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Managing the Airway Outside, Upside Down and Inside Out
In most EMS agencies, recurrent airway management training is limited and under-utilized, as most agencies do not have access to high-fidelity patient simulators and/or human cadavers. If access to these training methods is available, they are typically only used in the sterile classroom setting and not in simulated field situations that providers are most likely to encounter. Moving an expensive human patient simulator (some cost in excess of $50,000) to an outside setting or simulated rescue is not practical because of the cost involved with the equipment and logistical needs to run it.
Low-fidelity airway manikin practice should not be discounted. Because of the aforementioned downfalls of using human patient simulators and human cadavers, lower fidelity airway task trainers offer providers the ability to simulate situations that are most likely to be encountered in the field. This article briefly describes several unique, lifelike training scenarios that can be accomplished using airway task trainers.
LET THE SUNSHINE IN
EMS personnel must often intubate patients in direct, overhead sunlight or artificial lights. It is important for providers to get a "feel" for what may actually be encountered in those situations.
In this training session, an airway task trainer or ALS manikin is placed on a table, stretcher or floor. Position two high-intensity worklights directly over the manikin, directing the light into the airway. You will need to become comfortable with the heat of the lights, but will also have to contend with the bright lights as they "wash out" your view of the airway structures. Some techniques that can be practiced include putting your coat, towel or sheet over the manikin's head.
ENTRAPPED VICTIM
Face-to-face intubation of an entrapped victim is infrequently encountered but, with practice, can be successfully managed.
To make this scenario more lifelike, a single van or car seat can be obtained free or cheaply from a local junkyard. Mount it to a furniture dolly for ease of movement, place a full-sized ALS manikin in the seat and secure it with two nine-foot straps. Facing the front of the manikin, hold the laryngoscope in your right hand with the blade pointing forward, like a pickaxe or tomahawk. Introduce the blade into the right side of the manikin's mouth and sweep the tongue to the left, applying force toward you in a downward fashion. The airway structures that you observe will be upside down. Insert the endotracheal tube and confirm in the standard fashion. Using a gum elastic bougie can aid in successful intubation and can be used in supine patients.
THE TABLE HAS TURNED
This training scenario is a variation of the face-to-face intubation mentioned above. In this scenario, secure a full-sized ALS manikin or airway task trainer with ratchet straps to the underside of a sturdy six- or eight-foot table. The simulated "patient" is suspended from the table above you. This necessitates a face-to-face intubation attempt while you are positioned on your back. Again, a gum elastic bougie may make successful intubation easier.
THE AIRWAY TUBE
For this training scenario you will need a 2- to 4-foot section of 24- or 36-inch corrugated plastic drainage pipe. Piping of this type is inexpensive and can easily be found at local warehouse home improvement stores or may be donated by a local utility company.
Using an airway task trainer or full-body ALS manikin, position the manikin at different locations within the pipe. The area in the pipe where the manikin is positioned can determine the method of intubation to practice. Techniques that can be accomplished include confined space conventional intubation, digital intubation from the head of the manikin or from the feet, and face-to-face intubation. Both visual and tactile cricothyrotomy can also be practiced if the manikin is so equipped.
CONCLUSION
This article highlights only a few unique EMS airway management presentations. For extra realism, add lubricated jelly with red food coloring into the manikin's airway. The only limiting factor in unique presentation scenarios is your imagination. It is as important for providers to practice non-traditional presentations as it is to practice "routine" intubation scenarios. Manikin intubation practice is an invaluable training tool and should not be discounted.
Fred Ellinger, Jr., NREMT-P, is the owner/operator of SafeTec Training Services, a Pennsylvania Bureau of EMS-approved CE sponsor and trainer for many healthcare agencies and corporations in the tri-state area. He also serves as a flight paramedic for MidAtlantic MedEvac, Hahnemann University Hospital, Philadelphia, PA, and is a medical specialist with Pennsylvania Urban Search and Rescue Response System's PA Company 2 and the Bucks County Technical Rescue Task Force. He is also a Regional Course Director for The Difficult Airway Course: EMSTM and a contributor to Airway WorldTM, a unique online airway management knowledge center. Airway World is a powerful new resource that closes important gaps in airway management and resuscitation education and information for the medical community. Fred can be reached at fred.ellinger@difficultairway.net.
