Simon Clarke
Simon is a consultant in anaesthesia at University College Hospital, London. He has an interest in airway management and regularly teaches on an awake fibreoptic course & an airway simulation course.
Location London
Activity
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Agree that this perhaps seems a slightly illogical imbalance which I am sure you will not be alone with. Hopefully with the increased prevalence of Team Briefs and the trend towards the flattening of hierarchies then these sort of issues can be raised and highlighted and perhaps then a better balance achieved going forward.
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Some really good points reinforced and well made.
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To borrow a well known phrase, it certainly does help in an emergency when we are all singing from the same song sheet.
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Agree it’s always more challenging and difficult when not working with your normal or familiar team. That’s when the Proper Preparation (eg checklists) & Planning (communication etc) become even more vital to achieving a successful Performance. (“The 7Ps”!)
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Simon Clarke replied to Gregory Moore
I think you have summed it all up beautifully. More and more we really need to find out what is most important for the patient from their point of view in amongst everything else going on.
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Generally when a patient is decannulated there doesn't need to be any surgical repair so this can be done on the awake patient eg in an ITU setting. An appropriate dressing is applied to the site of the incision. The tract isn't formally closed and therefore the tracheostomy tube can be re-sited quickly in an emergency if required. There is some more info in...
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You are on the ball with what you say about "the toughest part" being the "acceptance of the situation & making the decision to use eFONA"
I feel the earlier it’s mentioned the better, i.e. the 'easier' it may then be to do.
So saying something along the lines of
“if this plan A fails we will have to go for eFONA”
....this might just make that hurdle a... -
Simon Clarke replied to Laura Cunningham
It's really great for the whole team to have the shared view. Suction can be handed over to the operator before they even ask for it, BURP or cricoid pressure can be more accurately applied and the resultant effect it has can be properly seen by the person applying the pressure as well as the rest of the team, and advice can be offered by other team members...
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Simon Clarke replied to Gautam Kumar
Completely agree with you Gautam!
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Simon Clarke replied to Jolene Galbreath
Its a fairly easy technique to learn and pretty simple to perform. If you have an U/S available in theatres then get it out and practice on yourselves or colleagues (or patients if you ask them nicely!) Then you'll become familiar with the normal ultrasonographic anatomy of the anterior neck.
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Simon Clarke replied to John Joseph Montalbo
Glad you're learning lots & also enjoying it!
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@RichardKingsley . You are absolutely right. Regular training and practice and simulation are absolutely key to improving your (and the team's) performance in these stressful situations.
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Agree Christian. Not only might it save precious seconds but if you start marking the important anatomical landmarks on the neck, (ideally using an Ultrasound Scanner to help identify the exact location of the cricothyroid membrane etc.), then other team members may possibly wonder what you are doing, & when you explain to them why, then it might help focus...
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@ChristianLeepo . Completely agree Christian. Devising an appropriate plan or strategy, preparing for that plan, and communicating that plan to all the team are all key elements for success. And Simulation training is a fantastic tool & practice opportunity to help bring together all these key elements.
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Simon Clarke replied to Ram Singh
@RamSingh It is indeed a very useful tool for some of the reasons that you outline and in that respect it complements the other available guidelines which generally have a more linear approach.
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Stacey. 'Your' trolleys sound like a Quality Improvement Project just begging to be done. The other very useful things are shadow boards for the selected intubation kit to be placed onto, on top of the airway trolley
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Simon Clarke replied to Gautam Kumar
Gautam, I never realised that you were that old!
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Simon Clarke replied to stuart sanderson
I agree. The Vortex provides an alternative nice & simple approach for managing an airway emergency, especially in which the situation is fluid and you can attempt each or any of the initial 3 lifelines (with their manipulations , adjuncts etc.) as appropriate to the situation.
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Simon Clarke replied to TARIQ juno
Great idea to make up some kits. Regular practise is essential and at our institution we have made eFONA part of our Statutory & Mandatory Training so all department members have to do the training every 1-2 years and all new arrivals (eg trainees) usually do it as part of their induction training.
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Simon Clarke replied to Zoe Huish
We do something very similar for all our new trainees in the week they start. And we try to keep everyone else ‘up to date’ by incorporating FONA training onto the Stat & Mand Training so everyone in the department is ‘encouraged‘ to do it at least very 2 years, although it’s probably better to do it even more frequently than that.
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Simon Clarke replied to Zoe Huish
You’ve hit the nail in the head!
I feel the earlier it’s mentioned the easier it may be to do.
So saying something like
“if this plan X fails we will (probably) have to go for FONA”
may make that hurdle easier and prepares the collective team in advance. -
I would estimate that the vast majority of hospitals in the UK use and follow the DAS guidelines, first published in 2004 then updated in 2015. Every hospital is recommended to have a designated ‘Airway Lead’ whose job it is to ensure appropriate training and ability to incorporate the relevant guidance into their hospital.
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As you allude to communication is vital so everyone involved clearly knows what the plan is (or plans are)
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Simon Clarke replied to Sasha Auld
You raise an important point. It’s important to retain our ‘old skills’ for multiple reasons and ultimately, for now at least, it would be the ideal to be equally skilled / competent in both techniques.
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As you’ve alluded to ‘less is more’.
Airway Kit dump sheets / templates are useful to have to keep things organised and reduce clutter. -
Simon Clarke replied to Michael Jami
No special setup. Use ‘standard mode‘ that you would also use for doing an US guided regional block or US guided Central Venous Catheter.
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Completely agree. Always more challenging when we are out of our domain and thus our comfort zone. Checklists can help to a degree but careful preparing & planning are key
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@SimonMacklin I agree. I think it safest to not put anything into the nose until after topicalising with a vasoconstrictor and only then would I carefully advance the tip of the fiberoptic scope looking both directly at the nares and at the screen
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@AlexanderPhilip There are many topicalisation recipes & methods and certainly nebulisation is one method which can be used in conjunction with e.g. spray as you go etc. It is slightly more time consuming and obviously there is some extra 'kit' required but it is an effective alternative when access is somewhat limited by reduced mouth opening.
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@PeterLindbloom We regularly perform nasal intubations both awake and asleep and over perhaps 20 years I have never seen any nasal trauma. We are obviously careful during nasal fiberoptic, usually following the floor (gutter) of the nose and additionally always use a vasoconstrictor (i.e. co-phenylcaine) to reduce the risk of epistaxis.
