thanks Scott Sorry to hear Janus General colleagues/admin were not so supportive of the hypothetical case management here. You are correct in that surgical airway is a dying skillset. Levitan said it is now regarded as a sentinel event rather than a part of reality of emergency medicine /emergency airway care. The proliferation of VL and other technologies has further cemented the notion in our collective minds that all airways can be managed non surgically. It is notable as in this case that it cannot prevent all surgical airways I dont think you should change your overall approach and what… Read more »

Thank you for another outstanding talk. What a perfect distillation of the concepts you’ve been teaching that have saved so many lives. Unfortunately, the vast majority of physicians outside the FOAMed community seem to believe that every patient deserves a trial of PEA arrest prior to cricothyrotomy. We know better, and must still do the right thing regardless of the emails that follow.

Scott, Amazing cast. I’d say if you don’t at least occasionally agonize, you’re not a true Resuscitationist. Leaning towards surgical airway will save many more lives than leaning towards “making sure we’ve tried everything else”. We MUST be confident: mentally, logistically, and physically prepared to perform the Surg Cric from the very beginning of each & every airway we take into our possession and control. Having said that, questions I have for you: Do you have intubating LMA’s @ JJ? If not, do you guys have, and/or is there preparation for:bAintree/LMA/Fiberoptic? Regardless, do you have the Fiberoptic plugged in &… Read more »

First off, great podcast as always. I absolutely love your approach to teaching and have used so much of this to reinforce my own skill set. The case you bring up would make my hair stand up as I have never done a surgical airway despite being in 19 different hospitals over several states as an ICU guy. You ED heros usually take care of this stuff for the patient before I need to get my little paws all dirty. However, there are times when my airways become a real challenge in the unit. The Monday-morning quarterbacks that sit on… Read more »

Happy New Year! Very nice case and analysis. A few thoughts: -Preparation is key. In the OR, when I work with ENT (see NAP4 data) I verbalize a plan A, B, C, and sometimes a D. This drops the energy level in the room and facilitates smoother care. -To reiterate what a previous contributor asked, did this ‘patient’ have a known potentially difficult airway? If so, then awake FOI is the standard of care. Otherwise your algorithm was ok. I’m not sure I would have gone for the 3d look w/ the Miller if the pt was de-satting and I… Read more »

Hey Scott, I’ve recently become a huge fan of the fiberoptic LMA technique (fiberoptic/aintree/LMA if no intubating LMA). Through conversations with my colleague & good friend Andy(Sloas), and through practice, I’ve come to realize the true power & potential of the technique. As you know Andy would prefer to intubate all comers in this fashion (directly to RSA and fiberoptic from there), and although I don’t think we should necessarily be doing this for every single intubation (for various reasons), I do think it may be the wisest approach in select cases. Even if not directly to RSA on first… Read more »

Great case grippingly presented. We all could have been there. Ironically, had an anesthesia or emergency resident given a bolus of propofol and the patient arrested on induction, then in all the hospitals I’ve worked he would have been pronounced dead with the cause attributed to his illness and no further investigation or criticism would have been likely. However, in your hypothetical case at JGH, your meticulous preparation, resuscitation, and pre-emption resulted in a surgical airway being a viable option and he made it to ICU alive with a good airway, and as always the downstream providers made fundamental attribution… Read more »

Scott, you are incapable of doing a ‘cast and not teaching me something. As I scanned the show notes before listening, I thought to myself: HOP killers, difficult airways, crics: now HERE’s a ‘cast in my wheelhouse. And then I listened, and I learned. I’ve never done inline waveform capnography when doing bag mask ventilation. For some reason, I’ve had a mental block whereby I’ve always reserved the inline capnography for post-placement of either ETT, SGA, or cric. But as you rightly point out, when doing BMV, it’s tough to tell by just feel and watching chest rise how successful… Read more »

Dr. Weingaert, As usual, I enjoyed you podcast. The sweat on my palms made me realize that I could place myself easily in this situation. I work as a PA in a remote environment where emergency airway management is a very rare thing to deal with. But, as anything can happen, and with a population of patients with many severe and potentially severe co-morbidities, I still have to be prepared. I have found much inspiration in your talks to look critically at my set up and, more importantly, my mind-set. Thought experiments like this have pushed me to better prepare… Read more »

I think it can not be said enough that preparation is the key in these situations. The method of getting the airway can be up for debate to some degree as you all have noted above. In the end getting the airway by whatever means saves the patient. I learned the hard way one time when I asked the RT for a bougie and they looked at me kinda funny. I am a full time locums so every new hospital brings new challenges and variance with practice comfort by the teams in work with. Preparation for such things is paramount.… Read more »

well…if folks are bringing up all sorts of airway techniques like retrograde, FOI via LMA..I think its prudent to remind ourselves of KISS principle. Blind intubation is , like surgical airway skills, a dying art. It was de rigeur in the past for ENT lists, Dental lists to do blind nasal tubes daily, with bottles of CO2 to induce hyperventilation to assist the procedure. But that is in spont breathing patients..so maybe not so suitable for this hypothetical case! Blind nasal as a rescue technique is terrible. patient is usually apnoeic so no guidance as to if in right direction!… Read more »

Great case that gave me flashbacks to my most recent cric. A couple comments, 1. Fortunately, not all hospitals look at a surgical airway as a Sentinel Event. In fact at my facilities I have never been criticized for my airway choices or performance. Even my most recent “cric”. Which turned out to be a supraglottic or sublingual airway, which was necessitated by comlete calcification of the cartilaginous and membranous structures of the neck. 2. Not all EMS medical directors consider a surgical airway a failure. Howeve, many medical directors are familiar with the “hero” mentality of some ems providers… Read more »

Wow… great podcast! I can’t agree with you more.. it’s a dying skillset that scares the heck out of most providers. The only way to be ready is learning from situations like you described, mental preparedness, and hands on practice whether that be simulation or by cadaver. The latter is hard to obtain for the average provider. While I’m genuinely heartbroken that I probably won’t be able to attend SMACC; however, I was able to attend CCTMC this past year and participated in the anatomy lab, in which Bill Hinckley (who’s comment I saw above) lectured on Cricothyrotomy. Forgive me… Read more »

RE: 141 (airway at Janus General w/ 45 y/o male w/ sarcoid).

Extremely nicely done.

I was sorta on the fence about re-upping for CME membership until I heard this one. Got on it today.

Jim Carroll, CRNA
Wisconsin

Good job on this Scott. Great case with great teaching. Also good discussion on the professional fallout of doing a surgical airway, i.e., the harassment that can occur in their aftermath. Let me add this encouragement to your lecture–always do the right thing. You may need to “justify” the cric after the fact, but if you were doing the “right thing,” it will be easy to explain–just tell the truth, just tell it like it is. I provided anesthesia recently for a patient in severe liver failure in an outside procedural area (a portosystemic shunt). Going through your case reminded… Read more »

Wonderful talk Scott. These points are so important and under appreciated. They must be more widely disseminated. Also excellent solid physiology basis. I agree with using the devices with which one has the most experience. Intubation over a broncoscope through either the nose or mouth is my preferred method. While learning intubation through the nose over a bronch in a large patient is very easy (but may limit tube size). Intubation through the mouth over a bronch takes very much practice esp with patients with large tongue and limited velo pharyngeal space. I have a few questions. First what is… Read more »