Day One of the smaccUS conference was a bit of overload for me. I was nursing a mild hangover from the post-workshop Faculty dinner and was somewhat anxious about my planned talk “All Alone on Kangaroo Island“. In fact, on that latter, I had even arranged a bail bondsman just in case the Yanks were offended by the finale of my talk and I was carted off in handcuffs…
However Day One of smaccUS was also special for me – that morning I received confirmation of two papers accepted for publication and available online. What a coincidence, publication same time as smaccUS! And especially poignant, as I’d received help from many collaborators within the #FOAMed and #smaccFAMILY world (see below)…
Airway Management of the Critically Ill Patient – modifications of RSI
First up was a piece I’d been working on since 2014 – and published as the debut article in Critical Care Horizons, the new FOAMed online journal from Rob MacSweeney and Andrew Ferguson.
This paper was born out of concern for the huge variation in accepted practice of RSI, with differences between craft groups and locations giving rise for potential criticism. The obvious example is that of cricoid pressure – to apply or not. Many have written on this, but the bottomline in many medicolegal claims remains that failure to apply cricoid by eg: a prehospital clinician could be heavily criticised by expert testimony from eg: an anaesthetist used to OT environment.
“I recently worked for an organisation where the decision to use/not use cricoid pressure in prehospital environment was left to the discretion of individual trainees”
This worried me; where potential exists for post hoc critique by expert testimony, any deviation from ‘standard’ practice needs to be supported by institutional policy or better still, international consensus guidelines backed up by evidence.
The more I delved into the practice of Rapid Sequence Induction (RSI), the more I found that many modifications existed from the original description by Stept & Safar. Indeed, examples exist of expert testimony being used to critique with devastating medicolegal effect (criticism of failure to place an NG pre-RSI and using a bolus of induction agent rather than titrated aliquots cited as examples of deviation from standard in one ‘fitness to practice’ tribunal case in the UK!).
There ARE variations in how RSI is practiced between individuals, organisations, patient groups, countries and of course situations. An obvious example is in the prehospital or emergency environment, teams may opt to omit cricoid on basis it is poorly applied by non-experts and may hinder laryngoscopy. Some practitioners may ope to gently ventilate after induction in certain circumstances (notably paediatric RSI). Many practitioners will now use ketamine (or propofol) over thiopentone as induction agent, and rocuronium over suxamethonium as paralysing agent….along with many other subtle changes from traditional RSI. Whichever way you look at it, the practice of RSI has changed significantly from the 1970 description.
This paper is just the first step in developing a consensus statement on RSI of the critically unwell – or what Casey Parker coined the OASIS consensus (Optimal Airway Strategy in Situation). It’s well worth a read of Casey’s 2014 post on this…certainly he summarises the issues well. I am grateful for the multiple inputs, especially Nicholas Chrimes, Minh le Cong & Casey Parker (Australia); Daniel Kornhall (Norway); Natasha Burley, Kirsty Challen, Marietjie Slabbert & Alistair Steel (UK); Salim Rezaie & Anand Swaminathan (USA).
I hope that this paper may serve as discussion to guide the development of institutional guidelines and SOPs on airway management of the critically ill, mindful of the accepted variations in practice between situation, craft group and geography.
An international consensus statement on RSI of the critically ill, backed by evidence-based statements, would be the ideal.
Have a gander via Critical Care Horizons and make your comments online there…
Potential for a National Rural Responder Network?
Back in 2012 I was looking at options for difficult airway equipment for rural doctors in Australia. The results threw up the interesting fact that 58% of rural GP-anaesthetists had been involved in some form of prehospital incident in their community in the previous 12 months. This number surprised me, more so because the people calling these rural doctors were the experts – ambulance and retrieval services. The doctors were being called either when local resources were insufficient or when retrieval services would be delayed.
Whilst this is all well and good, there exists heterogeneity in rural doctors skills – and the prehospital environment is no place for enthusiastic amateurs, especially if activation criteria are ad hoc and responders lack training and equipment.
I spoke on this at smacc13 in Sydney, but since then have been pushing for appropriate involvement of rural doctors in the prehospital environment if needed – Australia is a vast land, and the tyranny of distance means that in remote areas ambulance responders are often volunteers with limited skills and expert help may take hours to arrive via RFDS or retrieval services. And yet many rural doctors maintain skills in emergency medicine via oncall for their hospital, and many maintain airway skills via weekly lists in theatre. Why not use them? Especially as geographically smaller countries such as UK and NZ already utilise such expertise through BASICS and PRIME systems respectively.
South Australia already has the RERN (Rural Emergency Responder Network) system which is designed to support ambulance services when needed, prior to arrival of medSTAR retrieval. Responders are trained equipped and remunerated for their efforts.
So in 2014 I surveyed rural doctors to ascertain their interest in participating in a formal system of rural responding to prehospital incidents. The support was overwhelmingly positive, and it would be a wonderful achievement to establish rural responder networks in each State – something RDAA and ACRRM are interested in supporting.
I should emphasise that such a network would only serve to support existing services and offer an additional level of care where either local resources are limited (eg volunteer ambulance officers) or expert help is delayed (inevitable in this vast brown land). The prehospital environment is no place for enthusiastic amateurs – but the fact that 58% of rural GP-Anaes were already being called out by the prehospital experts, and yet such respondents were untrained or equipped, means that a formal network with defined call out criteria, appropriate training and equipment is overdue in Australia.
Well-trained rural doctors are the ‘swiss army knives’ of medicine – use them!
Of course, having such a network would add an extra degree of community resilience – rural Australia is prone to disaster (bushfire, cyclone, flooding etc) and being able to tap into a pool of trained clinicians in times of disaster may be of help – and of course feeds naturally into developing improved State-based and National disaster preparedness. My mate David Hogg and colleagues are doing this on Isle of Arran in Scotland as a community resilience model – and of course BASICS is a paradigm across the UK that uses both hospitalists and primary care responders to value add clinical support to ambulance in times of need.
The paper is available here – EMA paper 10.1111_1742-6723.12432-2
Have a gander – and I am of course open to any comments and criticisms…