Hi everybody, Mike Steuerwald here…
Recently, one of our FOAMed friends came to visit the University of Cincinnati. Jim Ducanto is well known for his innovations and general wealth of airway management knowledge. One wonderful thing that Jim shared with us during his visit was an airway mannequin that he “modified” to be able to puke…yes…puke. Not sort of puke…but REALLY PUKE!! Here is what Jim has to say regarding the motivation for building the device as well as lessons we learned while doing it’s “beta-test”.
Suction Assisted Laryngoscopy and Airway Decontamination
by Jim Ducanto, M.D.
….And so it began. Curiosity mixed with boredom, as well as irreverence for airway training mannequins. Irreverence? Yes.
If you look inside most of these things, you’ll find that the various manufacturers have made gross oversimplifications during their designs (anatomically non-correct in most cases). Furthermore, many employ simulated test lungs with the compliance of Zip-Lock bags that usually require such high flow rates to remain insufflated that stomach insufflation would almost certainly happen in real patients.
So, if the mannequin is not made to suit my needs, what’s to stop me from modifying it? Like, for instance, adding a functional esophagus that spews “vomit” to allow for simulation of one of the most challenging occurrences in emergency airway management. If you know something awful can happen, you must train to handle it!! Otherwise, you’re a sitting duck, and bad stuff is going to happen to you and your patients.
Modifying the Laerdal Difficult Airway Simulator Mannequin was not difficult — all it took was a few lengths of 5/8 plastic PVC tubing from the hardware store, some “quick-connects” from the garden section (the parts that allow you to connect water spray guns or sprinklers to a garden hose) and a suitable container to hold the “vomit”.
To make simulated vomit, I utilized Gum-Xanthem, a powder that mixes with water to form a slurry that is not too thin nor too thick. The guys over at SSCOR (manufactures of the Hi-D “Big Stick”) provided me with an ample supply. I mixed 10 ml of the powder in 1 liter of water, and got the perfect consistency for the test. Everything got decontaminated in water after the simulation.
Jeff, Mike, Ashley and I made this video in one take. As you will see, the standard hospital issued Yankauers were not equal to the task (i.e. they suck). We needed something with a larger opening — one that could handle the small clumps of un-dissolved Gum-Xanthem (just like half digested food). Enter the Hi-D “Big Stick”. The Hi-D looks like a normal Yankauer, but it is not. It has a 0.25” opening, compared to the 0.14” opening of a standard Yankauer.
The idea behind this video and technique is to explore the most efficient methods with which to handle suction alongside other airway equipment, especially during active vomiting. The development of a simulator and a technique around that simulation asks several questions, and furthermore, provides some interesting answers:
- Can the suction catheter itself be used cooperatively with other airway devices? Indeed, yes it can. The Yankauer can function as a tongue depressor to assist the optimal positioning of a DL or VL to enhance first pass success, it can actually be used to help control a wayward epiglottis, for instance, or it can be used to hold the tongue and larynx anteriorly while the blade of the laryngoscope is positioned optimally on the first attempt.
- Can suction be used continuously during active vomitting while the procedure also works to place a bougie, then a tracheal tube? Most definitely yes it can.
- Can a simulation of active vomitting during airway management build resiliency in Attending and Resident staff in preparation for facing such an event clinically? That is a research question, and indeed, we hope it might.