# Advanced Airway for QL 5 Med Techs



## Armymedic (14 Dec 2007)

Given technological advances and the need for more advanced skills required by our medics in the field, is it not time for CFHS to allow some advanced procedure to be delegated down to field (QL5) med techs?

Specifically, I am referring to the skills of intubation and cricothyroidotomy. Both should be taught and tested in our QL5 school and skill refreshed prior to each deployment to Afghanistan. Given that the OPA is not effective in either a tactical environment nor ensuring a truly secure airway, that device, whilst a "tool in the toolbox" should not be taught as the medics primary airway tool. 

As it stands right now, cric is the "standard" advanced airway for TCCC by operators (NPA being the basic airway) in the US and other countries. It is a relatively safe procedure that with practice can be done safely and effectively in 20-30 secs.

With new technology, such the Airtraq  http://www.airtraq.com/airtraq/portal.portal.action   , and skills like translaryngeal pressure, intubations in the field on difficult patients is quicker and slicker than ever.

Knowing the pros and cons of each procedure, there is no reason why troops can not be trained on mannequins and animal tissue prior to going over to the sandbox.


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## HItorMiss (14 Dec 2007)

St. Micheals Medical Team said:
			
		

> As it stands right now, *cric* is the "standard" advanced airway for TCCC by operators (NPA being the basic airway) in the US and other countries.



Quick question SMMT what is CRIC???


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## PMedMoe (14 Dec 2007)

HitorMiss said:
			
		

> Quick question SMMT what is CRIC???



Cricothyroidotomy.

SMMT, if I am reading your post correctly, you are saying that QL5 Medics shouldn't be doing intubation and cricothyroidotomy but personnel trained on TCCCS can?


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## HItorMiss (14 Dec 2007)

Thank you Moe

And I think SMMT was saying that intubation should be done by the QL5 medic where as Crics could be done by a TCCC or they are already done by TCCC in other counrties.

Thats just how I read it though.

EDIT: Spelling


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## COBRA-6 (14 Dec 2007)

That optical laryngoscope looks like a good piece of kit! How new is it? Is anyone using it in a military field environment yet?


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## PMedMoe (14 Dec 2007)

HitorMiss said:
			
		

> Thank you Moe
> 
> And I think SMMT was say that intubation should be done by the QL5 medic where as Crics could be done by a TCCC or they are already done by TCCC in other counrties.
> 
> Thats just how I read though.



You're right, HoM.   I reversed the "*is it* not time" in the first sentence to "*it is* not time".  Can anyone say dyslexic?  :-[


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## Armymedic (14 Dec 2007)

"Is it not time...?"

I am advocating QL5 medics and up be able to do cric and ET intubations, and all TC3 advanced trained providers do crics, if not already so in Canada.



			
				COBRA-6 said:
			
		

> That optical laryngoscope looks like a good piece of kit! How new is it? Is anyone using it in a military field environment yet?



It is very new, about a year or so old. And yes, military people are using it.


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## PMedMoe (14 Dec 2007)

St. Micheals Medical Team said:
			
		

> "Is it not time...?"



Hey! I admitted my mistake! (and you know how rare that is!   ) Don't rub it in!


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## DartmouthDave (14 Dec 2007)

Hello,

I went to the SLAM (Street Level Airway Management) conference in Dallas Texas.  Great course with evey possible bit of airway kit you could think of.  They had the Airtraq there as well.

I used it in the cadaver lab and it worked great.  I also spoke with some paramedics who used it on their tatical team.  From their experiences the major problems were blood and temperature changes.

Blood in the airway would smear over the lens.  

The lens would fog up with temp changes or the warmth of the patients breath.

Cheers


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## ModlrMike (14 Dec 2007)

Speaking from personal experience, endotracheal intubation is labour intensive, and there is usually no time on the battlefield to perform this advanced airway procedure. The skill is difficult enough to do accurately under controlled conditions as it is. In addition, if you miss and irritate the vocal cords, you hooped.


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## MedCorps (14 Dec 2007)

When I spent time working with the RAMC, I was pleased to see that Combat Medical Technicians have the endotracheal intubation, nasotracheal intubation, laryngeal mask airway, and combitube airway as part of thier QL5 (equiviant) skillset [D/AMD/113/29].  They were also being trained on needle cricothyroidotomy, jet insufflation, emergency cricothyroidotomy (with the Minitrach and Quicktrach sets), and surgical cricothyroidotomy.  

These skills were also part of the BATLS (Battlefield Advanced Trauma Life Support) course I taught on and were found as part of Casualty Treatment Regime #1&2.  

Yeah... it is about time to start teaching our QL5's some of these skills. 

Cheers, 

MC


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## ModlrMike (14 Dec 2007)

MedCorps said:
			
		

> When I spent time working with the RAMC, I was pleased to see that Combat Medical Technicians have the endotracheal intubation, nasotracheal intubation, laryngeal mask airway, and combitube airway as part of thier QL5 (equiviant) skillset [D/AMD/113/29].  They were also being trained on needle cricothyroidotomy, jet insufflation, emergency cricothyroidotomy (with the Minitrach and Quicktrach sets), and surgical cricothyroidotomy.
> 
> These skills were also part of the BATLS (Battlefield Advanced Trauma Life Support) course I taught on and were found as part of Casualty Treatment Regime #1&2.
> 
> ...



I don't disagree completely, but there's also the issue of skill fade. Those of us with this skill in our scope have very little opportunity to keep ourselves fresh as it is. As the majority of MedTechs who would conceivable use this skill are posted to Fd Ambs, it has the makings of an MCSP nightmare.


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## MedCorps (14 Dec 2007)

I agree skill fade is a problem for all clinicians who do not practice any psychomotor skill on a regular basis.  Advanced airway management when you are the only clinician around is just one of those things you need to know... 

If you need to do it, and you don't know how the casualty is dead without a chance. 
If you need to do it, and you know how to do it, and do it right, the casualty is good. 
If you need to do it, and you know how to do it, and screw it up, the casualty is dead with a chance given.  

Even if we teach some of these skills on the QL5 course, and they don't use them, at least they have read and seen them conceptually.  If then, they get a classroom refresher now and then, that is the helpful next step. If we work it into casualty simulation and walk-talk through the procedure with evaluation that is also helpful.  If they get practice on a simulator periodically that is better, and an animal model and/or cadaver lab is best... but expensive and hard’ish to coordinate, so maybe that should be saved for pre-deployment Med Tech's who are going outside the wire.  Hey, maybe even get a few intubations in a controlled situation in the OR or elsewhere for those medics actively requiring the skill set.  This is the British model, although the CF MCSP is conceptually better than theirs, and how the US SOCOM is doing it.  

Only a thought.  

This is the same problem for any of the advanced medical skills we learn.  We often learn it, and then don't do it.  At least we have the academic background (procedure, techniques, risks, anatomy, etc) to give it the college try if we must... when the only other option is watching someone suffocate during the next 6 minutes I will opt for the college try, and expect those around me to give it the college try if it is me laying on the ground. 

Again, ideally we would all be pro-stars at every procedure in the book, doing them all weekly on real casualties, but there are all kinds of skills we just cannot do on a frequent basis because the patient population does not support it, the volume of procedure to keep current on, and the other tasks that arise.  It happens from surgeons (e.g. traumatic amputation revisions) to critical care nurses (Swan-Ganz management) to paramedics (advanced airway management skills) to self-aid giving infantrymen (NBCD auto-injector administration).  

Cheers, 

MC


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## kj_gully (15 Dec 2007)

So a ql5 medic is going to do rapid sequence induction (paralytics and sedatives)?  We've been doing intubation for a while, but it takes 2 days in OR to get 6 intubations, with fewer and fewer being done in hospital all the time, as simpler airways and spinal blocks become more widespread.As I've said b4, we don't have paralytics, so only use it during cardiac arrest protocol, discontinue resus protocl, and consider it in post arrest stabilization, though tickling a larynx in a recently resus patient sounds ill advised to me. It is a difficult skill to maintain competancy in. By this I mean finding the training time to get the actual intubations that your competant medical authority deems adequate to allow you to maintain a qualification. Its easy to do a straightforward intubation on a sedated or recently deceased patient, but I don't think its a necessity with all the blind airways coming down the line. Now crics, I think is a different story. They are fast and effective access for your ptential facial trauma. We are ditching intubation for LMA. not as good as intubation, but better than OPA, and simpler than combi tube. my thoughts anyway.


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## ModlrMike (15 Dec 2007)

You can bet that if PAs can't use paralytics, the QL5 wont. I agree that the LMA is a good option in lieu of ET intubation in the field.


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## MedCorps (15 Dec 2007)

Whoa... I am not sure that anyone here is saying the QL5 should be using paralytics... and I cannot think of another allied army that has medic's using paralytics.   

LMA... that might be a good place to start with the cric following right behind it (or maybe reversed).  Interesting to see ET intubations are being replaced with LMA in the SAR Tech world, will save the days of sluming in OR waiting for tubes.  

Cheers, 

MC


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## ModlrMike (15 Dec 2007)

kj_gully said:
			
		

> So a ql5 medic is going to do rapid sequence induction (paralytics and sedatives)?



No, he wasn't saying... he was asking. I just responded. Still, there may be some value in teaching the skill we know the troops won't use. They can become very able assistants. The downside is that we'll hear more "Why did they teach that if I'm not allowed to do it?" type questions.


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## Armymedic (15 Dec 2007)

No paralytics. But there other less invasive ways to neutralize the gag reflex and do a "conscious" intubation. see link:

http://www.pitt.edu/~regional/Airway%20Blocks/airway_blocks.htm

which could be taught (ACP/Sr medic/PA level), but that is a whole different ball of poo. 

In training, given the advances of the SIM and Medi man trainers, all students can be trained and tested, given all the tools they need including difficult intubations, before they ever touch a real body.

Re LMA and ET, it is not designed to replace, but to give the SAR Tech a viable option to control the airway better that with a OPA. The LMA that the SARs will be getting has the capability to be able to put an intubation/gastric tube in afterward. The big drawback of LMA vs other blind insertion devices is that it is not internally secured like the King LT or combitube.

In my perfect world world, I as a QL 5 med tech should be taught this sequence of advanced airways:
Blind insertion device,
ET intubation,
surgical Cricoidthyroidomy


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## Armymedic (15 Dec 2007)

DartmouthDave said:
			
		

> Blood in the airway would smear over the lens.
> 
> The lens would fog up with temp changes or the warmth of the patients breath.



The new model I played with recently has a heating element with the light so that the fogging problem is solved. Blood in the oropharynx is still and issue, but any fluids there need to be suctioned to be able to see the cords properly. They are also working on the next model which will have replaceable batteries so that it can be reused in the field (as long as the light works)

But the Airtraq is just a tool...if you do not have 2 or more tools/options to defeat any obstacles, then perhaps you should not be doing it.


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## kj_gully (16 Dec 2007)

If QL 5 are reasonably expected to assist an advanced level caregiver place a tube, then this training would be invaluable. Familiarity with the procedure would allow them to anticipate requirements, ie, test ballons and laryngascope, apply lubricant, "BURP" patient, retract stylet etc. It is pretty tough to do the procedure, and talk thru an assistant under stress.


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## transvap0r (18 Dec 2007)

I know that most people agree that no medic, no matter what level of training you have, should be doing rapid sequence intubation (aka paralytics with induction), period. Nor will any doctor ever allow you! If you compare EMS accross Canada, there are very few EMS systems which allow RSI as part of a pre-hospital protocol (not including flight paramedics/ air ambulance, which are a seperate entity of their own), Alberta being one of the only provinces where paramedics can RSI. So if civillian paramedics cannot RSI, then obviously military medics cannot/should not when you compare the frequency of use of these advanced airway skills. I don't know how RSI came into conversation here, but I think most disagree with this idea anyway, so I won't talk anymore about it! Don't forget the reasoning behind performing RSI in the first place, and for acute traumatic airway management in the prehospital setting, "awake" intubation is probably ok. Adding Succinylcholine and versed/fentanyl/propofol mix will only complicate hemodynamics even further in the field.

I'm very confused however, maybe someone can clarify.. it was mentioned several times that cric's should be part of a QL5 scope, and that they are used as the initial advanced airway next to NPA's.... all I can say is wow, that's a pretty large gap in airway management. Has anyone ever heard of the acronym "BARS"? If you have, you will understand my frustration. I can't see how you can justify performing a cric on a pt in order to maintain an advanced airway, especially when there are blind-insertion endotracheal intubation methods which work very well, such as the lighted-stylet (Light Wand). Cric's are extremely invasive, and there are other options that are easily taught and used widespread, and are very fast to use. Just a thought!


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## Armymedic (18 Dec 2007)

The use of crics in military medicine is proven. When there is trauma to the upper airway, the only way to secure the airway is to stick a cut off 6.0mm tube into someones trachea.


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## transvap0r (20 Dec 2007)

Okay that does make sense, and cric's are definitly indicated in the situation of severe facial/ upper airway trauma where laryngoscopy and/ or endotracheal intubation is impossible.... this is an indication for a cric in all ALS EMS sustems who have cric's part of their scope of practice. My question is... if the patient has severe multiple system trauma to extremities, chest, back, etc, but no upper airway issues, and now needs an advanced airway in place in order to maintain a patent airway, a cric would be a very invasive unnecessary when ETT can/ should be performed. Do we still give the patient a cric in the field?


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## Armymedic (20 Dec 2007)

Circumstance dependant, yes. 2 primary issues without getting into the skills....

1. light - need to have a white light to see into the cords. Negated somewhat with technique that does not open the Lscope until it is inside the mouth, still ET skill > cric skill.

2. light - All the equipment needed for intubation is a bit heavy, and needs batteries. Cric just needs a half tube, a knife, a 14 ga catheter and a couple safety pins.


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## kj_gully (20 Dec 2007)

Another factor being overlooked/ taken for granted is positioning. you need very specific body position to accurately intubate, even with the new fibreoptic scope. I know you can't cric a patient just any old way, but with some of the prefab devices out there, it isn't as restrictive. Even surgically, you only need one body length area, vs 2 for ET


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## david_wright (22 Dec 2007)

Hello all.

I've been reading this topic, with some interest, as I am a serving doctor in the Australian Army Reserve as well as being an anaesthetic trainee in civilian practice.
I can add a bit to your debate, and I appreciate and respect the range of opinions on here, although I do not believe all are correct.
Firstly, I personally believe that advanced airway procedures should be taught to advanced medics. I don't believe the medics should be allowed to undertake these procedures autonomously unless they are unable to contact a more senior person. That is, if there is time, the medic should call a doctor, senior medic etc and outline the patient situation and then seek instruction. If there is no capability to speak to a more senior colleague, then it is a matter for personal judgement. I am not saying that medics lack the ability to appraise a situation and undertake a plan of action, but I have seen considerable damage done to patients by even experienced civilian operators. If an airway undergoes attempted intubation, and it turns out to be a "can't intubate" scenario, then the consequences are dire. That said, unless someone with a wealth of experience was immediately on hand, the casualty may die, and may even do so with expert help.

The use of neuromuscular blocking agents is a contentious issue. Suxamethonium remains the gold choice for rapid sequence intubation although there are questions about raised intracranial pressure, etc. If a longer acting agent is administered to a patient, then you may have a considerable lag time before intubating conditions are ideal. There is also the danger of encountering the "can't intubate, can't ventilate" scenario. This is a genuine brown underpants moment. I would recommend others to avoid the use of NMB in the field unless trained in their use in a variety of environments. I cannot advocate the use of airway blocks for emergency airway provision. The idea is risky as there are a lot of vascular structures in the neck, there is a risk of intravascular injection, there is also the risk of pneumothorax, nerve damage and failed block. Most nerve blocks take time to "mature", sometimes up to 20 or 30 minutes. There is simply not enough time in an emergency to do a nerve block unless the person doing the block has done heaps of them and is comfortable doing them. There is also the risk of infection from jabbing a needle in the neck in less than clean surrounds. Personally, having not done many airway blocks (partly due to the use of NMB etc) I would not want to do them if I could avoid it. An alternative is to spray the vocal cords with local anaesthetic, such as 4% lignocaine or even 2%. This can often prevent laryngospasm. Interestingly, intubation intself does not necessarily require a specific body position. The "sniffing the air" position merely maximises the chance of successful intubation. Patients with neck injuries can be intubated with manual inline stabilisation. Patients can be intubated sitting up, with the laryngoscopy held i the right hand like and icepick. They can be intubated lying on the ground with the person intubating lying next to them. Fibreoptic bronchoscopic intubation can be performed in front of, or behind the patient. Patient can be intubated orally or nasally. In short, a skilled operator should be able to intubate in a variety of postures and positions.

Cricothyroidotomy is a rescue technique and may be used to buy time. Jet insufflation is even less able to maintain oxygenation over a long period, but both of these are useful in an emergency. I would advocate the use of needle cricothyroidotomy in an emergency if other techniques failed. There are obviously large and important blood vessels in the neck, so adequate training is essential.

My advice would be to teach intubation and emergency airway techniques to advanced medics. I would teach direct laryngoscopy. I would also make sure that there was one single alternative to direct laryngoscopy (Airtraq, Pentax AWS, GlideScope whatever) and only one and that operators were familiar with it's use. I would include training in the use of LMAs and Proseals and have these as the first step after failed intubation. I would recommend that all who intubate patients are familiar with failed airway scenarios and procedures.

In summary, people die from a failure to ventilate, not intubate. Advanced techniques should be taught but everyone has their own opinion on who should be taugh what and by who. In Australia, paramedics undergo hsopital reaccreditation for intubation but they do not use neuromuscular blockers. They are also trialling the use of intubating LMAs in the field.


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