Category Archives: Videolaryngoscopy

The Love Affair may be over….

Well, no secret that I’ve been a fan of videolaryngoscopes

Not so much because I think VL will replace the skill of direct laryngoscopy (it won’t), but because I think they add another tool to our therapeutic armamentarium – particularly for the ‘occasional intubator’ or the isolated rural GP anaesthetist

The past 18 months or so has seen a proliferation of these devices….and with that comes the danger of ‘too many toys to choose from’

To my mind, the gold standard is a VL that performs like a standard laryngoscope and doesn’t require learning a new technique. Having a video-out port or an SD card to record video for audit and teaching/training makes it even better value. The C-MAC system ticks these boxes but is expensive – frankly too expensive for use in small rural units (although having just witnessed the Health Dept blow $17K on new anaesthetic machine monitors that we don’t need and were not requested nor sanctioned by the County Health lead for anaesthesia does make you wonder)…

The KingVision VL has been an affordable device for small rural hospitals….around A$1000 and with video-out ports so can be slaved to a monitor or PC to watch novices or to record intubations for training. I am not sponsored by them, nor have any affiliation…but it’s no secret that I have been happy with my purchase for the past year or so.

Imagine my surprise when today the screen packed up mid-intubation on a difficult case. Changed blades, battery…no use.

So switched to an iLMA and proceeded with blind passage of the ETT.

image

This is not the first time equipment has packed up on me this year – I have had two anaesthetic monitors fail mid-case, which caused me some grey hairs …. especially as we have no back up monitor here on Kangaroo Island (more cost saving, nice one CHSA). For a while I wondered if it was me causing electrical failures…but when the new $17k replacement monitor failed five mins into a case without me touching it, I realised this was just bad luck. Kudos to my trainers though, who ran through this sort of scenario in JCCA training.

Anyhow, the KingVision VL is now dead. I have emailed their rep, awaiting a response…let’s hope that they will cover this under warranty

If not, I will be mighty pissed. If this is a case of ‘planned obsolescence’ then it would be hard to support this device in the future. Better to go with one of the cheaper ‘throw away’ devices like VividTrac or stump up the dollars for a more expensive but longer lasting device like C-MAC.

Let’s hope KingVision come through with a replacement display/handle.

I will report back….

Rural GP Anaesthetists – a ‘special needs’ mob?

As a rural doc I’m very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the ‘best bits’ of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight – a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I’ve had this date ruled off in my diary for 12 months now…so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service…

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who ‘get’ rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists…as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting…but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as Resus.me, BroomeDocs.com, Prehospitalmed.com and LifeInTheFastLane – all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I’ll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned…

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like – all very interesting, but not translatable to the rural practice environment where such resources aren’t available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don’t have remifentanil..or desflurane..or BIS…or access to FFP/cryo/platelets…or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand ‘special needs’

So, what does the rural GPA really need?

- lectures from experienced anaesthetists? Hell yes.
- small group sessions and case discussions? Even better.
- topics targetted to the audience and suggestions for improvement. Absolutely!

…and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend…as if one doc is at the conference, the other needs to be oncall)

…and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a ‘rural anaesthetists’ email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling – yet operate in silos. Moreover there is little ‘top-down’ direction – certainly I have no sense of direction from the ‘Country Health SA Anaesthetic Consultant’ and it would be nice to see some more dynamism.

Maybe next year will be better…I’m going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.

Gear fetish

I’m in love…with my KingVision videolaryngoscope. It’s somewhat of a generalism, but anaesthetists tend to be ‘propellor heads’ – they like to fiddle with equipment, & they are invariably seduced by things technical…you can usually tell anaesthetic doctors at a conference – they’re the ones with MacBook Pros or iPads or iPhones.
But I digress. Last week was one for coincidences – the local rep sent the KingVision up for me to trial and at the same time Broome Docs posted on the issue of ‘which video laryngoscope‘, whilst Minh Le Cong of RFDS Queensland posted a review of the device on EM-crit. Then to top it off I spent the weekend at the NSW proceduralists conference, where videolaryngoscopy was discussed and utilised both in the simulation lab and in the conference talks. I was so impressed I forked out my own cash to buy one, rather than wait for my local health unit to come to the party.
I think that VL is a game changer. Don’t get me wrong, I’m diligent in developing and maintaining my direct laryngoscopy technique…but when faced with a difficult airway, the VL has potential to substantially improve the view.
We’ve got the C-MAC up in theatre where I am currently doing some anaesthetic upskilling. It’s a great piece of kit and I think that the ability to see laryngoscopy on the screen is both reassuring for everyone, as well as accelerating the learning curve for novice intubators (they reckon that it takes at least 60 intubations to progress from ‘novice’).
There’s also great potential to use the VL to simulate the difficult airway…given that Grade III and Grade IV Cormack-Lehane views are supposed to come along with relative infrequence (less than 1%), I reckon there’s merit in using the VL to take a look at the cords, then either reposition the patient or the scope to simulate a Grade III or IV view…then utilise techniques to still intubate the trachea (BURP, bimanual manipulation, blind pass bougie, stylet etc etc). Again, this greatly advances the learning curve. 


For the ‘occasional intubator’ (most rural docs) the VL gives additional comfort – particularly when our decision to intubate is often forced due to imminent respiratory failure, or severe obtundation…and invariably in an un-fasted, un-optmised patient with haemodynamic instability. In a collar. Maybe at the roadside. Quite a different kettle of fish to the ASA I/II selected cases fasted for theatre on whom we practice. Of course, the big drawback is money. The C-MAC comes in at around $15K. It’s not a device that is realistically affordable for Kangaroo Island or indeed other small health units in Australia.
Some doctors have opted for the AirTraq, which is not a VL as such (relies on prisms to give an optical view)…it’s cheap as chips at under $90 each, but I find that peering through the viewfinder is fiddly and that one loses situational awareness. 
Hence the KingVision with it’s built-in screen offers similar affordability (blades are about $30 each, the re-usable screen under $1000) and allows me to maintain situational awareness. I plan to have it to hand for anticipated difficult airways (trauma, collar, weird anatomy, failed LEMON etc)…and of course to use it now and then on routine lists to keep up skills (the technique is subtley different to DL).
Today I popped down to the local hobby store and haggled for a 12 inch TFT monitor with mounts for IV pole…then I’ve hooked up to the KingVision via the supplied composite-out video cable…so now I’ve got a system that allows big screen playback and recording, for a fraction of the cost of a C-MAC. Great for teaching. 
Bloody brilliant.
If you haven’t already, take a look at the KingVision. For the price, it does exactly what is says on the box. Given that tertiary centres insist on having some sort of backup device for the difficult airway, I think that it’s now indefensible for smaller hospitals not to have kit that does the same job.
[Please note that I am not affiliated with KingVision and that the model I purchased was with own cash at retail prices]