Allen Kennedy: Surgical Airway Training in EMS (5/2/25)

Let's get started. So welcome Everybody. It is May 2nd. It's another Friday. And we're very honored today to have an amazing guest. We're kind of continuing the theme here of surgical airway. And interestingly, after the last webinar, I actually bought that little crike a lot tool and maybe Alan will talk about that today. But something very interesting for all of us as we start to consider how we train our folks on certain procedures that are high acuity and low currents. So today we have someone that I met at namsp. He's out of the Denver metro area. He's a paramedic, he's a trainer.

And Alan, I'll have you do a further introduction of yourself. But when I heard this topic when we spoke, I said, hey, you got to come on the webinar. And we're excited to hear what you have. You have in front of you a group of EMS professionals, leaders, medical directors from all over the country. We have people from the state of Florida Department of Health on I see today. So you have a great audience and we have a big audience on LinkedIn and YouTube. So my friend, thank you so much for coming on and take it away.

Dr. Antebe, thank you for having me on here. My name is Alan Kennedy. Like Dr. Entebbe was saying, paramedic added in for metro area. I've been lucky to work on or work on several government contracts. I bounce overseas from time to time either in a training capacity or a clinical capacity. So I've been able to work with different pre hospital audiences. And through all that, I've kind of found this is what works for us. It's not saying this is the way. This is just the way that I have found that has good repeat success from people I see maybe once a year or anything like that. It's not meant as a train. The trainer is not meant as a hey, this is how you should crike. This is just like I said, this is what the path is that I have found that works decently well or works really well with the audiences that I'm a part of. I do have one disclosure, the wearable moulage. I work with a guy that makes it but as an end user I love it. And that's kind of what's helped me with the cris that I've had for sniff test. I've had two solo and then two assisted and then in reference to Dr. Patrick and Dr. Lula's, one was Trismas and one was severe trauma to the face. So I Kind of line up anecdotally with what they were saying for their system also, but moving forward as my computer's yelling at me, okay, so this is pretty much how we frame stuff or iframe things with the training. It's based off the stress exposure training model by Driscoll and Johnston and it's pretty much broken down into three phases. Information skill acquisition and then application and practice walk which is phase two, the skill acquisition size. The most important part and what I have found is doing dry marker drills or if you're someone that is into firearms like dry fire drills. That's where the biggest bang for the buck for me has been because it's people developing that muscle memory enveloping the skill from there. And if you get more complex patients, you have a framework to start from versus just looking at them going oh my God and you don't want any part of this whatsoever. If you're a training nerd like I am, you got two papers listed below. One is by John McCarthy, Andy Fisher and Mike or yeah, Mike Lauria. And it does a great job discussing stress exposure training, cognitive load theory, deliberate practice concepts and sim zones. And then another one is by, I think it's colonel Mueller. Mueller. And it was from a study they did RCT where it's pretty much breaking down.

Choose your own adventure versus a very structured didactic anatomy. And then hands on skills where it's very step focused of scalpel, finger bougie and the rel. How their success was with that training method for this as you. Oh, going back one, like I was saying for the crawl phase, psychology, anatomy, equipment, technique, explanation, what you can expect of the patient. It's like the gurgle, gurgle, stuff like that. And then what does write look like? What does that demo look like for your audience Moving into that. That's where like I was saying this phase two is the most important part. What does write look like? And then you start working through hands on drills. If you have large classes, this works great because you're getting your hands on maybe 10, 20 different sets of anatomy for free. And that's a really easy low cost thing with just expo markers and then models, whatever it's 3D larynxes, moulage, wherever the case may be and then from there scenarios and then that's the case where it might be a distressed patient but you're never looking for like the end of the world scenario and oh man, we got them good. You want building success from a no stress environment to one little stress or Two little stressors. And if they're accommodating to that, then you can add to it. If not, hey, just hang out right there for that person.

Moving on to psychology. This is one of those things that everyone talks about. I think this is where it's also very important. Probably one of the most important parts of it, as discussed last time with the recent part or the recent webinar with that first is that mindset. Removing the negative language. Replace it with having a plan. Because if you're saying I hope I never have to do this, you're already going into it kind of self defeated versus okay, if I ever come to this place, I have a plan or at least a place to start with it transitioning to that. Like what my plan is and the way my system works. It's intubation. I gel crike. Not saying I'm looking to go crike someone. I have that as part of my decision tree in case it comes to that point either immediately like it was discussed previously or if it's something that works to that direction for this Good opportunities for building that tactile feedback. If you're on airway for a cardiac arrest, when you're doing that pre ops period and you get your equipment out, hey, take a second feel that person's neck. Probably not going to happen, but you at least got an idea of what the landscape is moving forward with that patient if it does come to that. Same thing for anaphylactic patients like severe anaphylaxis or anything like that. It's hey, after you do all the appropriate treatments or anything you need to do, hey, also feel their neck have an idea what that landscape's looking like. So if you do end up in that position is not you reacting to something is more of a response. Next tactile skill. This is one of those things that I heard and I understood the words being said, but I didn't understand what they meant. And the last one that I had is actually ejection inside the road, middle of the night. And that's where it clicked for me where it's a tactile skill and not a visual skill because it's going to be bloody and all this other stuff. And at the end of the day it's kind of like where you're feeling IVs blind, where it's not. You're just looking for the vein, you're feeling for the landmarks and the anatomy that you need to make that procedure happen. And then finally stole this from Scotty Bollard or Don't convince yourself, give yourself permission to work. The easiest way I equate this for pre hospital is the first time you see SVT and you know you should give adenosine but you're kind of convincing yourself are they good to make it the hospital? Go ahead and do it. And as you move forward in your career is like, okay, cool, got svt. Here's my plan how we're working through this.

Tanner, I apologize for this slide is kind of a muddle of two different papers, but everyone has their anatomy slides. This is the one that I feel like is kind of lacking and it also helps prepare someone for that procedure as well. So what you're looking at, got the CTM circled in the red right here. And then from these two papers by Nutbeam and Kukulu, I think the mean neutral male CTM height is approximately 7.21 to 7.88 millimeters. For context of this, the usual ET tubes that we use are 6, 0, which means it's an 80 diameter on the outside. For women, the mean neutral female ctm height is 6 to 6. I mean sorry, 6.41. And you got the different age groups broken up. These, the, this lower table for both, both come from the nut beam paper. The 7.21 to 7.88 is a combination of the findings from both papers. So again Tanner, sorry about that one is kind of a jumbled, but this is kind of how I capture it. But the important part also from Nutbeam's paper is the height of the CTMA increase approximately 20% with maximal head extension and maximal dilation and mobility of the cricothyroid joint. So if you want to play along, put your finger on your CTM and then neutral position and kind of put a little more pressure on than you usually would and then tilt your head back and you feel you get more real estate. So if you got some of these patients that might have a tight ctm, this is something where I'm advocate for going from the cartilaginous borders of the ctm because doing that you can buy yourself more real estate. And that's also I ran into the last one, last one I had was a 17 year old and that's one where I was able to be aware and talk myself through that. This is just a reference table for anyone that wants it. It's based off the curaplex ET tubes and it's just showing the outside diameter in comparison to internal diameters, length and some of the bougie sizes that are compatible. So it might be a case of, hey, your system discusses 5, 5 or 5, 0 tubes because of the anatomy differences that people see. If you're a bougie system, then what you have might not work. And that's the only reason why I have this here paper below that kind of analyzes 21 devices, the NARS stuff.