In modern day medicine, these are countless specialties and sub-specialties that we can explore. There are fellowships on heart failure, fellowships on particular disease entities and so on. But there are some things that remain very basic such as basic airway skills that every physician must know. In contrast, who is the expert in advanced airways is a matter of debate though? Is it Emergency Medicine, Intensive Care, Anesthesia or ENT.
Managing Airways depends a lot on local protocols and systems but in general, it is either ITU, Anesthetics or EM personnel who do this. During initial bits of my training in a missionary hospital I learned and mastered my basic and advanced airway skills. I was fortunate enough to work with some of the finest EM and ITU gurus in the country. By the end of two years, I was pretty confident about my airway skills. Particularly at Vellore, Airway was definitely an EM physicians territory and I don't recall a single day when Anesthetists were summoned to ED for any airway. Later, I moved to a corporate hospital in Hyderabad where once again - Airway was an ED doctor's forte and Anesthetist/ENT was rarely called to ED to help with airways.
Surprisingly, a large population of EM physicians/trainees believe that Airway is best left to Anesthetists since they are experts in managing it. Well, by that logic we should stop reading ECGs, CT scans, X Rays or even doing abdomen exams as they are best done by a Surgeon who has done is 1000s of times. I guess we are getting back to those good old Casualty Medical Officer days..On the name of safety, support, courtesy and expert care we often let down EM as a stand-alone specialty.
Arguments from those who think Anesthetists/ITU should do all Airways
They do it several times a day and a few thousand times in their residency. So they are the best!
Any seasoned ED doctor understands how you feel when you intubate a desaturating patient with a full belly and high risk of aspiration. This a common scenario in EDs and not in Operation Theatres. ED RSIs are very different from elective theatre intubations. ED intubations happen over a span of few minutes and they should be dealt with a sense of emergency (not urgency).
Most Anesthesia trainees learn this crucial skill in a well controlled and elective environment and continue to polish it further in controlled settings whilst EM trainees learn this during Anesthetic Rotations/Emergency Department and continue to fine-tune it in A&E under the supervision of a Consultant.
Post-intubation care is tough and we can't manage that
Really!! EM is a tough specialty and this is not a reason to call ITU/Anesthesia to manage airways. Check this out to understand "post-intubation" care. Not knowing enough and being sloppy is not a valid argument.
We need more protocols and guidelines
Until recently, I was a big proponent of guidelines and protocols but lately, I have been questioning and thinking if these are leading to any benefit or more harm. As clinicians, we stop thinking when using these pathways. Patients are thrown into pathways and they all get worked up in the same fashion. Same initial workup for a 20yo Chest pain and 40YO Chest Pain and 65yo Chest Pain - unnecessary blood tests, false positives, invasive testing, incidentalomas and serious harms from procedures + inappropriate utilization of resources. Hopefully, things would not be the same for "Difficult Airway Pathways". I certainly believe that we should have difficult airway pathways in ED formed in liaison with Anesthetics/ITUs but we should NOT be summoning them for every airway in ED. Emergency Departments should have their own protocols for intubation and ED should be able to decide on intubation.
The Designation Bias and "EM Mindset"
Many are of the opinion that a patient does not need intubation when GCS is 9/15 (not <8/15). Well, it is not that simple. So here is my list of those patients who needs intubation (This is not an exhaustive list):
- Respiratory Failure or Impending Respiratory Failure (Type 1 or Type 2)
- Cardiac Arrest
- Airway Patency issues or Potential Airway compromise (Low GCS, Head Injury, Neck Masses, Stridor, Burns, Anaphylaxis)
- Anticipated Course of Care
- Unresponsive Shock
- Raised ICP
The way EM and Anesthesia think about "Emergency Airway Management" can be very different. If Anesthetics fail the airway in the first attempt, it is called a difficult airway but if ED fails in the first attempt, it is called as incompetency. (Designation bias)
Strong Leadership and Getting Support from Colleagues
The practice of EM is extremely variable in different parts of the world. There is often an overlap with Pre-Hospital, ITU, Anesthetics. To progress as a specialty, it is important to have a quintessential group of mentors who love what they do and want to progress EM as an individual specialty. Sadly, this is not always the case and EM is governed by other specialists with little or no EM training. Once in a while, things do go wrong with high-risk procedures and having support from your colleagues is then of utmost importance. This is only possible if the whole body of senior doctors is on the same page regarding airway protocols.
Summary
Managing airway is not left to an individual specialty anymore. It is a skill shared by EM, ITU, Anesthetics, and ENT as well.
Posted by:
Lakshay Chanana
Speciality Doctor
Northwick Park Hospital
Department of Emergency Medicine
England
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