successful intubation rates, increasing to 90% overall success with repeated attempts and the ‘Chandy manoeuvre’. It’s not a bad piece of kit and we’ve got one on our airway trolley.

However, the FastTrach requires some practice to get used to. I made a point of using it at least once a month during my anaesthetic year, just to get used to the kit. Using equipment in training is quite different to using ‘in anger’, especially when there’s an evolving airway crisis. Problems that I found were

• not always easy to pass the endotracheal tube into trachea
• removing the LMA whilst leaving the ETT in situ is fiddly and risks losing both
• overall success rate is 90% - so 1:10 will fail.

The C-Trach is an advancement on the FastTrach, improving rates for first pass and overall sucess to 96% and 98% respectively - basically this device is just a FastTrach with a video screen attached. Clearly then, addition of video allows visualisation of the cords and improves success rates.

However, neither FastTrach or CTrach allow you to place a nasogastric tube..unless you obturate the ETT and remove the LMA over the top, which is potentially fraght with difficulty.

Cue the AirQ iLMA.

This ‘new improved’ iLMA gets around the problems of FastTrach and CTrach - it’s similar in appearance to the FastTrach iLMA, albeit with a less acute angle. It also has a nifty side-port to allow passage of a nasogastric tube without having to remove the iLMA

Moreover, the device comes with dedicated nasogastric ‘blockers’ - an NG tube with an oesophageal balloon which can be inflated in the oesophagus to minimise aspiration risk and yet allow decompression of the stomach.

I tried it the other day in theatre and found it easy to use. As an LMA it functioned perfectly well, although I have heard some anecdotal evidence of increased supraglottic trauma with this device.

How then to improve success rates for passage of an ETT? Minh le Cong has described this elsewhere - use of a malleable intubating stylet such as the Levitan FPS allows visually-aided intubation through the iLMA conduit.

So we now have a staged procedure for the nightmare difficult airway where intubation has failed or priority is to oxygenate

• drop in an AirQ II and ventilate
• pass the oesophageal blocker to decompress the tummy
• use a fibreoptic device to intubate through the iLMA, improving intubation rate

This strategy (fibreoptic intubation through an iLMA) is Plan B of the UK’s Difficult Airway Society algorithm. Yet how many of us are really prepared to do this and have practiced on kit? Most rural docs have access to a FastTrach...so ventilation and blind intubation are possible - yet the addition of an NG tube port and allowance of fibreoptic intubation seems to offer a higher standard of care. Of course, for many small hospitals fibreoptic devices have traditionally been out of range - high cost and difficulty acquiring and maintaining skills.

But for under $3K you can pick up a Levitan scope (malleable fibreoptic intubating stylet) or the Ambu Ascope II (five disposable flexible fibreoptic scopes). They may not be as good as the fibreoptic towers that people use for an awake fibreoptic intubation...but they are bloody good gadgets to use with the above technique.

So, what would be my preferred kit for a ‘difficult airway’? Well, I’d use the Difficult Airway Society (UK) and ANZCA T04 guidelines as a starting point...and in addition to the AirQ and some sort of fibreoptic device, I’d add in a videolaryngoscope. Sounds expensive? Well my suggestions for purchase are in square brackets below - for under $4K should be affordable for small rural hospitals...

Plan A - Initial Intubation Strategy

Standard laryngoscopy - if fail, change position, blade, operator. Consider use of a videolaryngoscope in case of difficult airway. If fail, move to...

[KingVision Videolaryngoscope ~ A$1000 inc. blades]

Plan B - Alternative Intubation Strategy

iLMA to maintain oxygenation and ventilation, then secure airway using fibreoptic intubation through iLMA. If fail, move to...

[AirQ II iLMAs A$30 each]

[either Levitan FPS or AmbuAscope II fibreoptic devices to intubate through iLMA]

Plan C - Maintain Oxygenation & Ventilation, Abandon Procedure and Wake Up

Bag-mask ventilation and reverse non-depolarising neuromuscular blocker (suggamadex for rocuronium) or wait for suxamethonium to wear off. If fail, move to...

[Rocuronium for RSI - prolong time to desat]

[Suggamadex to reverse rocuronium]

Plan D - Rescue Techniques for Failed Oxygenation & Ventilation

Bag 1 - Paediatric or Easy Anatomy
Needle Cricothyroidotomy technique

Bag 2 - Adult or Easy Anatomy
Scalpel-Bougie-ETT technique

Bag 3 - Impossible Anatomy
Scalpel-Finger-Needle technique

[Melker Kit]

I wouldn’t bother with the pre-packaged kits like QuickTrach or Seldinger kits as first line for CICV - in the heat of the moment, faffing around with wires etc can be a disaster. Better to have three equipment bags set up as above using standard equipment - oxygenate first - then move on to seldinger or formal tracheostomy. Some have commented that doing the above is sufficient to ‘save the day’ then either wake up the patient or proceed to successful laryngoscopy.

Loving the Job

I reckon the work as a rural doctor is the best that medicine offers. Just heard from a colleague with whom I did anaesthetics last year in NSW.

"Mate I love this job! In the past 7 days I've thrombolysed a 44 year old with a STEMI, resuscitated a 5 year old who had a fit in the local pool, drained a 2L pleural effusion off an ol' fellas chest, gassed 5 people on a gen surg list, managed a snake bite, released two carpal tunnels, resuscitated a floppy neonate after a ventouse and seen a whole load of people in general practise. I LOVE MY JOB! Hope you're having fun mate. This job just keeps getting better!"

No, he hasn't been at the drugs cupboard. He is expressing the simple joy of being a rural doctor with the skills to do your work. As I've stated before, I reckon that being a rural doc is one of the best jobs around - especially for those with procedural skills.

Sadly skills aren't all you need - you need the equipment to do your work well and you need structures behind you to ensure that your work is sustainable in what is, ultimately, a high-pressure job. For most of us, that means adequate locum relief or being paid for the work you do.

With regard to equipment, I've just submitted my paper on the availability of difficult airway equipment for rural doctors. Of the estimated 448 rural GP-anaesthetists out there, I've got responses from 293 - a 65% response rate, which is apparently quite good for an internet-based survey. So paper has gone in for submission...

I won't give the game away (wait for the paper, if it survives the review process) - suffice it to say that there are common themes amongst the rural GP-anaesthetist cohort - lack of funding for basic and advanced airway equipment predominating amongst respondents. 

I've tried to outline in my paper some suggestions for affordable equipment to help advance the cause - for under $4K a small hospital can purchase some of the intubating LMA AirQ-II blockers, plus a fibreoptic device to allow intubation through the iLMA (something like the flexible AmbuAscope 2 or the Levitan malleable intubating stylet). There'll still be change leftover to buy a KingVision videolaryngoscope - all of this gives a fairly robust kit for the 'occasional intubator' or GP-anaesthetist.

A&E Services & Contract Negotiations

Meanwhile, the State opposition Minister for Health has finally twigged to the inequity of country patients being charged for non-admitted A&E services that their metropolitan counterparts receive for free through Emergency Departments. Minister Hill is now on record saying that the 'only solution' would involve putting in salaried medical officers which would 'send GPs in rural towns broke' (The Advertiser, p15 9/3/12). He neglects to consider the alternative option - pay the oncall rural GP for A&E under existing fee-for-service arrangements, regardless of whether patient is admitted or not.

This solution would ensure patients attending the A&E with problems deemed inappropriate for routine GP would not face fees. It would mean the doctor is paid by the Health Dept without having to chase fees. Everyone is happy...

And it would be fairer to rural patients who already face significant health inequalities due to rurality.

This issue is all the more relevant as the existing contract between rural doctors and CHSA expired on 30/11/11 and has been postponed not once, but twice. I dunno about other rural docs, but I'm a little fed up of CHSA failing to come to the negotiating table and sending missives advising of a 90 day 'contract extension' on the last day of the existing contract.

It's not a good way to do business and seems symptomatic of a relationship whereby CHSA treats rural docs and patients as a hinderance to their bureaucracy, rather than a vital component of the health service.

Back in the saddle

Well, have been a bit hectic the past few weeks since getting back to Kangaroo Island after my year away doing anaesthetics in NSW. Thankfully it's relatively easy to slip back into the groove of rural medicine - and in fact it's been a welcome relief after being back in the tertiary hospital system. But still had to get used to running on time, all the paperwork that seems to swamp us as well as catch up with friends and family back home.


Hence no blog posts since early January.


However today I am on call, sitting on the deck with a 12 month old kangaroo that Trish has taken on board in my absence, watching the rains over the north coast of KI.


Being on call again is actually quite refreshing - the Kangaroo Island doctors as a whole are now doing three weeks out of every four on the EM roster...the remaining (4th) week covered by a Country Health SA locum. I believe similar arrangements have been in place elsewhere in the State, where local doctors are struggling to fill the EM roster. Meanwhile between four of us we are providing full cover for anaesthetics and obstetrics, with two doctors doing each discipline.


I've also been getting to grips with delivering anaesthetics on KI - two lists so far which have been uneventful, although I'm still trying to work out how to make the anaesthetic machine display a minimal alveolar concentration of anaesthetic agent, and struggling with an end-tidal CO2 monitor that reads in unknown units (3.5-4.5 seems the average, not the 35-40mmHg I'm used to). One for the hospital to work out...


When not at work, I have been analysing the results from the GP-anaesthetist survey - over 370 responses so far, and a fair proportion are dedicated GP-anaesthetists as well as 'occasional intubators' (rural docs who are on an EM roster and may be called upon to intubate seldomly). Results have been interesting, with no surprises that rural docs don't have access to a lot of the airway kit that would be taken fro granted in the city. More worryingly, a session at the local (mostly volunteer) ambulance station last week showed me that they've got some kit on the ambulance that we don't have in our hospital! Had some helpful insights from airway giants like Paul Baker (NZ) and Minh le Cong (RFDS Qld), as well as lots of comments from the wider GP-anaesthetist cohort who seem to share similar frustrations as we do locally. But more on that later, as I polish my manuscript and hope to get published later this year. Meanwhile, will try and give a few talks during the year to interested parties.


But back to on-call....I've realised that it's been almost two years since I've done an EM shift on Kangaroo Island - away for all of 2011 doing anaesthetics and for 2010 the docs on KI were reeling from all the nastiness over contract negotiations with Country Health SA and the ACCC. Now I am on-call for anaesthetics for half the year and doing one emergency shift a week....and wondering where we are at with contract negotiations - the last contract was due to end Nov 2011, rather than the usual three years...as rural docs were generally unhappy with the contract terms but were prepared to accept an interim contract hoping things would improve.


Back on 30/11/11 the head of Country Health, Belinda Moyes, wrote asking for a three month extension to contract negotiations. That extension is due to expire on 28/2/12 and I've not heard peep from Country Health over contracts. One has to wonder if they are serious about negotiating a new contract, or will just keep 'extending' the current contract rather than negotiate.


A big issue for me (and many other doctors) has been the sheer unfairness of Country Health insisting that people presenting to the emergency department are billed privately by the on call doctor, unless they are admitted to a hospital bed. This seems plainly unfair - whilst patients in metro areas are treated for free in the Emergency Dept of public hospitals, their country cousins are charged. 


Many of these services are for things that are not routine 'general practice' ie: X-raying a fracture and setting a limb in plaster, suturing an extensive laceration, pulling a dislocated shoulder back into shape, dealing with an alleged rape or victims of a motor vehicle accident. Country Health has managed to formalise this in the most recent (well, in fact the first) contract from 2010 with a clause stating that:


"non admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from Medicare). For the avoidance of doubt, CHSA shall not be liable to pay any fee for such services"


Their rationale is that such patients are an extension of the doctors private practice. Indeed, CHSA states that:

"This funding model with MBS being paid for public patients attending state hospitals, is acceptable to the Commonwealth due to an exemption in the National Healthcare Agreement that ‘in those hospitals that rely on GPs for the provision of medical services (normally small rural hospitals), eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor.’ 

As far as I know, South Australia doesn't have an exemption under the National Healthcare Agreement but continues to obfuscate this issue. What really twists my melon, and that of the patients who I see who are charged for their attendance, is that they have neither requested treatment by their own GP, nor is there treatment part of continuing care or a prior arrangement with the doctor. Basically, it's not a private service...it's just Coutnry Health SA cost-shifting dollars from State to Federal expenses.

In fact, the on call doctor is called to attend patients in the ED as part of his/her role as the doctor on-call for emergencies in a contract with CHSA. There is no prior arrangement, they are not private patients and usually this is not part of continuing care.

Quite how the Health Department continues to get away with this blatant cost shift from State to Federal (Medicare) coffers amazes me. And it is cold comfort to our patients - the rural ones are already disadvantaged enough, and the metro or interstate ones are flabbergasted to be charged fees for services in ED that they would receive for free at home. And of course the overseas tourists (and we see a fair share on Kangaroo Island) are less than impressed to receive a bill and aren't covered by Medicare.

Bottomline, the doctor on call for emergency medicine for CHSA doesn't get paid to come and see emergency patients, unless they are admitted to hospital for over four hours...

Let's hope this issue will be resolved in contract negotiations - although with two days to go until contracts expire, I am not optimistic.

Country Driving

I’ve recently driven back from Orange (NSW) to Kangaroo Island (SA) - one of those long, two-day road trips that is characteristic of driving in Australia. I counted less than 200 vehicles between Orange and Tailem Bend - over 1200km of road over two days...and of course whilst driving you tend to think about stuff. Some things struck me...

• Australia is vast
• rural areas are sparsely populated

Hence If you have a crash out here, you are likely to face a long time before help arrives. And even then :

• the major cities are a LONG way away (>500km)
• there are smaller rural hospitals; some are little more than first-aid posts & some have capabilities for surgery (which implies the presence of a doctor with anesthetic skills)

Add to this :

• the prehospital response may be initially composed of volunteer paramedics/first responders, with more more advanced practitioners few-and-far between

All together it is no surprise that the outcomes from a motor vehicle crash are worse than in the city, with one Australian study demonstrating a four-fold mortality for rural vs metropolitan areas. Not surprisingly, mortality increases the longer the time to care...and concepts like the "platinum ten minutes" and "golden hour" of trauma become academic when crash victims may not be discovered or receive help for a considerable time.

As rural doctors, it behoves us to examine best practices to try and improve survival. Certainly we need to have to skills and equipment to provide appropriate medical care in our hospitals..and some may provide an extended role at the roadside. I've blogged before about the concept of training and equipping rural docs to provide a coordinated prehospital response...and the more doctors I speak to, the more seem to think this is a 'good idea'. Implementation however may take longer, and there will be hurdles to overcome (not least the oft cited response that such work is best left to experts, not enthusiastic amateurs).

Of course, the best 'bang for buck' is not necessarily in the delivery of expert medical care. I remember Karim Brohi making this point at one of the Australian Trauma Society annual conferences a few years back - "it's better to build a fence at the top of the cliff, rather than provide an ambulance at the bottom to pick up the injured". 

Locally we've had some small success with the 'Roadkill Recipes' project - recognising that many rural traffic injuries on Kangaroo Island were caused by wildlife-vehicle collisions, a satirical cookbook of local wildlife served as a medium to convey a road safety message to locals and tourists.  Places like Kangaroo Island (and Tasmania) are interesting in that roadkill (and hence wildlife-vehicle collisions) is abundant. But for most rural areas the notorious "fatal five" of speed, inattention, drink/drug-driving, driver fatigue and lack of seatbelts are the culprits in many road crashes. 

Which is why I was heartened to see new signage as I crossed the border into South Australia (below). The Motor Accident Commission's "matemorphosis" country roads programme aims to target country drivers, particularly male drivers who may respond to mateship peers.

The MAC campaign includes references to wankers, cocks, knobs and tossers.

I wonder if as rural doctors we need to be more proactive in injury prevention - especially when our work comprises mostly primary care as well as the 'fun stuff' like airways, trauma and emergency medicine. Driving change can be hard, but if we're serious about injury prevention we need to be active in local road safety groups, at sporting events, with families and spreading the road safety message. But concomitantly we need to ensure our training and local resources are fit for purpose.

So in 2012 my projects will be:

- actively engage the local community in primary prevention health strategies,

- work with colleagues around the country to develop a 'rural doctor masterclass' course, showcasing latest concepts, equipment and techniques relevant to rural proceduralists,

- try and establish a more formal framework for rural doctors attending prehospital incidents (as a minimum, appropriate training, equipment and maintenance of standards) - existing retrievalist courses like RFDS STAR (RFDS Qld) and the medSTAR short course seem to be appropriate building blocks, bolstered by some online case discussion and commonality on procedures/protocols,

- work on developing a bespoke airway skills course for rural docs in South Australia, with concomitant development of minimum standards for difficult airway equipment in our rural hospitals.

What are your News Year resolutions?

Tracheal Trauma

When I was a young lad, one of the things that would excite me was stories of pirates and murderous 'cut-throats'. At the age of ten, the idea of a 'cut throat' was somehow synonymous with a quick death. Fast wind forward a decade or so (ahem, well maybe more) and I'm reflecting on some of the more interesting cases of 2011.


One was a young man involved in a 'glassing' in the local pub. He presented to the ED via ambulance, maintaining his own airway but with an obvious zone 1 neck injury. Now, I teach in the animal lab on EMST courses and it amazes me how difficult it can be to identify the appropriate place to perform a tracheostomy. We aim for the cricothyroid membrane, but I've seen FACEMs bugger it up completely and transect the trachea (even once the oesophagus and damn near severe the vertebral column!)


Anyhow, this chap's assailant had obviously either been on an EMST course or had performed percutaneous tracheostomies in the ICU - because with just a broken beer glass, he'd managed to make a perfect incision in the victim's trachea, between 2nd and third tracheal rings. OK, not the cricothyroid membrane, but otherwise a damn near perfect tracheostomy!


So we took him upstairs and performed an awake fibreoptic intubation with a surgeon scrubbed and ready to perform a tracheostomy. And the patient did OK (had an injury to posterior tracheal wall with oesophageal perforation confirmed on oesophagoscopy, but no mediastinitis and injury healed over time in ICU).


So I've been thinking about these sort of injuries and how best to manage them with my (limited) kit back in the bush. Although reasonably rare, both blunt and penetrating laryngotracheal injuries present difficulties for the rural GP-anaesthetist...as the airway needs to be secured ASAP.


And this is not a hypothetical - such injuries are not uncommon in the bush - the classic is 'clothes-line' injury where a quad or trail-bike rider impacts a fencing wire at speed, sustaining tracheal injury. Add to that 'robust' sports, the usual gamut of farming and motor vehicle injuries..so the rural docs needs to have some form of game plan on how to manage these. And the 'exam answer' for ANZCA may not be applicable for the rural doctor, with limited equipment/backup.


The danger of course is that attempts at direct laryngoscopy may cause complete tracheal disruption, with subsequent passing of the ETT tube down a false passage, development of subcutaneous emphysema, failed ventilation and a spiral down into demise.


Every now and then, one hears of paramedics just popping a suitably sized ETT tube through the hole made in a traumatic tracheostomy - a fine strategy for the penetrating injury, but not available for blunt injury or small penetrating wounds.


How then to approach this? There isn't a great deal in the literature and my FANZCA colleagues fall back on the 'awake fibreoptic intubation' answer...which is fine in the tertiary centre, but impractical in a small rural hospital.


So, what to do when faced with a patient with tracheal injury and needing emergent intubation (let's assume they are becoming obtunded or failing to keep SpO2 up). My thoughts?


- direct laryngoscopy. May seem controversial, but this is what I am best at and the equipment is readily to hand (ETT/bougie). However DL risks disruption of the larynx/trachea and a false passage, making further attempts at intubation impossible.


- do a formal tracheostomy under local. Sounds fine, especially if can delegate to a surgeon. If I am in luck there may be an ENT surgeon visiting for a fishing trip, otherwise it's going to be a messy scrabble with a patient who may refuse to lay flat/be combative. Nasty, but potentially do-able with equipment to hand (betadine-gloves-drape-local anaesthetic-scalpel-lots of gauze-retractors-ETT-lots of light-assistant)


- indirect laryngosocopy using videolaryngoscope. I like this idea, as intuitively seems to involve less mechanical distraction of the larynx...and the KingVision allows easy passage of a bougie, then railroad ETT over the top. Parker-tipped ETT to try and avoid any 'hang up' at the arytenoids...


- use an iLMA to maintain oxygenation - then intubate with ETT through this using either AmbuAscope or a malleable intubating stylet such as Bonfils or Levitan. To my mind the Ascope seems to offer an advantage here as could use iLMA as a conduit then follow down to carina...ensuring no false passage - then railroad ETT over the top. The shaped intubating-stylets allow one to visualise the laryngeal inlet..but not to insert down to carina, so potentially will intubate through the cords, but suffer false passage further down.


- topicalise the airway and perform an awake fibreoptic intubation. Preferred technique of my FANZCA colleagues, but it's hard to do enough AFOIs to keep 'current'. Now is not the best time for a relative novice to be trying!




What do other's think?


- any thoughts on above?


- gas induction or classic RSI?


- what kit do you have available to assist you, either now..or planned.




Bring it on...

Nearly home...

Well, had my viva for the JCCA anaesthetic credentialling earlier this week - glad to report it was successful. Four more weeks to go in Orange NSW then I'm headed back to Kangaroo Island with anaesthetic credentials under my belt.


This video clip says it all really:


http://www.youtube.com/watch?v=5rJ8nCTgZ2Q&sns=fb


Now, where's my fibreoptic scope and some local anaesthetic spray? I've gotta try this at home.

Anaesthesia & Aviation

How many times have I heard people (usually other doctors) liken anaesthetics to flying a plane - 99% boredom and 1% sheer terror?

In only a few more weeks I return home to Kangaroo Island after a year spent upskilling in anaesthetics...like a pilot, I've accrued many hundreds of hours of 'flying time' and have a fairly impressive logbook. I'm flying solo (but with an experienced senior pilot readily available should I need it)...all good preparation for returning home and anaesthetising selected patients for the visiting surgeons who visit KI.

I recently attended an airway courses with Paul Baker of the ANZCA difficult airway special interest group. The Elaine Bromiley video was shown...and served as a discussion of human and technical factors in anaesthetic mishaps. Elaine Bromiley's husband is an airline pilot and he has brought the rigour of the aviation industry, particularly crew-resource management, to crisis management in medicine.

One thing that struck me was the tight adherence that the airline industry has to checklists. In addition to the human factors and difficult airway algorithms, I think that this is something that we could and indeed should incorporate into routine clinical practice, particularly in ED or resus, where clinicians may be taskloaded and team members have to complete complex tasks that they perform relatively infrequently.

It's true that in the Operating Theatre the surgical and nursing team perform a ritual known as 'time out' - a final check of patient identity, proposed surgery, consent and allergies. However I have recently been in some operating theatre scenarios where the communication between team members has been nonexistent...usually reflecting strained working relationships or one or two toxic individuals. What a shame that there is no anaesthetic-surgical team timeout - to confirm nature of proposed surgery and anaesthetic, to discuss plans in the event of mishap, and to clearly identify team member roles and responsibilities (watch the Bromiley video for an example of how copilot and pilot do this...something that I wish some surgeons and anaesthetists would do routinely). 

I found this on the web, which is an extension of the surgical time out and involves introduction of team members, discussion of critical steps and anticipated problems. It's from the WHO and I like it.

Checklists are all very well, but they are a form of strategy only...you've got to know how to implement actions in case of disaster. Scott Weingart has recently podcasted on the concept of logistics vs strategy, emphasising that knowledge of the former distinguishes a true expert from an amateur. It's all very well to trot out the medical student answer that in the case of a massive bleed we would give packed cells, FFP and cryo (strategy)...but the true expert needs to know how to activate the massive transfusion protocol, troubleshoot the level one infuser, transduce the arterial line and mix up prothrombinex etc. This distinction of theory from practice is one which can be applied in whatever field of medicine one practices.

Continuing the aviation theme, a mob of ICU trainees from the UK (www.saferintubation.com) have developed a useful 'intubation checklist' and I would commend this to people to copy and print out on their resus bay wall or on the airway cart.

However if we are going to extend the 'anaesthetics is just like flying a plane' metaphor, then Grant Hutchison's infamous 1998 essay "Biggles FRCA" from the UK's 'Today's Anaesthetist' remains the definitive text.

Airplanes, unlike Sick Patients, are designed to fly

For those who don't recall the 'Boys Own' adventures of Capt Biggles, the eponymous hero was a creation of Capt W.E. Johns and promulgated the adventures of a wartime aviation hero, who got into various scrapes and yet triumphed despite insurmountable odds.  Like Tom Cruise in 'Top Gun', one could argue that there was some homoerotic content at the bottom of all this (titles such as 'Biggles Takes It Rough' and 'Biggles Takes It In Hand' lend themselves to satire). Nevertheless, the concept of a rugged, unfazeable hero who triumphs despite the odds is one that I think could apply to anaesthetists - as they are invariably the doctors that other doctors turn to when the shit hits the fan.

Anyway, here's the Biggles FRCA story reproduced for your edification. Our hero Biggles is an anaesthetist...the Chief Engineer is a Surgeon:

[from Grant Hutchison (1998) 'Today's Anaesthetist']

If one more person tells me that giving an anaesthetic is like flying a plane, I will swing for them, I really will.

Look. The whole point of a plane is that it is designed to fly, and if it's not working properly then you don't take it off the ground. Human beings, in contrast, are not designed to be anaesthetised, and are often not working properly when the occasion arises. They are also rather poorly provided with back-up systems and spares, and frequently have long histories of inadequate servicing.

So if giving an anaesthetic is like flying a plane, then this must be what flying a plane is like:

Captain James Bigglesworth DSO stepped out into the thin sunlight, and took a deep breath of the damp air. It was good to be alive. He was taking up a new crate today, and he relished the little knot of mixed tension and anticipation that always formed at the pit of his stomach under such circumstances. He strode briskly towards the hangar.

The Junior Engineer was waiting next to the aeroplane. He handed Biggles a single sheet of paper, on which he had scrawled a haphazard note of his work on the craft. "Is this all?" asked Biggles. "Where is the service record?"


"It seems to be lost. The filing department say it's maybe still at the previous airfield."

"And the manual?" asked Biggles.



The Junior Engineer looked startled. "I don't think there is one. We thought you knew how to fly a plane."



A cloud drifted slowly across the sunny sky of Biggles' mind. He began his walk-round. "Where's this oil coming from?" The Junior Engineer frowned seriously. "I don't know."


Biggles sighed. But he too, long ago, had once been a Junior Engineer. "Where do you think it might be coming from?"

"The engine?" hazarded the youth.

"Of course. So what's the oil level in the engine?"

"I don't know."

"Have you checked the oil level?"

"No."

Biggles could feel his voice becoming a little tight, a little cold. "So could you check it now, please?"

"What? Now?"

"Now."

"But you're just going to take off. The Chief Engineer wants you to take off right away."

"Not without an oil level. And this undercarriage strut is broken. And the port aileron is jamming intermittently."

At that moment, the Chief Engineer arrived. "Biggles, old chap! Ready to take her up? Good man."

"She's not remotely airworthy. I need an oil level and some basic repairs."

The Chief Engineer sighed. "What do you want an oil level for? You know it's going to be low. We've got to get her into the air before we can control the leak. And that undercarriage and aileron aren't going to get any better while we stand here. She needs to be in flight before I can properly assess them. Come on, old chap - the tower's given us a slot in ten minutes' time. If we don't take off then, we'll be waiting all day." He eyed the plane despondently, and tapped a tyre with the toe of his boot. "And, frankly, I don't think she'll last much longer."

Biggles rippled the muscles of his square jaw. The Bigglesworths had never balked at a challenge, but this ... Well, there seemed to be no way out of it. He was going to have to take the old crate into the air, just as she stood. Deuced bad luck, of course, but no point in whining.

Twenty minutes later, they were aloft. The plane kept trying to fly in circles, and the engine temperature gauge was sitting firmly in the red. The Engineer was out on the cowling with a spanner.

"Just turn her off for a bit," he bawled over the clattering roar of the sick engine.

Biggles was astonished. "What?"

"Turn off the engine. There's nothing I can do about this leak until the engine's stopped."

Reluctantly, Biggles turned off the engine, and trimmed the aircraft for a shallow glide. The weight of the Engineer, out there on the nose, was not helping matters at all. Four minutes passed in eerie silence, as the treetops swam up to meet them. "I'm going to need power again soon." There was no response from the Engineer. Another thirty seconds passed. "I need power." No answer. "I'm turning on now." The engine roared, and the Engineer recoiled, cursing, in a cloud of black smoke.

"What's your game, Biggles, old man? I almost had the bally thing fixed, and now we'll need to start all over again!"

Biggles bit back an angry retort, and concentrated on guiding the crippled plane upwards. This time, now that he knew what was going on, they would start their glide from a lot higher.

After another protracted glide, the Engineer clambered back into the cockpit, beaming. "All fixed!"

Biggles tapped the oil pressure gauge. "Pressure's not coming up," he said. "It will, it will," said the Engineer breezily. "Don't be such a fusspot. Now let's get the aileron sorted."


He crawled out onto the wing, and began to strike the recalcitrant aileron with a hammer. A minute later, the plane rolled violently to the right. Biggles struggled momentarily for control, his lips dry. By cracky, they'd almost lost it completely, there.

"Don't do that!" he called hoarsely to the Engineer.

"Do what?"

"Whatever you did, just then."

"I wasn't doing anything, old man."

Almost at that moment the plane lurched again, more fiercely, and rolled through forty-five degrees. "That!" screamed Biggles, fighting the controls for his very life. "Don't do that!"

"Fair enough," said the Engineer, cheerily. A minute later he did it again, and the plane was inverted for ten long seconds before a sweating Biggles regained any vestige of control.

"Fixed! Undercarriage next!" called the Engineer, and clambered out of sight below the fuselage.

Ten minutes later, Biggles caught brief sight of a set of wheels dropping away earthwards. "Couldn't save 'em," said the Engineer when he regained the cockpit. "Better off without them, frankly."

"I still have very little oil pressure," said Biggles, worriedly.

The Engineer pursed his lips and tapped the pressure gauge reflectively. "Well, the leak's fixed, old man. Must be something about the way you're flying her." He reached under his seat and pulled out a parachute. "Look, I'm most frightfully sorry about this, but the nice men from Sopwith are taking me out to dinner tonight, so I've got to dash. Be a brick, Biggles old fellow, and just put her down anywhere you like. I'll cast an eye over her in the hangar tomorrow morning."

And with that, he was gone.

Biggles thought longingly of his own parachute. But he couldn't abandon the old girl now. It wasn't her fault, after all. Black, oily smoke was already billowing out of the engine cowling, however - he needed to put her down soon. He began to peer around for a flat place to land and, almost immediately, he spotted a distant grassy field. He moved the controls a little so that he could take a closer look.

He flew around the field once, and it certainly looked flat enough. Oddly, someone had painted huge white letters across the level green grass - ICU, it read. He had no idea what that meant, but it seemed vaguely comforting, for some reason. The engine coughed once, and then stopped. He could see a fitful orange glow beneath the cowling. This rummy ICU field would just have to do, it seemed.

As he swung the ailing aircraft around to make his final approach, he realised that the field was just a little too short for comfort. He licked his lips, and prayed that there would be enough room...


Sounds familiar to my anaesthetic chums? Happy landings, colleagues!

Teaching old dogs new tricks

I have just got back from the Airway Skills course held in Sydney and run by Paul Baker (airwayskills.com). Unlike other courses, this was was genuine small group learning with plenty of opportunity to discuss cases, get hands on with a variety of equipment and was suitable not just for anaesthetists, but also intensivists, ED docs and rural proceduralists.

Its amazing how much one can learn even when one is doing a job on a daily basis. Paul Baker is well known as the author of numerous papers and the ANZCA 'difficult airway' equipment recommendations. As such, he brings a calm authority to discussion of airway and was a patient teacher.

I got a chance to play with a variety of equipment, including understanding the vital difference between proseal and supreme LMAs, play with combitubes, fiddle with Frova's, Aintree catheters and confirm my choice of scalpel-bougie-tube for surgical airways. Also a great session on AFOI, as well as discussion of using 15l/min O2 via nasal specs as an adjunct to preoxygention/RSI and Levitan's excellent airway book...

Only one thing was missing - a 'soiled airway' mannikin, to simulate the emergency airway that is the province of trauma and emergency docs...I know Minh le Cong has been muttering about such a simulator, but I reckon it'd be a great chance to wet test some ideas like Weingart's ETT as suction catheter.

Rural docs have a plethora of courses to choose from - EMST, APLS, ELS, RESP, MOET, ALSO etc, as well as clinical attachments for procedural upskilling. I've blogged previously about the excellent Rural Doctors NSW procedural conference (combined with a day at the sim lab for GP-anaesthetists) and how I'd love to bring a conference with similar content to South Australia. The Baker airway skills course is so good that I reckon it'll soon become oversubscribed, and the rural proceduralist cohort may miss out...wouldn't it be great to bring this paradigm to a wider audience, rather than just 3-4 courses per annum on Oz and NZ?

Gear fetish

I'm in love...with my KingVision videolaryngoscope. It's somewhat of a generalism, but anaesthetists tend to be 'propellor heads' - they like to fiddle with equipment, & they are invariably seduced by things technical...you can usually tell anaesthetic doctors at a conference - they're the ones with MacBook Pros or iPads or iPhones.

But I digress. Last week was one for coincidences - the local rep sent the KingVision up for me to trial and at the same time Broome Docs posted on the issue of 'which video laryngoscope', whilst Minh Le Cong of RFDS Queensland posted a review of the device on EM-crit. Then to top it off I spent the weekend at the NSW proceduralists conference, where videolaryngoscopy was discussed and utilised both in the simulation lab and in the conference talks. I was so impressed I forked out my own cash to buy one, rather than wait for my local health unit to come to the party.

I think that VL is a game changer. Don't get me wrong, I'm diligent in developing and maintaining my direct laryngoscopy technique...but when faced with a difficult airway, the VL has potential to substantially improve the view.

We've got the C-MAC up in theatre where I am currently doing some anaesthetic upskilling. It's a great piece of kit and I think that the ability to see laryngoscopy on the screen is both reassuring for everyone, as well as accelerating the learning curve for novice intubators (they reckon that it takes at least 60 intubations to progress from 'novice').

There's also great potential to use the VL to simulate the difficult airway...given that Grade III and Grade IV Cormack-Lehane views are supposed to come along with relative infrequence (less than 1%), I reckon there's merit in using the VL to take a look at the cords, then either reposition the patient or the scope to simulate a Grade III or IV view...then utilise techniques to still intubate the trachea (BURP, bimanual manipulation, blind pass bougie, stylet etc etc). Again, this greatly advances the learning curve. 


For the 'occasional intubator' (most rural docs) the VL gives additional comfort - particularly when our decision to intubate is often forced due to imminent respiratory failure, or severe obtundation...and invariably in an un-fasted, un-optmised patient with haemodynamic instability. In a collar. Maybe at the roadside. Quite a different kettle of fish to the ASA I/II selected cases fasted for theatre on whom we practice. Of course, the big drawback is money. The C-MAC comes in at around $15K. It's not a device that is realistically affordable for Kangaroo Island or indeed other small health units in Australia.

Some doctors have opted for the AirTraq, which is not a VL as such (relies on prisms to give an optical view)...it's cheap as chips at under $90 each, but I find that peering through the viewfinder is fiddly and that one loses situational awareness. 

Hence the KingVision with it's built-in screen offers similar affordability (blades are about $30 each, the re-usable screen under $1000) and allows me to maintain situational awareness. I plan to have it to hand for anticipated difficult airways (trauma, collar, weird anatomy, failed LEMON etc)...and of course to use it now and then on routine lists to keep up skills (the technique is subtley different to DL).

Today I popped down to the local hobby store and haggled for a 12 inch TFT monitor with mounts for IV pole...then I've hooked up to the KingVision via the supplied composite-out video cable...so now I've got a system that allows big screen playback and recording, for a fraction of the cost of a C-MAC. Great for teaching. 

Bloody brilliant.

If you haven't already, take a look at the KingVision. For the price, it does exactly what is says on the box. Given that tertiary centres insist on having some sort of backup device for the difficult airway, I think that it's now indefensible for smaller hospitals not to have kit that does the same job.

[Please note that I am not affiliated with KingVision and that the model I purchased was with own cash at retail prices]

Networking and Silos

Well, just got back from the excellent GP Anaesthetists conference held in Sydney under the auspices of the NSW Rural Doctors Network. Apparently it's an event they hold every other year (alternating with an obstetric workshop) and manage to do each workshop twice in each year - delivering quality education to approx 80 of the 150 or so rural GP proceduralists in NSW. It's an extensive event that would go down well back in South Australia...although I reckon we'll have to get Dr Minh Le Cong and Dr Casey Parker along to emphasise the 'rural connection'.


What makes this event stand out was a day spent in the simulation lab at the Royal North Shore Hospital, with hands on quality simulation training in a variety of anaesthesia-relevant emergencies, then a conference dinner and the next day spent with a variety of speakers pitching content to the rural audience.


It was good for me to meet with other rural doctors, mostly from NSW and a few from Victoria. Interestingly, once they knew I was from Kangaroo Island, all were interested in the events of 2009 and our stoush with Country Health SA and the ACCC debacle (details of which I really should blog one day, as I should about upcoming contract negotiations with Rural Doctors in South Australia).


What I found interesting was that many of us rural doctors have the same problems - such as ongoing skills maintenance, lack of funding for nurse training and essential equipment, ongoing threats of hospitals being downsized and procedural services cut, remuneration for on call hospital work, as well as poor relationships with health bureaucrats. Most worryingly, many said that they were having to find own solutions to these shared problems, rather than a 'top down' approach. Basically, we're all operating in our little silos, rather than solving problems and lobbying for changes en masse.


It was particularly illuminating to hear some of the speakers (mostly metro-based anaesthetists) talk about difficult scenarios and resources to cope. In a few instances the speakers seemed aghast that many of the rural GP anaesthetists did not have access to equipment that their metro counterparts considered essential - things like suggamadex, desflurane, remifentanil, FFP, fibre optic intubation, modern anaesthetic 'workstations' etc. Sure, some of the rural docs had some of this stuff. But by no means all, in fact more like fingers of one hand. Out of 40 doctors.


Why? Cost, as always I am afraid. But that's OK. I think the key to being a good rural doctor is to "adapt-improvise-overcome". Luckily we stand on the shoulders of giants and most of the hard work is already done - providing we are well-trained, and equipment is well-maintained, it's perfectly possible to deliver a safe service using tried-and-tested agents.


So...anyone still using nitrous? I've been told that 'no ANZCA trainee uses nitrous' yet it's been around for ages and remains on the anaesthetic machines in most places.