Intubations this month:          27

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentation for January 2018. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

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Focus on: Beach

Some of our work takes us to the beach, particularly during the summer months, although the NSW climate is such that beaches are frequented by residents and tourists year-round.

This month we talked about the specific challenges inherent in undertaking our prehospital work in a beach setting.

The Location

• The downwash of the helicopters used in our service can cause issues with sand blasting the patient, caregivers, and bystanders on landing and take off.
• Beaches are very public spaces so we may experience reticence from our flight crew towards shut down of the helicopter in beach location (rather than hot offload etc)
• Crowd control can be an issue, particularly if we are the first asset on scene. We can expect bystanders and onlookers aplenty encroaching on ‘our space’ and this adds to the mental load of the team
• The inherent instability of sandy surfaces creates challenges for moving and positioning the patient & the patient’s airway
• Sand is also very ready to swallow our equipment; we should be cautious around placing items on the sand as we may never see them again! This is particularly true of smaller items like syringes or the thoracostomy kit but we should be mindful of the additional challenges of equipment maintenance in these environments
• For patients who have been immersed, even if they are out of water by the time of our arrival, we might experience airway flooding with sea water or even pulmonary oedema at laryngoscopy

Solutions from the Sydney HEMS Hive Mind

• Consider the possibility of winching to scene – though there may still be significant downwash generated
• Clearing the beach whenever possible and using additional resources (Police, road Ambulance crews) to do this
• Moving the patient to a solid surface or ideally to an ambulance stretcher for RSI
• Laying a surface covering over the sand to create a treatment area for kit dump. Examples we came up with that might be available to us included
  • a blanket or towel (most road crews have these)
  • a beach towel
  • thermal shock blanket (AKA the “space blanket”) weighted at the corners
• Anticipate the need for suction and have two sources of suction (ideally) ready

Other Airway soundbites this month

• Ability to confirm tracheal placement of endotracheal tube can hampered by time for waveform ETCO2 to ‘warm up’ on some monitors if not already warmed up-> remember the EMMA capnometer is widely available from NSW Ambulance crews as well as being carried in our blue prehospital pack.
• Intubating the acidotic patient – apnoea feeds hypercapnoea and acidosis – hyperventilation is needed to both fight the patients own CO₂and that generated by exogenous bicarb administration. Any ventilations during RSI should be done in a way that limits gastric insufflation – we suggest 2 person bag-mask ventilation, limiting inflation pressures and use of a guedel (oropharyngeal) airway.
• Inadequate paralysis at RSI – note our new RSI operating procedure recommends a dose of 2mg/kg Rocuronium. This gives an average paralysis time of 2 hours from onset.
• Our training and clinical governance processes for RSI include frequent currencies for doctors and paramedics in our service to maintain efficient team working and safety. Only paramedics and doctors within this clinical governance framework can perform laryngoscopy within our service.