SALAD on the beach

It’s hotting up ‘down under’ and we are planning to spend summer on the beach as is traditional at Xmas/New Year.  It is going to be a hot one … Adelaide (nearest city) is supposed to be the hottest city in the world for Xmas Day!

Meanwhile plans for #DAS smacc airway workshop are shaping up for Berlin in June.  As usual the airway workshop is fully booked, but there are plans to host a series of ‘pop up’ events in some of the venues around the conference during smacc week….The SALAD sim (suction-assisted laryngoscopic airway decontamination) will feature – this is the brainchild of evil genius Jim DuCanto and has been enthusiastically adopted by many worldwide to practice management of the soiled airway.  Many of us are refining airway trainers to ensure the ‘SALAD Sim’ popups are fun and memorable for all in Berlin.

What then could be more Australian than a beach BBQ?  An esky full of beer…some ice…and SALAD?

Dr Tim’s Beer and SALAD Sim

In true summer style, I have been experimenting with a traditional beach esky – filled with ice, cold ‘Dr Tim’s’ beer and cunning use of a 12V battery and bilge pump to deliver a constant stream of simulated vomitus to the airway mannikin. The entire set up is portable – and better still, can carry beer!

Make one yourself – you KNOW you want to!

 

Portable Vomit Simulator

I’ve just got back from another Critically Ill Airway (CIA) course at The Alfred, run by intensivist Chris Nickson of LITFL.  This packed two day course is designed for anaesthetic, emergency, intensive care and rural doctors and combines a multitude of hands-on task training with immersive simulation scenarios.  Great fun and highly recommended, although heavy demand means that there is a wait list for places!

For the first time, I brought along the ‘SALAD sim’ – this is the brainchild of Milwaukee anaesthetist Dr James DuCanto; we’ve used it at smaccCHICAGO and smaccDUB airway workshops and it’s nice to see the paradigm being adopted by many enthusiasts around the globe.

Suction-assisted laryngscopic decontamination (SALAD) is a task-training technique to cope with massive emesis (whether vomit or blood).  Instructions on how to make one have been well-described by the inventor, Dr DuCanto.  See a guide here from Airwaynautics.

In past few months I’ve been looking to refine my version for easier transport and obviate problems of large pumps and power supplies.  At the Critically Ill Airway course, several people asked me how to make one.  Here’s a quick guide to parts.

The Compact Vomiquin

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PELICAN STORM CASE IM2500

I like this case as it has wheels and a handle, making it useful for lugging around the countryside.  It contains power supply, a bilge pump, on/off switch mounted in casing, reservoir for fluid and is large enough to carry airway head and assorted airway kit.

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I’ve drilled a couple of holes in the case

(i) to accommodate a marine grade rocker on/off switch (with light)
(ii) a tank fitting to connect internal pump & hose to the airway head, via socket/collar quick connect fitting
(iii) a threaded cap port in lid to allow rapid filling of reservoir with case closed

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Port in lid for rapid “hot refill” of reservoir even when in use & lid closed

AIRWAY HEAD

I am using the Laerdal trauma head (kindly donated by Dr Andy Buck of ETMcourse.com). This head has a metal bar that can slide via the right cheek across the mouth (obviating bag-mask ventilation, supraglottic insertion and impeding laryngoscopy) and an inflatable tongue.

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I’ve kitted mine out with a cheap USB-camera on a 2m long cable, which is placed via the left nares to allow video of the oropharynx via Quicktime recording on a Macbook.

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USB camera placed in oropharynx with long cable to Macbook for video of rising tide

VOMIT RESERVOIR

Jim DuCanto uses a separate reservoir for his ‘simulated airway contaminant’.  I found that having another container to carry took up too much space, so have made a reservoir within the Pelican case using a sheet of perspex (plywood is fine) cut to shape and then secured with waterproof sealant.  Initial experiments with Sikaflex were OK from a waterproofing perspective but failed under rough handling.  I’ve now fibreglassed the divider into place, which adds to both waterproofing and strength. So far no problems with leaks despite multiple plane trips.

Internal divider for reservoir, reinforced with fibreglass

Internal divider for reservoir, reinforced with fibreglass & contains Rule 360 bilge pump

Simulated emesis can be made simply with water and food colouring – green for vomit, red for GI bleed.  One can thicken it up using xantham gum powder, but to be honest I’ve found liquid vomit teaches the skill as much as using thickened versions.  Omitting the use of xantham also saves on tedious pre-mixing and is easier on the pump!

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Barfume used by Sim Ninja in paramedic training (chunky vomit too)

To simulate the smell of vomit, one can either use white vinegar or add ‘Barfume’ (available online from the makers of ‘Liquid Ass’ faeces odour, this is s potent ‘simulated vomit’ odour which can be mixed in with the coloured water). Kudos to sim ninja Michael Borrowdale for this one!

Using barfume means props are small and easily packed, as opposed to having to carry around litres of white vinegar or source at destination!

PUMP & HOSE CONNECTORS

Rather than use a large grey water pump and variable control rheostat to control the flow,  I’ve found that a simple Rule Bilge Pump (360-500) is more than able to cope with pumping simulated vomit/blood.  Flow rate is adjusted by an inline valve which can be turned from full on (impressive spurting out of mouth, nose, eyes) through to intermittent bursts, down to a steady trickle or just ‘off’.

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Head connected to inline valve, which then connects rapidly to tank-fitting on case

The inline valve is connected to a simple threaded hose fitting placed in the oesophagus of the airway head and secured with a worm-screw clip.  The lungs can be left in situ, or removed and bronchi plugged with barb caps (saves on subsequent cleaning of the lungs).

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With the head stored in the Pelican case, it’s important to be able to connect/disconnect easily.  I have used standard plumbing fittings from the local hardware store.

A tank fitting is placed in a hole drilled at one end of the Pelican case and connected to the pump via flexible hose, secured with worm screw clip.  The inline valve (flow control) is then attached to the head and the whole assemblage can be attached to the tank fitting. Importantly neither head nor tank need to be rotated; the collar/cap fitting allows connection with a few turns only until tight.

POWER SUPPLY

I took advice from the local marine store and have used a 12V MotoBatt battery which can be recharged.  It’s secured in place with bungee and connected to a marine-grade rocker switch on the side of the Pelican case.  This means the vomit reservoir can be filled, the head connected and case closed – with pump turned on/off via the switch out of view.

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Less than 100 Wh – check with airlines & CASA regarding specific carriage regulations

Having portable power means I don’t have to carry cables, worry about power supply at destination nor risk electrocution.

The MotoBatt battery is able to be carried in both ‘carry on’ and ‘checked’ baggage with airlines if is considered part of installed equipment, but do check beforehand as limits may apply based on Watt/Hours (typically less than 100 Wh).  Rules regarding carriage of batteries as ‘spare’ or not connected to equipment should be checked before travel.

The Australian Government Civil Aviation Safety Authority have a ‘dangerous goods’ app for iOS, or check out the information on batteries online, as well as with individual carriers.

I make a point to disconnect the battery from switch, protect terminal, cover switches (secure in off position) and discuss with airlines/border protection if any concerns. especially as am also carrying what appears to be a human head onto the aircraft…

Put it all together and you have a portable ‘vomiquin’.  

There’s space in the box for a couple of laryngoscopes (both DL and VL), spare suckers, bougies, ETTs, syringes, Barfume, food colouring, collapsible buckets and so on.

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I have been trialling different suckers – the traditional Yankauer sucker vs open tubing vs the SSCOR Hi-D and ‘oral evacuation tool’ suckers.  Some fascinating preliminary results for flow rates of various options…

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Sadly the current set up doesn’t have space for a suction unit – ideally this is available on site, but if not it will need to be carried in another bag.

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So – that’s it.  How to make your own vomiquin using parts in most hardware store, and which can be easily packed up and transported (just empty the vomit reservoir using suction and dispose down sink). I can generally get this set up in under five minutes and pack away in same time (provided the suction works and a sink is handy!)

Was it a success at the Critically Ill Airway course?  Judge for yourself? I think Chris Nickson’s smile says it all…

Coming next on KIDocs :

– comparison of different suction devices (Yankaeur, Hi-D, S3, tubing)

– other techniques for dealing with massive emesis (intubation in head down position to avoid aspiration, intubation in left lateral, deliberate intubation of oesophague with 9.0 ETT to divert GP bleed etc)

Refinements on SALAD Sim

Along with many others, am playing around with various combinations of airway trainer, simulated vomit, pump and suction to develop a self-contained portable SALAD sim (SALAD – suction assisted laryngoscopic airway decontamination)

SALAD is of course the brainchild of James DuCanto, Milwaukee airway fanatic and well known to the FOAMed world. Instructions on the SALAD set up are here and training videos here

I’ve had the privilege of assisting Jim in airway workshops in Chicago and Dublin as part of the smacc conference series most recently assisted by UK anaesthetists Ben Shippey @rallydoc and Barbara Stanley (@theneurosim).  We’ve managed to train several hundred people in the nuances of airway decontamination, under both ‘static’ (simple deposit of simulated airway contaminant) and ‘dynamic’ tests (an ongoing tsunami of vomit which threatens to overwhelm the intubator unless master the art of continuous suction whilst intubating – not as easy as it sounds!)

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SALAD sim shenanigans in Dublin

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Barbara Stanley (@TheNeuroSim) ready to serve up some SALAD in Dublin

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Even experienced airway operators feel the pressure under the SALAD Sim (smacc Chicago 2015)

 

The future challenge will be to create a SALAD sim set up that is both compact & self-contained

Present SALAD setups rely upon an open container of ‘simulated airway contaminant’ (a heinous mix of xanthem gum, white vinegar and food colouring) which is then pumped to the oropharynx using variously

  • a drill-powered inline siphon pump
  • a submersible bilge or pond pump
  • a dirty water sump pump

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Flow rates can be adjusted by either use of inline valves or a variable rheostat speed-controller to reduce pump speed and hence flow of vomitus.

The contaminated airway is then suctioned out, using a medical grade suction device. I struggled with this in Dublin, as the two loan units rapidly became overwhelmed…I didn’t realise that the bags within suction cannister are designed as single use and the inlet valve soon became clogged.

In contrast Jim DuCanto’s units (from SSCOR) functioned brilliantly despite multiple rounds (200 litres each I reckon) of vomit passing through.

The SSCOR Medical Grade Suction Pump performs brilliantly - but this, submersible pump & head consume a lot of space!

The SSCOR Suction Pump performs brilliantly – but suction, submersible pump & head consume a lot of space!

Problem is, lugging around suction pumps, submersible pumps and the containers for vomit is quite bulky.

The purist in me wants to design a closed system, namely

  • bladder which can be removed, filled with vomit and then emptied at end of session
  • both submersible pump and suction pumps small enough to sit within Pelican case and be self-contained
  • suctioned contents to be automatically returned to the bladder, for further pumping to airway head
  • controls for pumps to be available on outside of case, once closed
  • variable controller built in

So the challenge will be to create something that can be carried in a Pelican case (Storm IM2500, on wheels).

It might look something like this:

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I’d envisage the whole unit being self-contained, the “simulated airway contaminant” (vomit) being cycled from bladder to oropharynx and back via the two pumps.

Bladder needs to be removable for filling/emptying at start/finish of session and able to tolerate periods where inflow < outflow (suction out < pump in to oropharynx).

Ideally the whole unit should function with lid of Pelican case closed, with control switches for pumps accessible on outside.  Marine rocker switches are ideal, as would a variable control rheostat panel control, flush with case.

Marine rocker switch

Marine rocker switch

A simple mains socket could be mounted in the Pelican case, such that the SALAD Pelican case can be plugged into mains power.

Really interested to hear from anyone with ideas on how to make this happen…preferably on a budget!

 

Difficult Airway Training – The Wookie Wins!

Full credit for this goes to Dr James DuCanto, airway geek and innovator from Milwaukee, USA. It’s been my great privilege (and crazy pleasure) to facilitate with Jim at smacc airway workshops in Chicago and Dublin, using the SALAD sim (suction assisted laryngoscopic airway decontamination).

This is a great setup to teach techniques to manage the contaminated airway and tends to put even experienced operators under a degree of stress.  Check out more on SALAD here or make your own…

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smaccDUBAirway Workshop@jducanto @theneurosim @rallydoc @kangaroobeach

But DuCanto is also notorious for innovative education – who can forget the ‘laryng-o-beer’ task trainer from smacc Chicago – a laryngoscope blade attached to a full beer bottle, with the challenge to see if could perform gently epiglottoscopy without inadvertently detaching the lid and losing the beer…

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Laryngobeer Hinds

John Hinds has a crack at laryngobeer #smaccUS

Meducation – in the Pub!

After a hectic full day of meducation at the smaccDUB airway workshop, we de-camped to the EMS Wolfpack ‘pop up’ session.  This was one of many satellite get-togethers that happen at a conference like smacc, wherever there are like-minded people around.  Walking into a small Irish pub, we were warmly greeted by prehospital colleagues…and with a few minutes drinks were poured, ultrasound gel was applied and the meducation (ultrasound & airway) began.

The Dublin folk, bless them, seemed to take this in their stride, calmly sipping on Guinness whilst around all around them live demos of sonography and intubation took place!

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Suction, beer and a licence to thrill…what could go wrong? Meducation with the #EMSWolfPack

 

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Andy Brainiard @TheSharpEnd nudes up in pub to demo ‘pint-of-care’ USS


Difficult Airway Training with Chewie

A stand out success was the ‘Chewbacca mask’ challenge.  If you haven’t already seen them, the Chewbacca mask emits a wookie roar when the mouth is opened.  It is, quite simply, one of the silliest things on the market and has become a bit of an internet sensation.  Of course, the roaring of a wookie is just what is needed when practicing difficult intubation….

https://youtu.be/KPWSE5I1Qto

Now this is idea is definitely DuCanto’s baby…but I have to share my impressions after making my own Chewbacca Difficult Airway Trainer post-smacc. It is great fun – not only to hear Chewie roar, but also to practice…

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Chewbacca Intubation #smaccDUB Airway W’shop

The premise is simple – take a Chewbacca mask and add it to the Laerdal airway trainer oropharynx; you can pick both up from eBay with relative ease (although needless to say the Chewbacca mask is easier to source)

Laerdal

The next step is to drill a couple of small holes in the Chewbacca mask and attach the oropharynx model; there is also a chin plate inside the mask – use fine picture hanging wire or fishing line to invisibly anchor the oropharynx to this pate within the mask (there are a couple of small screws on the oropharynx model that can be removed, wire threaded and then replaced)

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Secure the oropharynx to chin plate so it moves freely when jaw opens

I mounted the whole ensemble on some wood offcuts from the shed – the mask straps allow it to be slipped on/off with ease.  Raising the mask allows the oropharynx to be placed in different positions, markedly changing the difficulty of this airway trainer….

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Raising the oropharynx onto blocks makes it a Grade I view…

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DL view – hard to capture with camera, but is Grade I for intubator

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View with the KingVision VL – nice and easy…

Shades of Difficulty?

Now I am no expert at Wookie anatomy, so it took some experimentation to work out what was happening.  With the oropharynx dropped distally, the intubation became a lot easier

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Optimal intubation position for the Wookie trainer

But dropping the entire oropharynx lower (a degree of retrognathia), the intubation became incredibly gnarly…

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Note position of oropharynx compared to previous….

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Best view obtained with videolaryngoscope; DL is Grade IV

In fact, at one point the ONLY view I could get of the cords was via the orbit…

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…and of course airway geeks will be familiar with the ‘trans-orbital intubation technique’ – it’s in the literature and kind of makes sense…provided the eye is enucleated completely along with the orbital floor (see Fernando et al Anaesthesiology 2014 121 654 doi:10.1097/ALN.0b013e31829b36af)

Transorbital

Fernando et al Anesthesiology 09 2014, Vol.121, 654

 

What else is great about this trainer?

  • Well, it’s cheap and easy to make
  • It encourages you NOT to put their hands in the mouth when placing supraglottic devices (else Wookie may bite)
  • Allows move from Grade I to IV view (and all stages in-between) depending on positioning of the oropharynx
  • Can compare DL and VL views with a variety of devices (I will post some views of the C-Mac and D-blade soon)
  • Can practice the art of gentle epiglottoscopy & limited mouth-opening, lest one inadvertently unleashes the Wookie roar!
  • Ideal trainer for fibreoptic skills, in context of limited mouth-opening
  • It’s stupidly fun.

 

Thanks to the mad genius of Dr James DuCanto for this idea

Imitation is sincerest form of flattery…

 

 

Next up, proposed improvements to the SALAD SIM…

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CICO Trainer for under $5

The dreaded ‘cannot intubate, cannot oxygenate’ scenario is one which most clinicians will never encounter.  In elective anaesthesia, the CICO rate has been described by Cook & Macdougall as 1/5000 in elective cases, proceeding to emergency surgical airway in 1/50,000 (a more recent study from Japan describes CICO as 1/32,000 – either way, a rare event). CICV although rare, accounts for for up to 25% of anaesthetic deaths!

The frequency is higher in emergency airway management, especially in the management of trauma with an incidence reported of 1/200.

As such, it’s a skill for which emergency and anaesthesia clinicians train – even though, like pilots training for ejection at altitude, this is something they hope to never perform.  Failure to perform the technique is not uncommon, due to the high cognitive burden in such a situation – loss of situational awareness and breakdown of communication can be contributing factors in any crisis – as exemplified by the case of Elaine Bromiley (see the excellent review here from Nicholas Chrimes and Martin Bromiley).

As for technique, most of us use a scalpel-finger-(bougie)-ETT approach, having identified the cricothyroid membrane reliably using Levitan’s ‘laryngeal handshake’ approach.  Andy Heard of Western Australia has also been instrumental in delivering a standardised approach to what the UK Difficult Airway Society is calling ‘front-of-neck access’ (FONA).  Unless you are terribly bad at anatomy, it would be hard to conceive any other surgical approach to the trachea then front-of-neck…some of Dr Heard’s videos are here.

There are a variety of options for teaching this skill – the ATLS/EMST course typically uses an animal model, as do many induction and airway courses which use pig or sheep larynx-trachea to give clinicians the feel of handling real tissue.

 

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A typical CICO trainer – not cheap!

Non-animal task trainers are also available :

These aren’t cheap.  Back in 2004, Varaday, Yentis and Clarke described a simple DIY cricothyrotomy trainer  “A homemade model for training in cricothyroidotomy” Anaesthesia 2004, 59: 1012-1015

Variations on this theme are well known amongst the FOAMed community, including

  • Sim Central’s simple DIY version from common kit in theatre, desrcibed here by Richard Morris
  • & of course legend of Australian prehospital care, my mate Robbie Simpson of AMBOFOAM has chipped in with this version
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DIY CICO trainer – cheap n cheerful

One thing strikes me – the vast majority of these trainers do not have a head attached.  Is this important?

Well, actually YES.  it’s all very well to practice the procedure of scalpel-finger-(bougie)-tube…but one also needs to consider the ergonomics of the procedure – do you approach from the head end? Or from the side of the bed? If so, how does this work – are you left handed? Right-handed? Will the anaesthetic circuit/suction/monitor leads impeded your access to this side of the patient when need to perform a surgical airway in a time-critical manner?

One of the things that frustrates me is teaching this technique on models that are essentially just a pipe covered with simulated flesh and landmarks.  There’s no chin in the way. There’s no blood.

A recent conversation with Andy Buck of the rather wonderful ETMcourse reinforced this (Andy is a powerhouse of invention – his garage is full of wonderfully crafted sim kit – do yourself a favour and book into the ETM COURSE or ED PROCEDURES course to see what marvels he has created)

AIME George Kovacs makes a good case for using cadavers, but of course these aren’t available to many of us.  Nor are high fidelity mannikins or trainers.  The DIY models described above are good for task training – but could be improved by consideration of the position of the patients chin, especially if using a needle access technique.

So – here’s a simple model that can be made for under $5 AUD – yep, under $5.  Yes it’s not a cadaver, no it doesn’t have the feel of tissue…but rather than train infrequently using expensive models (cadaver-animal-commerical trainer) there’s more bang-for-buck in using low cost models to task train and focus on aspects of technique. And I reckon the angle of approach with regard to the chin is important to consider.

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ADDIT

Since posting this 26-06-16, I’ve had a few comments re: improvements. The most obvious is to simulate the importance of resting the dominant (cutting) hand on the sternum in order to perform the ‘laryngeal handshake’ if using a scalpel approach.

I agree 100% – simple options include abutting the head against a pillow, box or FOAMed block to mimic the chest wall and ensure the haptic feedback of hand postion when performing this procedure.  An alternative is just to mount the head against an old Resusci-Anne torso.

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You CAN also pick up polystyrene heads with busts on eBay – these would be perfect!

Thanks to Chris Nickson of the Critically Ill Airway course for reminding me of this – perhaps we’ll give it a go next CIA course! See you there….

What do you need?

– polystyrene model heads (on eBay – 10 for A$10)
– homemade model larynx (I make mine from Oogoo, using the technique described by Michael Edmonds when we were mucking about at MedSTAR – see his write up here). Unit cost is around A$2 each

Bingo!

It’s not pretty (Chris Hicks @HumanFactorz) reckons it was a bit Prometheus!) but it works.

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Next step – add a sachet of tomato sauce – a technique tried by Anthony Lewis and Rob Simpson in the airway sim session at #smaccDUB – then we’ll have the simulation of blood and STILL be under $5 AUD per model!

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Polystyrene head, hollow out a cavity for the Oogoo moulded larynx to sit

 

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Craft knife and a finger are all you need to hollow out a cavity – it’s a bit messy though

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I am still working on making a realistic ‘cut the throat of Minh le Cong’ model, but wrapping in Co-Plus soft bandage is easy and keeps unit price low

 

ADDITIONAL THOUGHTS

Making a simple styrofoam cutter

Making a mold for larynx

http://www.makeyourownmolds.com/how-to-make-molds