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I always have a great time at the Essentials of Emergency Medicine conference, not just because it is an amazing conference, but because I get to hang out with my buddy, Rob Orman. This year, we did a on-stage demo of central line tips and tricks. Hope you enjoy:

Here's the Vid:

 

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You do perfect patient positioning.

You open the mouth.

A beautiful, gentle, stepwise insertion of the laryngoscope allows you to get the tip of your video Mac into the valeculla.

And you see...

Nothing!

What now?

Abandon the attempt--nope!

Use the Kovacs Kata

The Kovacs Kata is dedicated to my friend and airway Guru, George Kovacs.

George had described his EVLI approach to laryngoscopy as a kata (see EMCrit 236). That struck me more as mental rehearsal however. A kata in my martial arts experience was always a fight against multiple imaginary opponents. The way I taught the kata for rescuing a failed laryngoscopy is a fight against 5 opponents of success using 5 techniques:

1. Neck

Neck refers to external laryngeal manipulation (ELM).

* Bimanual Laryngoscopy on LitFL

* Levitan Study on BiManual/ELM

2. Head

If you do not have a good view with your pre-intubation positioning, keep lifting and if necessary, flex the head.

* Kovacs Head Lift Video

* Keith Greenland on Why this Works

* Head and neck elevation beyond the sniffing position improves laryngeal view in cases of difficult direct laryngoscopy

3. Hands

If you are not strong enough to lift the patient's head off of the bed with one hand, use two. Then maintain the lift with one hand, aided by locking the left elbow against your body.

4. Scoop

If you have an epiglottis that you can't see past, despite the optimizations above, then just lift it with the Mac, i.e. use the Mac as a Miller.

* Levitan Article on Managing an Omega Epiglottis including the Scoop Maneuver

5. Pull Back

This one is for the hyperangulated blade. You have a great view--you just can't get the tube to go into the glottis.

* Why too close is too bad

* George on Hyperangulated Problem-Solving

* Levitan on HyperAngulated Blade Use and the Kovacs Sign

Additional Attributions

* Full Kata Video

Now on to the Vodcast...

Today, I present an excerpt from an interview with Andrew Davies, host of the mastering intensive care podcast. The full interview was over an hour long, but this is a polarizing excerpt.

The Full Mastering Intensive Care Interview

* Scott Weingart being interviewed by Andrew Davies

REANIMATE 7 Conference

* reanimateconference.com

Now on to the Podcast...

There is a group of clinicians operating on the front line of war zones with no other purpose than to save lives. Global Response Management's Helen Perry comes on the show to discuss their work.

Helen Perry ACNP-BC, MSN, RN, CCRN, CEN

Their motto is semper vitae--always life. Their mission is to provide life saving emergency and prehospital care to those impacted by war and conflict.

Find Global Response

* The website is www.global-response.org

* Instagram global.response

* Facebook

* Twitter @GRM_Global

Volunteer

We are always looking for qualified volunteers and we use Paramedics and above. EMTs are welcome to apply, but they may not be working in a clinical capacity due to World Health Organization minimum operating standards. We even need non-medical folks (social media marketing, finance, smart computer people, grant writers, etc.)

Donate

They are a registered not-for-profit (501c3) and their admin budget is super low. Please consider helping these folks.

Note

I have had to close this post to comments b/c there have been a number of comments made by folks with false names and/or false contact information. The policy of this site is that all commenters must use their real identity linked to a real email address. There seems to be a group of folks out there that doubts the veracity of the GRM. If you have verifiable information on that, please get in touch by the contact link above.

Now on to the Wee...

 

 

In Part I of the philosophical diversions series, we discussed free will. Today, let's bring up some other thoughts:

Conscious Decisions

Consciousness by Annaka Harris

Podcast Episode

Naïve Realism

Perception isn't Reality

* Ross, L., & Ward, A. (1996). Naive realism in everyday life: Implications for social conflict and misunderstanding. In T. Brown, E. S. Reed & E. Turiel (Eds.), Values and Knowledge (pp. 103–135).

Fundamental Attribution Error

Synopsis

Umvelt

The RCM is Back in Stock

resuscrisismanual.com

Now on to the Podcast...

Pendell Meyers is attempting to change the paradigm of classifying MIs as STEMI vs. NSTEMI. An important first step in this attempt was his publishing the

OMI Manifesto

However, many folks just don't read, so here is a video version.

Ideas to Think About...

* False Negative Paradox

* Why did the term stemi equivalents not catch on?

* Why is there not currently a retrospective coding of missed occlusive MIs?

Please, please put your thoughts and comments below

Updates

Literature proving STEMI sucks

Now on to the Vodcast...

 

You Can Either Learn or You Can Blame, You Can't Do Both

--Sydney Dekker

 

Steps Prior to the M&M

Find a Case

The standard referral paths (hospital reporting, pissed off administrators, mortalities) will happen automatically. But you also want to establish yourself as a Master of Whisperers. The way to get people to report cases is to inspire trust. You need to offer protection, establish clear patterns of non-putative motives, and show that you actually do something with the information reported.

Build a Thin Timeline

Comb the chart to build an initial time-line. This will only reflect events, but will offer little actual understanding of what took place.

Interview Primary Decision-Makers

* Dr. Douros asks lets them know he wants to meet over coffee and asks them to write up a 1 paragraph description of events.

* He sends out a Pre-Reading Sheet of what to expect.

* The goal is to find the inflection point where things diverted from optimal care

* Then to get to the point where the actions that occurred make sense

* Seek to Understand Local Rationality

* Knowledge at the time

* Focus at the time

* Goals at the time

* Goals of this interview overlap greatly with the skillset of a simulation debriefer. As such, check out Simulcast for amazing resources.

Build a Thick Timeline

Incorporate the results of the interview(s) into the timeline

Remember, ED cases are not contiguous they are stimulus/response based

Analyze for Systemic Problems and Brainstorm Solutions

Behavior must be judged as if the outcome is not known. If it was ok when things go right, it is ok when things go wrong.

 

Presenting the M&M

Dr. Douros does 2 cases in a one-hour block, 1 of them an M&M and the other a Safety & Success case (similar to the Amazing & Awesome Rounds).

PreBrief

Remind the group that this is about learning and identifying systemic problems, not about blame & shame.

Present the Thin and Thick Timelines

* Should take about 10 minutes.

* Exclude extraneous information

* The case can be presented by a Junior, but there needs to be a master facilitator at all sessions

Discuss the Case

~10-15 minutes

Probe for Systemic Problems and Solutions

~10-15 minutes

Send F/U Email with Lessons

To reinforce for those who attended and fill in those who did not

Recommended Resources

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[easyazon_link identifier="1472439058" locale="US" tag="emcrit-20"]The Field Guide to Understanding 'Human Error'[/easyazon_link]

This is the first go-to, a must read. It will change your vision of error.

Next, you can move on to another Dekker book:

[easyazon_image align="none" height="160" identifier="1409440605" locale="US" src="https://emcrit.org/wp-content/uploads/2019/06/41UnTiuYgTL.SL160.jpg" tag="emcrit-20" width="105"]

[easyazon_link identifier="1409440605" locale="US" tag="emcrit-20"]Just Culture[/easyazon_link]

At the last SMACC, I yet again taught the surgical airway station of the airway workshop. I was joined with amazing faculty and together we taught 160 people our method of performing cricothyrotomy. We've been doing this for 4 years, but this past session was the first time it really felt just right. In this podcast, I want to go over some of the lessons learned and how they may contribute to your own self-training on surgical airway.

Models

Each participant had their own 3-d printed model. This was absolutely crucial and a big difference from prior sessions.

We have found models to offer a more realistic experience than animal parts​1​

Who Gets a Cric & Mental Prep

including a discussion of CricCon2

see this prior episode for more on CricCon

Finding the Membrane/Cut Site

Start Low, feel high

Laryngeal Handshake

We teach Rich's choke hold as a backup method​2–4​

* Practice_of_Ultrasound_Guided_Palpation_of_Neck

Build the Model

We used the same steps as in my how to practice crics video

Teaching the participants to build their own was hopefully encouragement to get their own model and practice each month.

All they need is:

* the 3D-printed model* Good gaffers tape* 4x4s* Plastic Bags

We had a few of the frova cric trainer holders, which would have been nice to use, but we didn't have enough for everybody, so we left them in the box.

Rapid Cycle Deliberate Practice (RCDP)

I learned about this teaching method from Alia Dharamsi at the amazing ResusTO conference. I also used the a modified version of her delphi-derived steps as a handout taped to each station.

Hear more from Alia

* Alia Dharamsi on Delphi-Study and RCDP

Alia Dharamsi

Steps of RCDP​5​

* Splitting Cases/Procedures into small segments* Micro-Debrief after each one* Add progressive challengesfrom Taras & Everett

* EMCrit-Modified Cric Steps* The Original Delphi Article

Iterations

* Step-by-Step through the Procedure * Dominant Side Palpable Anatomy* Look-Up* Non-Dominant Side* Non-Palpable Anatomy / Cut and then spread to air* Under Stress

I was demonstrating up front with a video camera--this was huge as it allowed real-time correction with a much lower instructor to participant ratio.

Today, we talk about the theory and practice of the Dissociated Awake Intubation. This technique allows the rapid provision of an intubatable patient while preserving spontaneous respirations.

A few days ago I posted George Kovacs' thoughts on the matter.

* George Kovacs on KFI

This was in response to a blog post by frenemy of the show and brilliant airway tactician, Reub Strayer.

* Ketamine-Only Breathing Intubation (KOBI)

What is Dissociated Awake Intubation?

I coined this term to describe the administration of a dissociating dose of ketamine to allow a patient to be intubated for many of the same circumstances as the traditional topical awake approach.

This is theoretically distinct from the idea of using ketamine in a sedative-only intubation. The two ideas are separated by the intent, with the former subbing for a topical awake and the latter for a RSI, in systems where for whatever reason, paralytic can be used. In practice, they look the same--it is often the users that look different.

Kovacs has used the term ketamine facilitated intubation to encompass both uses. This post and podcast only deal with dissociated awake.

Awake Intubation Posts

* Emergency Awake Topicalized (EAT) Intubation – An Awake Intubation Update

* Podcast 194 – Definitive Emergent Awake Intubation with George Kovacs

 Why Awake Intubation?

If an airway is predicted to be difficult, consider an awake approach. This predicted difficulty could be an anatomic. It could also be physiological: namely Hemodynamics Kills, Oxygenation Kills, or pH Kills. When there is a combination of two or three of these elements, awake becomes almost a must.

Awake vs. RSI

RSI and awake are tradeoffs

* RSI gives you the easiest laryngoscopy/tube delivery at the expense of safe time for intubation

* Awake gives you a markedly harder laryngoscopy/tube delivery rewarded by a markedly extended safe intubation time

You must be a much better intubator to perform an awake laryngoscopy and tube delivery.

Topicalized vs. Dissociated Awake

In some cases you will try topical first, and then when the pt won't cooperate or you can't adequately topicalize, that will push you to dissociation. However, there are definitely a group of patients who I will choose primary dissociated awake. It comes down to cognitive bandwidth.

Nuts and Bolts of the Technique

* Give small aliquots of ketamine every 15 sec. or so until dissociation (25 mg at a time

* Have everything ready for RSI and failed airway, including paralytics prepared and ready before first dose of ketamine

* I still topicalize

Awake Intubation from George's Online Textbook

Kovacs AIME Airway Textbook (Infinity Edition) - Awake Intubation Chapter)

Now on to the Podcast...

This Article is a Must Read if you Found this Episode on Free Will Interesting

The Lucretian Swerve

Attributions

While 1% of this episode may be independent thinking, the rest was surely based on influences too countless to cite. Some that clearly remain foremost as inspiration are the article above, Dan Dennett's work, Sam Harris' book, the book, Four Views on Free Will, and all by poor undergrad professors that had to put up with the utter annoyance of my stubbornness.

One of the Most Critical Articles to Read on the Topic

* Chun SS et al. Unconscious determinants of free decisions in the human brain. Nat Neurosci. 2008 May;11(5):543-5. PMID: 18408715

Image by Narcournus

Now on to the 'cast