By Jim Radcliffe, BS, MBA, EMT-P
I hope everyone is having a great year. I know the economy is tight and there’s all this political stuff going on in and out of our industry, but that’s not why we got into this business in the first place. Somewhere in our lives, we were bitten by the EMS bug. Some of us really came down with it and we have spent most of our lives serving other people. Believe it or not, I’ve had the honor and privilege of knowing some paramedics and EMT’s in their 80s still serving and teaching, running circles around their younger counterparts.
However, it doesn’t matter how old or young, new to medicine or experienced you are, we all have to understand the anatomy and physiology (A&P). Few have the luxury of going through programs with excellent science programs that mirror what medical school students must learn, so A&P becomes scary. One particularly scary and disorienting area of A&P is the airway. The A&P of the airway is scary for a couple reasons, I know it was to me and still is today—but for different reasons. I would like us to take a few minutes to take a look at the A&P from a couple perspectives and talk about how we might make it a little less scary for everyone.
Bring on the Nightmares
Do you remember when you were a student or a new paramedic and going into the operating room for an airway rotation? How about that first field intubation you did? It was probably in front of your preceptor or field training officer (FTO). Wow, I know it was a couple decades ago for me, but I still remember that my hands were shaking and I was sweating while trying to verbally walk myself through the steps and reviewing the A&P in my head.
I did all this as I attempted to impress the anesthesiologist behind me, whom I had met only an hour before. Then I remember noticing that he was right behind me, and his chin was almost on my shoulder as he was trying to look down my laryngoscope blade to see what I was seeing. I know it sounds like a Steve Berry cartoon, but it’s true. It took me several years and my turn as a preceptor and instructor to understand that intubation is not just scary for the student but also for the preceptors and FTOs.
Over the past several years I’ve learned a couple things I think could really help us conquer this fear of the airway A&P and help us all to be better providers and paramedics. So the first thing we have to do is what my good friend Charlie used to say, “Take a deep breath and relax and think about what’s for lunch.” To be a good provider, you have to know the A&P upside down and backwards (and I like to say so well that you have nightmares about the epiglottis.)
Monsters, Dragons & Beasts—Oh My!
So let’s start at the top and review some basic A&P that we all must know. Air comes into our patient through the nose and the mouth as they breathe or we breathe for them. The air going in through the nose is warm filtered and humidified as it goes over the turbinates lined with cilia to filter out the dust and things floating in the air to keep it out of our airways. That air then proceeds down through the nasal pharynx, connects with the posterior oral airway and goes down to the larynx.
Remember that the oral and nasal passages are separated by the hard and soft pallet. The air going in through the mouth must pass by the teeth and proceed the first monster of the airway, the tongue. Yes it seems like and looks like a monster the first time you attempt to slay the dragon of an airway and you are staring down a laryngoscope blade at that beast. No wonder it’s the largest and most common airway obstruction. After getting passed the tongue there is this strange character that you meet called the uvala. He is just hanging there off of the soft pallet pointing you south toward the darkness of the airway. When the patient is breathing this is like a wind tunnel but when you are marching through here with a little metal stick with a light on the end of it the air is still, stagnate and full of foul odors. As you begin to round the corner to head down to the larynx the uvula reminds you, “watch out for the epiglottis just around the corner.
Oh yes the epiglottis, not quite as large as the tongue but still a monster that’s slippery and illusive. For years, I would intubate by looking for the vocal cords Then one day, I realized that everyone has an epiglottis and it’s always in the same place. Think about it for a minute; pull up that old A&P picture from the recesses of your brain and look at the side view. Yep that’s it. Follow the center of the tongue, the forough, to the base of the tongue. At the base of every tongue is an epiglottis. The landmark between the tongue and the epiglottis is called the vallecula. The epiglottis comes in many sizes depending on the size of the patient and how many Whoppers they consume daily.
If you’re intubating, then you most likely have laid the patient flat on their back. (I’m not sure who ever thought to do that, because all the stomach content is now running toward the posterior oral airway and we have to lift all of the structures out of the way.) If you can, place the patient in a low Fowler’s position, it will make your life so much easier and help fix that crook in your neck as well.
Weapons of Choice
If your patient is large, you’ll most likely find a large, floppy epiglottis lying in a pool of slime at the bottom of the posterior oral airway, just waiting to jump up and ruin your day. You’ll need one other weapon in your arsenal to slay this monster, which would be your suction, never leave home without it. It seems that this monster is a lot easier to defeat when you take away his hiding places. Also when you put the patient in a low fowler’s position and put about two inches of padding behind the patient’s head you straighten out the airway and take away the corner’s for the epiglottis to hide. Choosing the correct light stick (laryngyscope blade) is important here, depending on the size of this epiglottis you may need a thin, wide or curved stick to defeat the monster. We will save the choice of weapon for another discussion. Once you defeat these two monsters, entering the cave of the airway dragon is pretty easy from there.
Over the past several years, numerous additions to the EMS airway resources have improved prehospital airway management. One simple change has been the introduction of fiberoptic and LED lighting systems on laryngoscope blades, which has made illuminating the airway much easier.
The introduction of video laryngoscope, which enables users to capitalize on a superior glottic view and access provided by the video image, has significantly changed first attempt success rates When you’re dealing with difficult airways in which you can’t get good line-of-sight visualization, video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. It has also given us a huge educational advantage. In teaching settings, the video laryngoscope allows the preceptor or instructor to see what the student or new provider is observing. For the classroom or lab setting, video trainers allow the instructor to walk the student through the airway and discuss issues that are encountered. I have found the use of video laryngoscope in cadaver labs has been extremely helpful to the students. Many video laryngoscopes have a “video out” feature that allows you to push the image to a larger screen for a group to be able to see what the intubator—whether the instructor or another student—is observing.
No More Fear
Over the years teaching in cadaver and airway classes, students will ask why they were never told these things in their initial training. I have found that understanding the A&P, the use of landmarks and the introduction of video laryngoscope has helped to take the scariness out of prehospital airway management. Hope this helps your practice.
Jim Radcliffe, MBA, BS, EMT-P