in the real world these are the steps you should practice there's only a few techniques you need
to learn so your five years of training is to rehearse these feel free to take pictures of these
slides because then i i you know i want you to write them out because that is an extra repetition
that you'll get so you can memorize this better i want you so i'm going to show you all of them
now so you can begin slowly adding these to the arsenal and just know that not many residents
know these so i think it's just really useful for you to have all this stuff straight away so
imagine you're an anaesthetic registrar you're training hospital you're about to anaesthetize
a 50 year old male for lap collie no allergies past history meds or anything and you're consulted
impressed with your ability and wants you to do your case on your own but just imagine you
give the induction after all the positioning and preparing of theater i've just noted that it's a
non-reversible act relaxed in any way just to keep it simple or rather not simple difficult for you
uh and you attempt to bag mask but unable to move air think about all the steps you do you
attempt intubation but cannot get a view what do you do then and then you attempt lma ventilation
but are unable to ventilate what do you do so in the next few pages and slides what i'll do is i'll
just go through exhaustively what you would do um so you need to know this back to front
there's no room for error each optimization step should be drilled into your memory
and part of your medical reflexes so let's go through this and see if you've got all the steps
um you want to be aware of these techniques as i mentioned know how it fits into the difficult
airway algorithm and then to be able to drill and repeat these techniques from the start
so this is the das guidelines which pretty much says laryngoscopy optimize that lma optimize that
and revert to face mass oxygen oxygenation optimize that and then an lma and if all of
those fail then you're looking at a surgical airway let's get to it practically we'll do
a step-by-step method practice these techniques electively for every theater session when you're
training do these as drills so you've got the insight to you know do them when it really matters
for endotracheal intubation i always think of apb call for assistance earlier because you're junior
and most of you when you start out won't be doing this alone have a good position of the patient and
ensure paralysis so apb finally i do burp boujee and blade i rehearse this time and time again
i make sure my nurses know this as well i say burp first because backwards upwards right break
pressure only requires your hands so you don't have to get any extra equipment and it's just so
effective boozy's in the theater but needs to be taken you know opened out of the packet so that's
the second thing i would request and then failing that or at the same time i would ask a theater
tech or another nurse to get me the video lingerie scope or a different blade if that was available
those are the things i drill every single time and i want you to know that that's an exhaustive list
of all the techniques you need to know finally for the advanced techniques later on in your training
intubation intubating lmas fiber optics and some other advanced techniques which i won't go through
so that's everything you need to drill for endotracheal intubation bar none okay bag
mask drills again do this time and time again the advanced steps are literally just these few things
jaw thrust inserting a goodell using two hands and getting your assistant to ventilate
that's about as much as any consultant and these this knows how to do and the only difference
between me and you will be the fact that i've done it a thousand times and you will eventually get
there as well you might as well drill that from the start to know how to use each of these steps
after your first couple of weeks ask to do these extra steps lma drills is a bit more brief but
essentially jaw thrust rotation of the lma use a smaller lma a larger lma or a different lma and
just carefully use more force to proceed down if the lma isn't bentling you can mic do micro
adjustments of it give more prop full or give more muscle relaxing so quick summary you've now got
the advanced drills to practice in your rotation for all three techniques and you know how to if
you predict difficulty you'll be far more likely to use those extra techniques and optimize the
patient like we mentioned before these will and must become your innate airway management reflexes
and now like here are some of the things that you know practically speaking you can actually
drill so why not use the advanced bag mask technique every time for a week so gidell two
hands jaw thrust assistant ventilating every single time for a week you use that technique
maybe hold a mask as the airway for a few short cases so all you're doing is just holding the mask
and that's great but then your consultant can do the um the notes and the emr if that's if that's
relevant um but what you do then is you really get this you know the muscle memory in your hands
um you find you learn all about micro adjustments of the of the bag mask technique um as well as
just getting that um you know fatigue resistance in your hands as well it's painful but it's really
good for you uh maybe use a bougie electively if you never use one just ask to use one and use that
every single time for a week or maybe you've got really good at using a bougie why not use
a bougie with an artificial grade 3 airway what i mean by that is you get your best view let's say
it's a great one with the laryngoscope then i drop the view and make it worse for me intentionally
and then i now can only see the epiglottis and then i put a boozy under if you do that
a hundred times when you actually have a proper grade review it will be second nature that you
know that you've got this so practice what's hard while it's still easy electively this is
something i do with a lot of things by the way um so again use a video learning scope use it with
a d blade with a stiletto or bougie maybe try an inhalation induction using ilma or intubating lma
and you know this other technique is use use a 14 gauge cannula uh you know for iv access electively
do what's hard while it's easy because when the time comes and you actually need to do a 14 gauge
for a massive transfusion you'll already have done it electively a few times
obviously use your judgment to you know talk to your consultant
depending on your level of expertise and how comfortable you are with the basics
that's how i'd approach this get the basics right first and then quickly advance don't get
bogged down with just perfecting the basics if you're already pretty good at them you