I was driving to the airport after speaking at a conference and hearing Dr. Ed Racht’s lecture. ED (Emergency Department) Ed, as I like to call him, is a renowned speaker at national EMS and healthcare conferences and is ED (Extremely Dedicated) toward teaching ED (Emergency Didactics), including such topics as ED (Excited Delirium), ED (Erectile Dysfunction), ED (Explosive Diarrhea), ED (Ethanol Discourse), ED (Epidermal Detachment), ED (Eelworm Disentanglement), ED (Earwax Dialysis), and last but not least, ED (Edematous Duodenums).
ED Ed has a skillful way of making his attendees laugh while learning, which I can appreciate because I have an ED (Edification Disorder).
I chuckled as I reflected on Dr. Racht’s presentation on ED (Epiglottic Delinquency) to ALS providers: compromising patient outcomes secondary to prolonged advanced airway management techniques in their attempt to secure an airway. Not that this isn’t a serious subject matter, mind you, but Dr. Racht came up with a clever anecdote for medics who waste invaluable metabolic time while attempting to traverse infraglottic airway devices down hypoxic tracheas.
I know that medics, specifically the old guard, have a tendency to get tunnel vision when it comes to going for an ET tube to secure an advanced airway. So much so that they can neglect to keep track of time or of the patient’s color, pulse or rapidly developing rigor mortis. Dr. Racht proposed the idea of a voice-activated command quality assurance system that would provide immediate feedback for the medic—warning of a patient’s impending hypoxic demise should they not stop their intubation attempts and start BVMing the patient’s pearly EDs (Exposed Dentures).
Non-invasive ED (Electronic Data) gathering sensors would interpret the patient’s PO2 and EtCO2. At first, in a kindly, sultry tone, it would warn the medic of the patient’s inadequate cellular saturation levels. Should the medic ignore these cautioned articulations, the voice-driven command system would then take on a less-than-cordial profile, similar to that of an ED (Exasperated Driver), “Hey, moron! Pull over already and let the EMT ventilate %#&! You’re killing me here!”
While continuing my drive and reflecting on Dr. Racht’s humorous anecdote to airway management, when my rental car’s GPS suddenly informed me that I had missed my ED (Exit Drive) to the airport.
“Hmm,” I hummed. Maybe we could expand on Dr. Racht’s idea and add a navigational system to aid those who haphazardly become lost traversing unfamiliar laryngeal terrain. A location-specific, voice-driven personal assistant, if you will, providing the intubator with the fastest and most efficient route with turn-by-turn directions.
Navigator: Entering the mucus tunnel. Stay on right and proceed straight ahead. Destination, 22 cm.
Medic: The tongue is in the way.
Navigator: Veer tongue left and proceed straight ahead past the hard palate.
Medic: I can’t see #&%!
Navigator: Take off your sunglasses dumb ass.
Medic: Oh, heh! Heh! My bad.
Navigator: Epiglottic landmark ahead. If at the helm of a straight blade (Miller), proceed straight posteriorly of the epiglottic exit. If curved blade (Macintosh), take the roundabout to the vallecula and proceed anteriorly of the epiglottis.
Medic: My nose itches.
Navigator: Focus! Elevate. Do not use a fulcrum approach. Watch for frontal incisor hazards and proceed with ETT.
Medic: Subway ahead … sandwich, that is.
Navigator: Recalculating … Suction.
Medic: Pallid pillars ahead!
Navigator: Proceed straight ahead and take the vocal fold exit. Continue ahead until you’ve reached your destination of 22 cm and then inflate airbag. Scratch nose.
This example was based on a near-perfect ETI first attempt—just like all my ED (Ego Driven) tubes.
Seriously though, I don’t blame medics for their intense focus on “getting the tube,” specifically an endotracheal tube.
Years ago paramedics were ingrained to get the tube at any cost, and we did—sometimes at the patient’s cost. There’s a real fear of oral intubations going by the way side for EMS. I personally believe—like anything else in EMS—practice makes perfect, and ETI is superior in providing a patent airway. But we should be reevaluating our airway management approach to patient care? Sure, but there should be no limit to managed airway techniques including BVM, oral airways, supra and infraglottic devices—as long as we are adequately educated, trained and armed with the best airway tools available.
Until next time, stay EDucated. JEMS
This article originally appeared in February 2012 JEMS as Glottic Passage Steering: A little airway assistance.”