EMS World

JAN 2019

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30 JANUARY 2019 | EMSWORLD.com COVER REPORT: AIRWAY MANAGEMENT Research by emergency physician Henry Wang, et al., supports Braude's assertion that SGAs are robust airway management tools. Wang and his team showed improved cardiac arrest survival and neurological outcomes after prehospital insertion of SGAs versus ETTs. 2 Before promoting a reduced role for ETI, though, Braude feels educators have to confront practitioners' unrealistic expectations of SGAs as fail- safe instruments. "We've implied these tools are so easy to use, you don't have to think about what you're doing," he says. "No device is that good. "Providers grab an extraglottic airway, and when it doesn't do exactly what they want the ver y first second, they're like, This thing is worthless! It confirms all my suspicions, and I'm going back to intubat- ing! But that's not how it works. You have to be patient and focus on the basics, the physiology." Braude suggests starting with a moment of contemplation and a realization that you won't succeed 100% of the time. "Consider the patient, the anatomy, the device, and the technique," he offers. "Understand there's a 'fiddle factor' involving fine adjust- ments. That should relieve some of the stress. Remember, none of us are perfect at this." Ogilvie buys into Braude's philosophy. "I try to have a plan and a backup to the plan before I start (placing an airway)," the 43-year-old volunteer explains. "Maybe even a backup to the backup. I just wish my school had gone further than, 'Put the blade in the mouth, move the tongue, and find the right hole.'" Accentuate the Basics, Get the Reps Paul Werfel understands the imperatives of airway management from the perspec- tives of both teacher and pupil. In fact, the director of Stony Brook University's para- medic program says his students have to work harder than he did as a paramedic candidate at Beekman Downtown Hospital in New York City 35 years ago. "Back then it was about how many hours you did," the Long Island native recalls. "Now it's about competencies: 50 airway interventions in our program, including at least five endotracheal intubations. You can sign up for whatever ambulance and hospital rotations you like, but you're going to keep going until you meet those criteria." Like Braude, Werfel believes airway pro- ficiency begins with the basics: "We start with EMT stuff people didn't learn properly or don't use often enough: manual maneu- vers, OPAs, NPAs, BVM ventilation. You'd better know the anatomy, too, or you might as well stay home. "Then we move on to more advanced levels. We address endotracheal intuba- tion pretty aggressively—the indications, contraindications, and pitfalls, plus RSI and DFI (drug-facilitated intubation)—but we're also teaching that not everyone needs a tube." The Stony Brook program covers SGAs such as LMAs, King Airways, and Combi- tubes with the caveat that inflatable cuffs can impede cerebral perfusion. 3,4 "Properly placed and monitored endotracheal tubes are still the gold standard," says Werfel, who often serves as an expert witness on airway mismanagement cases. "If a board- cer tified anesthesiologist has to have waveform capnography to confirm tube placement in the OR, you better believe that should be happening prehospitally too." Werfel acknowledges paramedics have long considered ETI to be a specialty, if not a privilege of the position. "That's one of the reasons they aren't always up to date on the research," he says. "They think they know it already. The attitude becomes, You'll have to pry that laryngoscope from my cold, dead hands." Even diligent paramedics who know what they don't know sometimes struggle with ETI. When that happens Werfel says it might be because they're rushing: "Med- ics can develop tunnel vision and think it's a measure of professionalism to get the tube within a certain number of seconds. That's when you forget to prepare—to have SGAs are robust tools for airway management. Photo: Rebecca Heigel

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