RGN MBBS DipIMCRCS(Ed) MMed(Clin Epi)
MD FRCS(Eng) FANZCP FRCEM FACEM
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
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.
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
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.
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.
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.
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!
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’.
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).
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.
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.
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.
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.
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…
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.
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)
It’s good to see the topics of clinician self care being more commonly discussed, both in FOAMed circles and at regular conferences. At the recent RDASA Masterclass in SA, Thinkwell psychologist Hugh Kearns and myself delivered a short session on self care, and I was thrilled to hear Dr Roger Sexton of Doctors Health SA talk at a recent GPex session for supervisors.
Roger has done much to establish a network of ‘doctors for doctors’ here in South Australia, with the Doctors Health SA providing a bespoke service to doctors and medical students, a group that famously fail to look after their own health. Some pearls from Dr Sexton’s talk deserve a wider audience. The following is based on my synthesis of his expertise from a talk he delivered recently to GP supervisors. Check out more at the Doctors Health SA website
Have a hard look at HOW you work in your practice. Many of us are busy, making numerous decisions in a time-pressured environment. Whilst many people think decision-making in an emergency is stressful, I find that my work in ED or prehospital environment is far less stressful than that in the consulting clinic. The former situation (let’s say a resus or sorting out an unwell patient) is relatively straightforward – there’s a simple algorithm (ABC…), there are established techniques to help teamwork (shared mental model, closed-loop communication, use of cognitive aids and appropriate resource allocation etc) and the momentum is usually upwards (from critically sick, to stabilised).
Whereas in clinic (especially in primary care), the problem is often poorly-defined (early stages of disease are far-removed from textbook descriptors), there is a huge element of gestalt and risk (sieving the important from the inconsequential) and there are limitations of time and resources (no pan scan or immediate access to investigations). No small wonder that doing good primary care well is an intellectual challenge – often underestimated by those who’ve not done it – and sadly all too east to do poorly.
Whichever situation (whether a prehospital clinician, an emergency room clinician or a primary care clinician), one thing is certain – you have limited time, limited resources and important decisions need to be made with safety-netting. Three concepts can help you in your busy day.
THE WHEELBARROW : like this garden tool, you only have a finite carrying capacity. In short, there is only so much load you can carry. The lighter the load, the easier it is to get ahead. Problem is, everyone wants to dump THEIR problems into your barrow. Therefore you need effective tools avoid unsustainable load from being dumped in your barrow!
A common strategy is the idea of ‘sticky fingers’. Imagine if someone dumps a problem or task into your barrow. With ‘sticky fingers’ you HAVE to pick it up and look at it – but here’s the trick – once picked up (or accepted) you must do ONE of only three options
As doctors we are inculcated through training to try and be helpful – to solve problems. Moreover as (mostly) successful high-achievers, we tend to thrive on problem-solving and are used to taking on extra work. This a trap for new players – particularly in the first year or so post-Fellowship, when there is a natural temptation to take on exra work on committees, running rosters or running projects.
My advice? Play the long game. Take on small bite-sized chunks of work and be effecctive with them. And learn the art of saying ‘No’ (the phrase…”I’ll have to check my diary and get back to you” is an effective strategy to avoid the natural temptation to please others and say ‘yes’ to new work).
THE BATTERY : ever got home at the end of a busy day and felt mentally and physically exhausted? Of course. decision-making and stress can pound the adrenals. Getting home exhausted may lead to slumping on the couch and ‘vegging out’ – an inevitable result of the batteries being run down throughout the day. Why is this? As a clinician, we are a source of energy for others. Our decisions, our leadership are important parts of the team. But giving off energy, especially in multiple repeated consults, can rapidly deplete the battery.
So – try not to let the battery run down! Make an effort to recharge throughout the day and keep your batteries charged. Take breaks. Book ‘catch up’ slots. Get out of the office in lunch break and take time to walk around the block. Spend some time in the sun. Interact with work colleagues where possible. When rushed, make an effort to slow down. Breath. Be mindful and ‘in the moment’. Spending 10-15 mins a day in meditation or ‘being mindful’ is beneficial.
Make a conscious effort to find something positive in every interaction, even if ostensibly challenging from outside appearances. We are privileged to deal with patients throughout life’s rich tapestry. Appreciate this.
THE TENT : clinician resilience is something I am interested in. I think we need to develop skills in both cognitive resilience (making decisions under pressure) as well as emotional resilience (dealing with the impact of our work). Although challenging, being comfortable to demonstrate our soft vulnerability (rather than a hard unbreakable veneer) can be an interesting space to throw up improvements. As Brene Brown says, being vulnerable is about courage – to allow ourselves to be seen as fragile human beings. And understanding vulnerability can be the birthplace of innovation, creativity and change.
So – our outer protective shell – the canvas of our tent. This layer – call it RESILIENCE – protects us from the elements. rather than being rigid and inflexible, it is soft…deformable…yet affords wonderful protection even under significant pressure. Resilience is something that can be cultivated.
Of course we need supports – much like guy lines of a tent, we will need to cultivate and anchor ourselves to supports around us – our family, our friends, our colleagues. Maybe outside interests – whether sport, a hobby, religion…whatever. These anchors add to our resilience.
“Have a look at what’s happening in YOUR typical work day.
How well looked after are your wheelbarrow? Your battery? Your tent?”
As well as thinking about your wheelbarrow, your batteries and your tent, have a think about other protective approaches to long-term clinician resilience – to keep thriving and surviving…
Have a health check : senior executives in corporations have annual health checks. How many intensivists do this? How many surgeons? How many GPs?
Get good independent advice : do NOT fall into the trap of self-diagnosing or ‘corridor consults’ with colleagues – see your GP! But as well as seeking expert independent advice for your health, make sure you have appropriate advise for finances, for mental health (seeing a counsellor 6 monthly can be a powerful ‘future proofing’ technique). Seek out mentors (SoMe and FOAMed helps). And if a specific area of your life is struggling (relationship, career, spiritual) then seek appropriate expert advice.
Get fit : shift work and busy days take their toll. Make time to exercise. Get your 10,000 steps in each day. The healthier you are, the easier your work will be.
Rediscover your passion : think about what you’ve given up to be where you are today. Medical training is gruelling. University and postgraduate training eats into the time from school through to late 20s as a minimum. Whilst those in non-medical jobs may enter into the labour market early, contributing to house purchase and superannuation, clinicians-in-training work long hours for little reward for the first decade. Financial security comes late and may be compounded if working in private practice (no leave, superannuation, significant practice costs). think what you’ve given up to do medicine – friendships, sports, holidays, time with family. Is it worth it? Make time to rekindle the passions you’ve given up.
Mobilise endorphins : the best sources of endorphin are NOT the Doctors Bag or Drug Cupboard (although this is also a common trap for some!). Natural highs are found through seven sources – laughter, sex, exercise, crying, singing, music, & meditation.
Value relationships : with spouse, with family, with colleagues, with friends…and with patients!
Have roles and fulfil them : not just our role as a clinician (indeed, one should try not to define worth through ‘doctoring’) Instead anchor yourself to other roles – as parent, as partner, as colleague, as coach etc.
Fulfil existential needs : much as we should acknoledge our vulnerabilities, we shoudl also ensure our existential needs are met. As humans we crave love, hope and meaning in our lives. Teaching is a common strategy to ensure our work has meaning (remember the origins of the term ‘doctor’? Docere, to teach). Control is also important in life; lack of control over one’s destiny (common when working as a salaried junior) can be a big contributing factor to dissatisfaction and burnout.
Recognise WARNING SIGNS and HAVE A PLAN : evaluate your wheelbarrow, your batteries and your tent on a regular basis. If something is failing, do something about it!
DoctorsHealthSA is running workshops (the next is September 2016). Many conferences include speakers on self care and resilience nowadays. At the very least, make sure YOU have a GP and ensure you have regular health checks.
Bren Brown on vulnerability ‘ https://www.ted.com/talks/brene_brown_on_vulnerability
Thinkwell – Hugh Kearns and Maria Gardener on clinician self care http://iThinkwell.com.au
Doctors Health SA – doctors for doctors (and medical students) – http://www.doctorshealthsa.com.au
Jellybean with Paramedic Rusty – http://lifeinthefastlane.com/jellybean-040-paramedic-named-rusty/
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