Category Archives: Airway

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.

Affordable Difficult Airway Kit

Well, this week I’ve been playing with some AirQ II blocker intubating LMAs (iLMAs) sent to me from a rep.
For those of you not familiar with an iLMA, the device is designed to allow ‘blind’ intubation of the airway, using the laryngeal mask airway (LMA) as a conduit.
The progenitor, with which most rural doctors and anaesthetists will be aware of, is the FastTrach LMA. It’s reported to allow up to 73% ‘first pass’ successful intubation rates, increasing to 90% overall success with repeated attempts and the ‘Chandy manoeuvre’. It’s not a bad piece of kit and we’ve got one on our airway trolley.
However, the FastTrach requires some practice to get used to. I made a point of using it at least once a month during my anaesthetic year, just to get used to the kit. Using equipment in training is quite different to using ‘in anger’, especially when there’s an evolving airway crisis. Problems that I found were
  • not always easy to pass the endotracheal tube into trachea
  • removing the LMA whilst leaving the ETT in situ is fiddly and risks losing both
  • overall success rate is 90% – so 1:10 will fail.
The C-Trach is an advancement on the FastTrach, improving rates for first pass and overall sucess to 96% and 98% respectively – basically this device is just a FastTrach with a video screen attached. Clearly then, addition of video allows visualisation of the cords and improves success rates.
However, neither FastTrach or CTrach allow you to place a nasogastric tube..unless you obturate the ETT and remove the LMA over the top, which is potentially fraght with difficulty.
Cue the AirQ iLMA.
This ‘new improved’ iLMA gets around the problems of FastTrach and CTrach – it’s similar in appearance to the FastTrach iLMA, albeit with a less acute angle. It also has a nifty side-port to allow passage of a nasogastric tube without having to remove the iLMA
Moreover, the device comes with dedicated nasogastric ‘blockers’ – an NG tube with an oesophageal balloon which can be inflated in the oesophagus to minimise aspiration risk and yet allow decompression of the stomach.
I tried it the other day in theatre and found it easy to use. As an LMA it functioned perfectly well, although I have heard some anecdotal evidence of increased supraglottic trauma with this device.
How then to improve success rates for passage of an ETT? Minh le Cong has described this elsewhere – use of a malleable intubating stylet such as the Levitan FPS allows visually-aided intubation through the iLMA conduit.
So we now have a staged procedure for the nightmare difficult airway where intubation has failed or priority is to oxygenate
  • drop in an AirQ II and ventilate
  • pass the oesophageal blocker to decompress the tummy
  • use a fibreoptic device to intubate through the iLMA, improving intubation rate
This strategy (fibreoptic intubation through an iLMA) is Plan B of the UK’s Difficult Airway Society algorithm. Yet how many of us are really prepared to do this and have practiced on kit? Most rural docs have access to a FastTrach…so ventilation and blind intubation are possible – yet the addition of an NG tube port and allowance of fibreoptic intubation seems to offer a higher standard of care. Of course, for many small hospitals fibreoptic devices have traditionally been out of range – high cost and difficulty acquiring and maintaining skills.
But for under $3K you can pick up a Levitan scope (malleable fibreoptic intubating stylet) or the Ambu Ascope II (five disposable flexible fibreoptic scopes). They may not be as good as the fibreoptic towers that people use for an awake fibreoptic intubation…but they are bloody good gadgets to use with the above technique.
So, what would be my preferred kit for a ‘difficult airway’? Well, I’d use the Difficult Airway Society (UK) and ANZCA T04 guidelines as a starting point…and in addition to the AirQ and some sort of fibreoptic device, I’d add in a videolaryngoscope. Sounds expensive? Well my suggestions for purchase are in square brackets below – for under $4K should be affordable for small rural hospitals…
Plan A – Initial Intubation Strategy
Standard laryngoscopy – if fail, change position, blade, operator. Consider use of a videolaryngoscope in case of difficult airway. If fail, move to…
[KingVision Videolaryngoscope ~ A$1000 inc. blades]
Plan B – Alternative Intubation Strategy
iLMA to maintain oxygenation and ventilation, then secure airway using fibreoptic intubation through iLMA. If fail, move to…
[AirQ II iLMAs A$30 each]
[either Levitan FPS or AmbuAscope II fibreoptic devices to intubate through iLMA]
Plan C – Maintain Oxygenation & Ventilation, Abandon Procedure and Wake Up
Bag-mask ventilation and reverse non-depolarising neuromuscular blocker (suggamadex for rocuronium) or wait for suxamethonium to wear off. If fail, move to…
[Rocuronium for RSI – prolong time to desat]
[Suggamadex to reverse rocuronium]
Plan D – Rescue Techniques for Failed Oxygenation & Ventilation
Bag 1 – Paediatric or Easy Anatomy
Needle Cricothyroidotomy technique


Bag 2 – Adult or Easy Anatomy
Scalpel-Bougie-ETT technique


Bag 3 – Impossible Anatomy
Scalpel-Finger-Needle technique
[Melker Kit]
I wouldn’t bother with the pre-packaged kits like QuickTrach or Seldinger kits as first line for CICV – in the heat of the moment, faffing around with wires etc can be a disaster. Better to have three equipment bags set up as above using standard equipment – oxygenate first – then move on to seldinger or formal tracheostomy. Some have commented that doing the above is sufficient to ‘save the day’ then either wake up the patient or proceed to successful laryngoscopy.

Loving the Job

I reckon the work as a rural doctor is the best that medicine offers. Just heard from a colleague with whom I did anaesthetics last year in NSW.

“Mate I love this job! In the past 7 days I’ve thrombolysed a 44 year old with a STEMI, resuscitated a 5 year old who had a fit in the local pool, drained a 2L pleural effusion off an ol’ fellas chest, gassed 5 people on a gen surg list, managed a snake bite, released two carpal tunnels, resuscitated a floppy neonate after a ventouse and seen a whole load of people in general practise. I LOVE MY JOB! Hope you’re having fun mate. This job just keeps getting better!”

No, he hasn’t been at the drugs cupboard. He is expressing the simple joy of being a rural doctor with the skills to do your work. As I’ve stated before, I reckon that being a rural doc is one of the best jobs around – especially for those with procedural skills.

Sadly skills aren’t all you need – you need the equipment to do your work well and you need structures behind you to ensure that your work is sustainable in what is, ultimately, a high-pressure job. For most of us, that means adequate locum relief or being paid for the work you do.

With regard to equipment, I’ve just submitted my paper on the availability of difficult airway equipment for rural doctors. Of the estimated 448 rural GP-anaesthetists out there, I’ve got responses from 293 – a 65% response rate, which is apparently quite good for an internet-based survey. So paper has gone in for submission…

I won’t give the game away (wait for the paper, if it survives the review process) – suffice it to say that there are common themes amongst the rural GP-anaesthetist cohort – lack of funding for basic and advanced airway equipment predominating amongst respondents. 

I’ve tried to outline in my paper some suggestions for affordable equipment to help advance the cause – for under $4K a small hospital can purchase some of the intubating LMA AirQ-II blockers, plus a fibreoptic device to allow intubation through the iLMA (something like the flexible AmbuAscope 2 or the Levitan malleable intubating stylet). There’ll still be change leftover to buy a KingVision videolaryngoscope – all of this gives a fairly robust kit for the ‘occasional intubator’ or GP-anaesthetist.


A&E Services & Contract Negotiations


Meanwhile, the State opposition Minister for Health has finally twigged to the inequity of country patients being charged for non-admitted A&E services that their metropolitan counterparts receive for free through Emergency Departments. Minister Hill is now on record saying that the ‘only solution’ would involve putting in salaried medical officers which would ‘send GPs in rural towns broke’ (The Advertiser, p15 9/3/12). He neglects to consider the alternative option – pay the oncall rural GP for A&E under existing fee-for-service arrangements, regardless of whether patient is admitted or not.

This solution would ensure patients attending the A&E with problems deemed inappropriate for routine GP would not face fees. It would mean the doctor is paid by the Health Dept without having to chase fees. Everyone is happy…

And it would be fairer to rural patients who already face significant health inequalities due to rurality.

This issue is all the more relevant as the existing contract between rural doctors and CHSA expired on 30/11/11 and has been postponed not once, but twice. I dunno about other rural docs, but I’m a little fed up of CHSA failing to come to the negotiating table and sending missives advising of a 90 day ‘contract extension’ on the last day of the existing contract.

It’s not a good way to do business and seems symptomatic of a relationship whereby CHSA treats rural docs and patients as a hinderance to their bureaucracy, rather than a vital component of the health service.