In the pre hospital and retrieval medicine field there is always the push to put as much of the hospital out there as possible. Scott Weingart calls It maximally invasive care everywhere. This is not without certain hurdles and those of us involved in the work on the PHARM know this all too well. One aspect of medicine that is often practiced, taught, and talked about is airway management. This is often taught by an Emergency Physician to the prehospital providers. There is nothing wrong with that and in fact EM physicians are the closest to us as prehospital personnel from the clinical side. What about Anaesthesia themselves? Can we learn anything from the operating theater and put it into practice in the field? Quite honestly, the answer is yes.
Certain things to consider are obviously the difference in environment and the difference in training. Most of the Anaesthesia providers out there do more airways in one day than some field providers do in years. It is just the nature of what each provider is asked to do. The nature of the Anaestheisa provider is to manage the airway, period. There is not a whole lot else that they are asked to do in the operating theater. In the United States, these providers do not venture outside of the OR, but in other countries they do retrieval shifts and often prefer the prehospital arena. How is it that their OR techniques can or do translate to the field? Simply put, application.
Not all things from the Operating Theater can be put into place in the field because they are two different environments. However, things like patient positioning, NODESAT, medications, and the techniques of intubation transition quite nicely. There are often comments that the OR way of managing and airway and the field way are different and there cannot be integration of techniques. This is where I disagree. All of our invasive airway skills that we use now have all originated from the OR at one point. The things that we use are things that we can pick and choose over. We cannot put everything into place because the field is not a controlled environment. We can utilize simple positioning and techniques to make airway management easier and safer for all involved.
Dr. Rich Levitan always says that if there is something in medicine you are afraid of run towards it instead of away from it. So, run toward airway management. Talk to an Anaesthetist, CRNA, or other airway guru and figure out how you want to manage your airways. It is far better to practice, prepare, and never need the skills than to not practice or prepare and need these skills. Yes, the two environments are completely different and the two specialties of Emergency Medicine and Anaesthesia are different, but we are all working toward the same goal. There is much to be learned by both specialties from each other. As a provider of prehospital and retrieval medicine, I make it my goal to learn from all specialties to provide the best possible patient care.
So, it is not about airway being anaesthesia’s job or something being the job of the Intensive Care Unit. If it involves medicine, it should be OUR job. No matter who has traditionally handled certain things, we should all prepare to handle things that are not traditionally “our” jobs. I do not think anyone in PHARM is arguing that the airway is NOT our job, but I do think that some things that could be done to manage the airway are sometimes left out because they are felt to be the job of Anaesthesia or a higher level provider. The answer to this question is to simulate, train, use checklists, and repeat. The best providers out there are those who know their people, their equipment, and most notably, their weaknesses. Spend some time in the simulation lab with your team and just maybe you WILL get water from a rock.
Klint is a critical care educator for Distance CME, LLC. Klint writes for Prehospitalresearch.eu, the Distance CME Blog, and has guest authored on several other blogsites. Klint is a full time Flight Paramedic for Midwest MedAir in Hastings, NE. Klint’s clinical interests are airway management, neuro critical care, mechanical ventilation, and pediatric/neonatal critical care transport. Klint can be reached at firstname.lastname@example.org and on twitter: @NoDesat