Light at the end of the tunnel?

We’ve all been there. Anyone involved in airway care and intubation have all had that experience. You look down and cannot see anything, or certainly nothing you can slide a tube through. Sometimes it maybe predictable – trauma, small chin, fixed neck – but a lot of the time it just isn’t.

‘Get the thingy’ I hear you cry, ‘you know that toy we’re meant to use for difficult airways, the one that’s kept in theatres’

‘How do you switch it on? Which blade should we use? Where are the blades kept anyway? How do you get the tube round the corner? ’

Sound familiar? No? Well then you’ve had a much better experience of introducing videolaryngoscopy to practice than I have. As with all procedures in medicine, using a new piece of (unfamiliar) equipment in an emergency situation is a recipe for disaster. Whatever is going to be your preferred rescue device for a difficult or failed intubation, you have to be familiar with everything about it. But how do you do that? Hardly anybody does many emergency intubations outside theatre these days, and most of those are fairly straight forward. How do get the practice using the very piece of equipment you need to rely on in a potentially dire situation, when you might only really need to use it a few times in a career?

Simulation is good. Training is effective. Practice in theatre works. But unless you use something on a regular basis, familiarity and expertise will wane. The answer seems obvious then, doesn’t it? Just use it all the time. Use it for every intubation, ensure that everybody – and all teams – who intubate patients get all the practice they can. Only then can you be sure that when it really is needed there is no drama, that the most you might need to do is use a different blade or perhaps change the operator.

So, let the discussions begin. Get stakeholder buy in, write a business case, get financial support – yes, it looks like it might be achievable in the emergency department. Oh, hold on – wouldn’t it make more sense to do the same right across the Trust so that every operator and all of the support teams are familiar? So that every procedure is safer? Yes, it certainly would, the logic is indisputable. Back to the drawing board then, get the big guns out, write a better business case, get the executive team involved, negotiate a good deal from the company …. and a considerable time, and some grey hairs, later …. hey presto videolaryngoscopy is the default means of laryngoscopy across all theatres, critical care and the emergency department.

Success then? In many ways, yes, absolutely. There remain some niggles. How do you maintain the equipment and ensure that all blades are always available in every area of the hospital? A bit of a nightmare when everything is so expensive, a palaver to clean and an audit trail of blades and patients needs to be maintained. But these niggles pale into insignificance when you appreciate that every intubator, and all the individuals involved in intubation, are familiar with the equipment, irrespective of where they are called to intubate. When you appreciate that all intubators can be observed and trained in their practice, that it doesn’t necessarily diminish their direct laryngoscopy skills, that the whole team can be much more involved in the process, that it’s much more likely that a patient will be intubated first time, every time.

In every TEAM course you will hear the mantra – ‘make your first attempt your best attempt’. Preparation is the key to ensure this is always the case. Preparing the patient, the team, the drugs and the equipment are crucial to ensure success on an individual basis. Preparing the environment, training the teams, ensuring the right equipment is available in all areas where intubation is being performed is equally important. But this cannot be addressed when the patient requiring airway intervention is in front of you. If you want your patients’ to be as safe as possible, if you want your teams to perform the best of their ability, if you don’t want to be investigating how things could have gone better, surely doing some preparation on a more corporate level is advisable. Whilst videolaryngoscopy may not be for everyone, ensuring there is a common, Trust wide response to managing a difficult airway situation will reduce risk, improve patient care and reduce the non-clinical workload in the long run.

Dom Williamson

Consultant emergency Medicine

RUH Bath

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