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Surgical Airway Summary

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Our online walkabout on the emergency surgical airway is coming to an end. I hope you’ve found this helpful, I know I enjoyed doing it. The emergent cricothyroidotomy presents many educational challenges. It is a high stakes, low-frequency procedure performed in the stressful failed airway situation, where time is not on your side.

Preparing yourself for this scenario requires several key technical and non-technical skills outlined in summary here:

  • A working knowledge of airway anatomy and the confidence to quickly identify important anatomical landmarks.
  • Familiarity with the necessary procedural skills – ideally practiced and reviewed in cadaver as well as sim labs so that the muscle memory is there when you need it.
  • Situational awareness: a term that encompasses the logistical, emotional and psychological skills necessary to take appropriate and effective action. In this case it is defined by how effectively you can identify the failed airway and move through the failed airway algorithm in order to put scalpel to skin. It includes the recognition of normalcy bias and focus lock and the danger of repetitive attempts at laryngoscopy to the hypoxic patient,

This exercise is not a substitute for good clinical training, rather it is designed to highlight key concepts by drawing together disparate online resources into a coherent and educational narrative. As the name EMBER Project (EM Bundles & Education Research) suggests, our goal is to provide bundles of educational material and to discover innovative ways to bring it to you. This time. the entire bundle of resources presented over the last couple of weeks, along with commentary and opinions from other physicians and experts will be up on the EMBER Project’s Facebook page and on Storify today for review – and for future reference. Please join the conversation and add your insight. Until then, may the airway be ever in your favor!

 

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May the Airway be Ever in Your Favor!

May the Airway be Ever In Your Favor

May the Airway be Ever In Your Favor

Presentation for the 2014 Airway Course @NYP

This year I’m giving the lecture on emergency cricothyrotomy at our annual airway course. This is a relatively simple procedure, but it’s mastery presents several training challenges. Beyond knowledge of relevant anatomy, and familiarity with a rarely performed procedure, this low frequency event almost always occurs in the high stress/high stakes environment of the failed airway.

Success in this environment requires more than knowledge of anatomy, or familiarity with the steps of a procedure: it demands leadership and teamwork, situational awareness, logistical preparedness, and insight into how the mind works in moments of stress. Unless you can move quickly through the failed airway algorithm and arrive at the point where scalpel meets skin then your technical knowledge is useless.

Over the next two weeks the EMBER Project’s daily posts will highlight these technical and non-technical skills related to the surgical airway, and the environment in which it is performed. We will curate some great online resources, and guide you through a multiplicity of concepts to create a clearly demarcated roadmap to master the material. After the course “The EMBER” (a bundle of online resources) will be posted on Storify in a concise format that will offer a permanent reference and future resource for review.

If you’re attending the course, this will be an essential addition to your learning, and will prep your knowledge base for the upcoming sim and cadaver lab work. For others who want a good review, this is a free and open access resource. Before getting started, I want to thank all the great educators and airway experts out there out there, who have taken the time to make their experience and knowledge available to all of us.

The adventure will get started in earnest tomorrow, so get ready for some cricothyrotomy madness by following here, AND on Facebook or Twitter to get the full program. See you at the head of the bed, and may the airway be ever in your favor!

 

 

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C-Spine Clearance (Hawaiian Style)

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After two wonderful years in Hawaii, I’m returning to New York to take up new clinical and educational challenges.  Before I do, I thought it was appropriate to send one last “postcard from the ED”. This one comes from a case that reminded me that when it comes to decision rules, “there are more things in heaven and earth…than are dreamt of in your philosophy.” Here it is:

A 38 year old surfer comes into the ED by private vehicle. He was driven by a friend to get some pain medication for “spraining my neck”. After being hit by a large wave and tossed around he felt a pop and began to notice severe pain in his neck. At first he tried to paddle back out, but the pain forced him to come to the beach.  After about an hour the pain had not improved and he decided he needed some stronger pain medication.

He had no other injuries, no focal neurologic deficits, and had not been drinking. On examination he had no change in his level of consciousness, he had a normal neurologic exam.  The location of his pain was para-spinal located in the upper cervical muscles by the occiput, and he said “his throat hurt”. He was unable and unwilling to rotate his neck in any direction.

Based on NEXUS this patient could have potentially been cleared clinically.  However, having lived in Hawaii for some time, I have learned to respect the power of the ocean. For me any surf related injury is a high risk mechanism until proven otherwise. If you were not to treat this as a high-risk mechanism and were using the Canadian c-spine rule, you would have gotten to the “able to rotate neck” part before slapping that cervical collar back in place, which is what I did.  Below you can see the reformatted image of a C1 fracture. The patient was accepted for transfer to the trauma center, where he was treated and released with no neurologic deficits.

In hindsight I believe the absence of midline tenderness was due to the extreme amount of soft tissue pain he was in, and the muscular splinting of his unstable C1 fracture. To me it could have counted as a distracting injury however I’m not sure I’ve ever considered para-spinal strain as a distracting injury. Maybe it is a flaw in the language, since the word distracting means “taking your attention elsewhere”. This implies that the pain should be somewhere other than the neck.

Other than mechanism, the real red flag for me was his unwillingness to move his neck. In my experience the alert patient with an unstable c-spine fracture DOES NOT want to move!!!  I’ve also come to realize, working in rural community hospitals here in Hawaii, you paradoxically see more of the isolated serious walk in traumas than you do in a major trauma center. Often the rules of tertiary care practice do not translate. Here are some of the key take away points for me in this case.

North Shore Surfing Accident

Postcards from the Emergency Department (Hawaii)

  1. A patient with a mechanism that is unfamiliar to the physician may be overlooked as high risk due to lack of experience with that type of injury.
  2. For obvious reasons clinical decision rules in trauma are designed using a patient pool which is skewed towards common injury patterns. Unusual mechanisms or patterns of injury unique to your clinical environment (in this case surfing) should be treated as potentially outside the scope of these rules.

There has been some recent trauma literature suggesting that these rules don’t apply to trauma activation criteria patients, This was a reminder that they do not always apply to non-trauma activation patients either. We teach these clinical decision rules, but it is imperative that we also teach the inclusion and exclusion criteria used in the studies, the potential flaws in the human application of these rules, and the limitations of all studies to be generalizable to all patients, so that we can better decide if they apply to the patient in our ED at any given moment.

Finally, if you do use the rules I would consider the combination of NEXUS and Canadian algorithm.  Dr Scott Weingart has a compelling argument and a nice diagram showing how the two can work in synergy.  In this case my patient would have also failed to be cleared clinically based on the combined rule.

The EMBER is a small bundle of free open access resources to deepen your knowledge. Thanks to all the educators out there putting time and energy into teaching others.

http://emcrit.org/podcasts/cervical-spine-injuries-i/

http://www.mdcalc.com/nexus-criteria-for-c-spine-imaging/

http://hsc.unm.edu/emermed/resident_readings/EDArticles_PDF/Trauma/NEJM_03-%20CAN%20C-Spine%20v%20Nexus.pdf

http://www.ncbi.nlm.nih.gov/pubmed/21610391


Case Reports from the ED

The EMBER Project.002

Note the subtle venous congestion and edema of the right hand and wrist in this patient with an upper extremity deep venous thrombosis (Paget-Schroetter Disease),

Here is a slightly different twist on Virchow’s triad, and one that I had not seen before until yesterday:  a spontaneous upper extremity DVT (Paget Schroetter Disease) in an otherwise healthy person with no risk factors.  It’s uncommon, but not a complete zebra.  The pathophysiology and subsequent management also differs from your traditional DVT, so I thought it was worthwhile to highlight some of the features that make it unique.

The EMBER Project.003

The EMBER: as always, a collection of interesting information about this topic from around the web.

Paget–Schroetter disease – Wikipedia

First rib resection for Paget-Schroetter Syndrome – YouTube

Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome) - Up To Date

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It’s De-lightful, it’s De-lovely, it’s De-winter?

New STEMI equivalents keep showing up all the time.  What is a STEMI equivalent you ask? For those ECG nerds out there (you know who you are, yes the one’s with the calipers in my ED) it is the rapidly expanding number of ECG patterns, beyond the traditional ST elevations, that suggest an acute coronary occlusion and therefore require emergent revascularization..  Here is one I was unaware of until just recently. Add it to your list.

Photo from Dec 3, 2012

The EMBER:

Dr Smith’s ECG Blog  Back Pain Radiating to the Chest in a man in his 40′s

Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction


Can Anyone Tell Me How I Got Here?

Tales of the Cunningham technique and one EP’s eventual journey to success through reverse engineering

The successful practice of medicine hinges on two things. A detailed grasp of medical knowledge, and being able to translate that knowledge into a positive patient interaction. For the emergency physician sometimes it’s a crash intubation, sometimes it’s talking to an elderly patient who lives alone about nursing home placement after their 4th visit to the ED in a week.

Whatever the road to a positive outcome for our patients, all physicians experience the nausea of staring into the dark chasm between knowledge and practice. Like neural dendrites gingerly reaching out to make a connection, the journey starts as a tenuous thread in the dark and can eventually become a well-lit pathway with clear signposts if given the right encouragement.

Giovanni Battista Piranesi

Giovanni Battista Piranesi: 1720–1778. An Italian artist famous for his etchings of fictitious and atmospheric “prisons”. He was a strong influence on the work of M.C Escher and his “impossible constructions”.

For me today the path comes in the form of learning the Cunningham technique for shoulder reductions. It’s no secret I’ve always liked doing joint reductions. Ask any of my colleagues and they’ll tell you I’m the first to jump in and help putting a displaced body part back where it belongs. I take satisfaction in doing them quickly, efficiently, and with minimal pain. I also like my patients to be happy with the whole experience; so it’s been a natural evolution for me to become enamored of a technique that requires less time, sedation or analgesia, and that makes my patients happy.

I started using the Cunningham technique about a year ago and I’ve refrained from writing about it until I had enough reduction attempts under my belt to make a post worthwhile. I think I’ve done about two dozen shoulders or more this way now, and I’m four out of five in the last two months (five out of five if you count some scapular manipulation added to one of them).

Like anything new I had plenty of failure in the beginning, and when I did achieve success I had no idea why, and couldn’t have reproduced it even if you put a gun to my head. Now I’ve reached a tipping point, and the Cunningham technique makes doing shoulder reductions feel almost like magic. Often I can see the signs of success begin to appear even before the humeral head slips gracefully into place. No secondary trauma, time-outs, sedation, traction/counter-traction, twisting, pulling or other nonsense.

How did this tipping point happen? Of course that’s the challenge of learning and subsequently teaching medicine.  It has never been a straight line from medical knowledge to clinical practice. Success requires absorbing a skill-set distributed across a multitude of strategies. Within these strategies are embedded a deep understanding of context, relationships, and timing; a detailed knowledge of our tools, and the logistics required to employ them. That “magic” experience of success is the emotional summation that all the pieces coming together to achieve a something good for one of your patients.  It’s one of the reasons I love my job.

However that “magic” experience of success is also why the signposts to it are so often invisible and thus difficult to teach. The signposts were there, but before you were in the dark. Now, you look back and wonder why you didn’t see them before.  It’s so obvious. But it’s the mind’s illusion that suddenly the light just went on.  In fact, a closer examination reveals an unconscious accumulation of multiple tools arranged across an array of skill-sets that allow you to consistently reproduce good outcomes.

How do you illuminate some of those signposts for yourself and others walking the path?  I don’t know exactly, It’s one of the reasons the EMBER project was started – a reverse engineering process in education.  Here are some of the signposts I’ve marked along my path with this particular technique that have helped me improve my success rate. They remind me that being a physician is about knowledge and skill, but also about context and relationships, pattern identification and intuition, resource management and logistics.

  1. Get the patient on board. Like most procedures on awake patients it requires co-operation, so explaining what you need them to do before you start and talking them through it is key. I like to think of it as a coach/player relationship. They are doing the work, you’re simply encouraging, leading and imparting knowledge. I also find that many patients find this active participation very satisfying and empowering. They get to share in the success.
  2. A little tincture of analgesia is never a bad thing, but once you get comfortable doing this you need very little or none at all.  The key is sizing up your patient.  Since there is no significant force or traction applied, if your patient is comfortable before the procedure, they will likely be comfortable during it. If they are uncomfortable before you start you’re going to have trouble, so give them something.  If they’re anxious treat the anxiety, if they’re in pain, treat the pain. Removing these barriers to success prior to an attempt at reduction just makes sense.
  3. Work on visualizing the anatomical and mechanical obstructions to reducing the shoulder. Surgeons have the advantage of being able to review this anatomy frequently in the operating theater, but we don’t have that luxury, so we must work with palpation, surface anatomy, and a visual image in our minds of the anatomic relationships. Use your eyes, your hands, and your mind to “see” the position of the humeral head and the barriers to slipping it back in place.
  4. The ideal position for the glenoid fossa is achieved by moving the scapula posteriorly and rotating it inferiorly.  This is achieved by having the patient sit up straight, adducting the rhomboids and having the patient drop their shoulders towards the ground. This is why having the patient sit in a chair is helpful and also reminding them repeatedly to sit up straight. It’s also why a touch of scapular manipulation by a partner can help in resistant reductions.
  5. The ideal position for the head of the humerus is to place the humerus in adduction with gentle internal rotation to present a greater articular surface to the glenoid fossa superiorly and laterally. This is why having the patient in front of you with your body to the outside of their affected arm is helpful to allow gentle physical reminders to keep their elbow in towards their body. Often I will stand or sit close to patient’s elbow to unconsciously force them to keep their elbow in and their arm internally rotated.
  6. Once the bones are in position it’s all about relaxing the muscles of the shoulder to overcome the dynamic forces that are pulling on the humeral head and trapping it, usually in a sub-glenoid or sub-coracoid location. This is why flexing the elbow and having them rest their hand on your shoulder is effective.
  7. Massaging the biceps, upper trapezius, and deltoid are equal parts physical and emotional. It is comforting, and it relaxes the mind and the muscles of the patient allowing the dislocated humeral head to “unlock” itself from its current uncomfortable position.
  8. Resist the urge to pull.  Remember muscle spindles?  Those sensory receptors within the belly of the muscle will actively resist excessive traction and make the spasming worse.  Once you are in the cycle of pulling and feeling resistance you are in a battle that can only be won at the cost of more force and likely sedation. There is also a psychology to this. If you radiate a relaxed and calm persona your patient can feel this and also begin to relax.  If you have sweat pouring from your face while you grimace and pull how can you expect anyone near you to be relaxed. Slow and gentle is the key.

Occasionally I have to revert to another method of reduction, or supplement this technique with scapular manipulation, but this is definitely the option I pick before anything else now. Once you feel the beauty of a non-traumatic reduction requiring no force you will never want to go back.  In my career I’ve gone from Conan the barbarian with heavy sedation, and traction-counter traction to Jedi mind trick:  “This is not the Propofol you’re looking for…”

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