“…obnoxious sound-bytes like, ‘the only prehospital fluid of use is gasoline’, outdated dogma like that needs to be put in a box with the rest of 1980’s ATLS crap…”

Amen! [reader note, US providers prefer diesel boluses]

Here’s an update since that was recorded.

(1) Equipment: we know carry iGel instead of LMA. We are likely to acquire the King Vision as our video laryngoscope, to be carried on interhospital missions (not for pre-hospital trauma).

(2) Since recording the podcast, we have had two failed intubations pre-hospital, both in obese trauma patients. Each case was rescued effectively in the field by laryngeal mask airway without desaturation. One case was successfully intubated in hospital by an anesthetist using video laryngoscopy; the other had failed intubation attempts by anaesthesia staff in the receiving ED and ended up requiring a cricothyroidotomy.

(3) The proposed trial of video laryngoscopy (VL) vs direct laryngsoscopy (DL) – we have decided not to embark on this at this time, prioritising other research questions that we feel will be more contributory. A study proposal on pre-hospital ultrasound is undergoing ethical committee (IRB) review. A VL vs DL study is being done in France – http://clinicaltrials.gov/ct2/show/NCT01374061

(4) I shall in future try not to burst into random spasms of laughter like a scary crazy person.

Cliff

Hi guys what a coincidence! I was taking some photos of us testing the King Vision video laryngoscope only yesterday for that review you wanted Scott! The article will be on the way to you soon! I have to agree with Cliff about having the device in the prehospital setting. Its the only VL we have tested that gives a decent image in direct sunlight and does not cost an arm and leg to purchase. I saw the French study proposal looking at GLidescope vs DL..it follows on from case reports and retrospective studies out of GErman HEMS experience with the GLidesScope. There was a positive study out of Austria earlier this year looking at the CMAC VL system. The killer factor about the King Vision is its aggressive pricing. You would pay more to go to an airway course! Anyway my review is coming! About the intubating LMA, I find it odd not many prehospital services are using it as it is evidence based in the prehospital setting and cheap for the disposable versions. I use it almost exclusively in predicted difficult airways. About the iGel, there is less published evidence in the prehospital setting versus even the Classic… Read more »

Great pt 2 of the interview. Fantastic stuff on prehospital amputation.

about prehospital needle cric, my RFDS colleagues in Western Australia have done two successful ones and in QLD a Careflight doctor did a Melker seldinger cric last year on a guy with Ludwigs

Hi Cliff, on your interview Scott challenged you on the notion of protocol based management and I have to agree with him. Protocols are a necessary evil as they establish ground rules for safe and quality practice. Sure they should be improved and promote current best practice. The concept of doing whats best for the patient at the right time by the right person etcetcetc, is a very elusive one. Experience and keeping up to date does count but thats only half the story.The airway cases I cited are testimonies to that.And Scott’s right, you can’t have experienced doctors everywhere. Your concept is like the great Bruce Lee telling us “My style is no style”. Whilst advanced practitioners may benefit from this teaching, it is of little help to the beginner who more benefits from a systems based training and method.
I make this reference as Cliff and I share a common background in Wing Chung kung fu, the original fighting style of Bruce Lee!

When looking at supraglottic airways in Rich Levitan’s cadaver lab the four physicians from our service all agreed on the following:

Cookgas was our favourite
iGel was beautiful in its simplicity and great for our paramedics as well as our doctors

Both were easy to intubate through using a ‘fibreoptic’ guided technique (using the Ambu A-scope, which technically is not a fibreoptic device but behaves like one).

Of the VLs, King Vision won hands down.

Unfortunately, we were unable to find a supplier of Cookgas in Australia, which is why we went for the iGel.

We therefore now have:

Prehospital: Mac & Miller laryngoscopes, iGel, ENK, surgical crike set
Interhospital: As above plus King Vision, Ambu A-scope

I’ll let you know how we go.

Cliff

“Before I learned the art, a punch was just a punch, and a kick, just a kick.
After I learned the art, a punch was no longer a punch, a kick, no longer a kick.
Now that I understand the art, a punch is just a punch and a kick is just a kick.”
— Bruce Lee

Cliff, what an airway kit you guys now carry! I understand the iGel decision now that you also got the Ambu Scope. Having said that your stats show only two failed intubations in how many years? I would have just gotten the King Vision VL and left it at that but hey its only tax payers money…hahahaha
Be like water, friend.

My colleague Dr Karel Habig made this video of our training for new retrieval physicians in July.

http://www.youtube.com/watch?v=VWuX8pV7Ceg&w=560&h=315

Cliff

[…] after watching this video of a recent physician induction!Hat tip to @Cliffreid from Resus.ME via EMCrit Podcast 058 – Interview with Cliff Reid – Part IIRelated posts:Palpable ExcitementAustralia lead the way in improbable researchThe Social Media […]

Minh

Can I get you to clarify your comment on the iGel/Ambusope connection? Do they play together well, in your view?

Our ED uses iGels as the supra-glottic rescue device of choice (the inventor of the iGel is one of our anaesthetic doctors).

I’m currently discussing with our anaesthetists the issue of adding an Ambuscope to our difficult airway trolley and wanted any views on the role of the Ambuscope in the ED when it comes to the difficult airway.

Thanks

Dean