Drs. Casey Patrick & Al Lulla: Surgical Cricothyrotomy in EMS (4/11/25)

So we are, by the way, we're on LinkedIn Live. This will go on YouTube. So welcome everybody. It is April 11, 2025. This is the Florida EMS webinar, where for the past probably four years, maybe five years, we've been doing weekly webinars. We bring the best and the brightest onto this webinar with bleeding edge EMS topics and today is a very popular one because it's something that we don't really do and seek frequently. We have a very close friend of the pod here, Dr. Casey Patrick, who's been on this webinar multiple times. I just saw somebody who said, oh, Casey is amazing. We've ripped off a lot of things from them in the past. And that is certainly true. Al, welcome as well to the webinar. So I'm going to pass it over to you guys if you want to make any further introductions. But we're excited to hear the topic and the paper. So guys, take it away.

Thank you, Peter. When y' all reached out to me regarding this paper, I was really excited to talk about it just because from a core medical direction standpoint, looking at our surgical airways over a 10 year time period, this wasn't a lot of fancy stats. It wasn't big numbers. There wasn't R or Stata or other things involved here. This really was the sickest of sick patients that we had in Montgomery county north of Houston. For those of you who don't know, I am the medical director for MCHD EMS north of Houston. And we looked at 10 years worth of surgical airways. Now the catch was during this time period, I was transitioning into the medical director role from Rob Dixon, who's since retired and is probably riding his bike somewhere beautiful right now. And I was lucky. I was lucky enough to have some amazing help from Al Lula. And so I will let Al introduce himself. Al dug into this data. We worked on this together, but we could have never gotten it done without Al.

Yeah. Thanks, Casey. So, you know, not a lot of data out there about how we perform surgical airways in ground based EMS systems. A lot of the data that we.

Looked at as part of our literature.

Review, a lot of it was in sort of dealt with more critical care transport type scenarios and some really high functioning systems. And so we wanted to see sort of in this ground based service what we were doing with surgical airway. Again, you know, we say that it's a halo procedure, right? So high acuity, low occurrence, requires a lot of really extensive training. Quality, quality assurance, quality improvement, which Casey and his team really did a great job of. And we sort of wanted to dive into the data over that 10 year period.

You know, as expected. You know, I guess I'll start with the limitations. With a study like this, we're not going to have huge sample sizes. In fact, I would say if we had huge sample sizes, I would be a little concerned about, you know, how many surgical airways we're doing. So I actually thought, I was actually pleased that we didn't have to do as many surgical airways, which is also, I think a testament to improved sort of primary airway management skills.

Right.

You know, this is sort of a backup, sort of a secondary thing. And with the improvement in supraglottic devices and intubation skills and video and all that other stuff, you know, I suspect that people are doing this less. But we ended up having 31 patients. And again, I'm just, I just got the abstract pulled up. We can dive a little bit into the data.

And we found that 42%, so 13 patients, it happened in trauma while 18 patients were medical calls. One of the things that we were really interested in wanting to look at is how long is it taking folks to do this procedure. We do not want to put folks in a place where we're doing multiple intubation attempts and then we're kind of at the end of the road and that's when we decide to do a surgical airway. And what we found is, is that sometimes people ended up having to do one or two attempts. I suspect this is changing and we've moved more towards like, you know, drop an eye gel if you can't, if you can't ventilate them, you know, move quickly to, to, to surgical airway as opposed to doing multiple sort of intubation attempts.

So that's sort of the kind of data that we looked at. We also kind of looked at, you know, the indications why people had required this. A lot of times it was related to trauma, foreign body obstructions, sort of the run of the mill things that you would, that you would expect. And you know, we'll go to our table one here just to sort of give you a sense of the data. Overall, we used end tidal CO2 as a marker of success. And what we found in this study is that we were 94% of the time we were successful. So 29 out of 31 subjects in the study had confirmed end tidal CO2, which I think speaks to the, speaks to how well we can train these folks and how successful we can be doing this, doing this procedure. And people should be empowered, doing it in the right scenarios for the right patient. Casey, I'm going to let you chime in. I just tried to give sort of the bird's eye view of what we did.

Yeah, you know, there was when we decided to pull this, I don't know that we knew what the answer was going to be. So finding out first and foremost that we had positive end title in a high, high number of these cases from just medical director standpoint was it blew me away. I don't think I would have said it would have been 29 out of 31. I would have probably gone a tad lower. So that is number one, probably the most relieving and encouraging part of the study. I will say, just for, you know, those, those y' all who are listening and haven't read this or watching. We use and have taught scalpel, finger bougie technique and MCHD throughout this period. This wasn't a kit or a complicated tracheal hook situation. This is a scalpel, your finger and a bougie with a 6, 0 tube and end tidal waveform. And we taught waveform capnography for confirmation, just like we would for, you know, a standard or a tracheal endotracheal situation. So what Al did was dig through those charts and look for evidence of positive waveform and those were successful. The ones that had no waveform capnography were not. Lots of questions have been asked us after the fact about survival rates and hospital outcomes and, you know, some of the things that we would all want to know. If we lived in a perfect world, we did not have, especially over a 10 year time period, we did not have access to that. So we can't really speak to morbidity and mortality per se. More towards just, can paramedics be trained to put the endotracheal tube through the cricothyroid membrane into the airway in the field in these, you know, high risk, low frequency situations. And our answer to that question is yes. The other elephant in the room is, you know, timing of this and was this the right time? Were we too slow? Were we too quick? And as we all know, that question is really difficult to answer and it takes a case by case assessment really to get there. So we didn't precisely try to answer that question as well, because that's something that, you know, as we all do, everyone on this call that's got an adjacent or direct medical direction role. If you have a surgical airway in your service, you're talking about that a few minutes afterwards most of the time, and then for the next several days in a row trying to figure out whether or not this was good, bad, ugly, or all the above. And most of the time, honestly, when we get to that surgical airway situation, it usually is some combination of those things. But to know that we can train and we can accurately hit our mark and you know, to get some idea of who these players are going to be, because the other piece to Al's point on these were the, to us, these were the patients that we would have expected to get surgical airways trismas, foreign body obstruction, massive facial trauma. I believe if you had given me a multiple choice beforehand, I would have picked those as the top three. And so really that allows us to teach that even more firmly as far as, hey, if you see massive facial trauma, if you have trismus that you can't overcome, if you have.

Massive facial trauma, choking on a big piece of steak that you can't remove, those are the situations we're going to have to go maybe from crike plan C up to plan B or plan A Without those 6, 7 intubation attempts that I was discussing.

Yeah, and the other thing I just want to add on to this, a lot of these patients were in cardiac arrest. I think that just goes to show sort of the acuity that you're dealing with with a lot of these patients that are, that are requiring surgical airway. So, you know, I don't think we really anticipated folks necessarily were going to have great outcomes in terms of neuro intact survival. But yeah, I think our study had upwards of 84% of the patients were in cardiac arrest, whether from trauma or medical. Some of the other data that we looked at when we were writing this paper showed that, you know, other studies have quoted upwards of 60, 70% depending on the study. So, you know, again, with small sample.

Sizes, I don't know how much stock.

We can put into that, but it's just something that I thought was, was interesting.

Excellent. Casey or Al, would you mind discussing the type of training, not exactly how you do it, but the frequency and the cadence by which you guys are doing this training?

Yeah, I can speak to that one. And that one is it's a lift every year and it's evolved over the 10 years. It hasn't been exactly the same over the 10 had.

We've had some, some pig labs in the distant past. We've moved away from those to cadaver labs. We also have.

You know, tissue trainers, necks that we use. But everyone who does Surgical crike. Who's credentialed for surgical crike in the service? And this is not all of our providers, this is not all paramedics. This is our in charge subset and above. So out of our 350, this is probably somewhere about a third of those or less. So it's, it's at least a less unwieldy number. And they're required to undergo for high frequency, or, excuse me, low frequency high risk skills training every year. So we.

The goal, and I can't say, you know, with, with supply chain and Covid and everything that's happened over the last five to ten years in there. We aim for cadaver training yearly on this with augmented model training in the, in the interim.

That's amazing.

We've not been perfect there, but we're pretty close.

Other question I have, and this relates to a friend of mine who called me up last year and said that as soon as they did the training, the number of surgical crikes spiked. And I wonder if you saw that same, that same effect.

Honestly, Surgical airway has been in the service longer than me. I started at MCHD in 2015 and our data here stretches back to 2012. So historically, I don't know the exact timing as far as introduction of surgical airway into the service. It's just been there since I've been there. Our frequency over.

My tenure there has been relatively stable. We average about three a year. And with our intubation attempts numbering between 300 and 400, that puts us right in that 1% range, which is where the NEAR database would suggest. We have to crack people in the ed so we feel like it's pretty reasonable. And like I said before, all of these get a microscope in real time and then some sort of. Have some of these been questionable? Absolutely. It's ems, it's medical direction. These are tough decisions. Have some of these required lots of discussion and could you have done it sooner? In the ones that I've reviewed during our time. That's been a question. Were you late on this? That's been a question. So the exact timing and the exact details are always murky at best.

I want to get Dr. Lee in, but my other question as a follow up is have you ever received like massive pushback from the ED when you get there, second guessing you doing, you know, evaluations afterwards, getting you into meetings, second guessing any of these calls, or have they all been pretty straightforward?

I mean, I don't want to say all of them have been straightforward. I think anytime we Bring in a surgical airway to the ed. It raises their, you know, level of concern, their level of. Oh, really? I will say that we have great relationships with the. We have three level two trauma centers in the county. We have great relationships with all three of those. So the hospital feedback side of it is very open and a two way street. Thankfully we also have really good relationships with the medical examiner for confirmation, you know, on the unfortunate ones that end up in an autopsy situation. So I, I don't remember any massive dust ups in the time that I've been here. I can't say that I reviewed every single one of these. Some of these ended up with, with Dr. Dixon during that time period. And then some of these are pre. Both of us. So I, I imagine that there were some that had questions, there's no doubt about that. But as far as massive. No, not that I recall.

Excellent. Let me bring in Dr. Wayne Lee. Dr. Lee, how are you? Come on and ask a question, please.

Hey, good morning. Good morning. I'm not sure that my thoughts are any order or that they're particularly useful. However, it's kind of interesting looking. I see there are 39 people on this and, and you know, we'll see your calls, Peter, where we'll have this bigger number. But I think it sort of validates how, how interested we all are in this particular item now. You know, I've been a medical director for a long time. I used to have seven fire rescue systems and I wasn't, you know, and so each one of those we might have a crike attempt. And this is in the early days, we might have a crike attempt every one or two years. And, and, but the advantage of having seven cities was that I saw seven crike attempts in a year. You know, and I realized that first of all, the problem we, one of the problems we had is that our, our crag kit was actually the blade in the OB kit. And so we had to go open up the kit. And this goes way back, you know, so I'll try not to. But at any rate. And so then I began to think about equipment, etc. And make it easy, etc. I do like this simple technique. I always have liked a tray cook, but I do think that a blade and a finger, etc. The thing that. And I used to do a pig lab also with my medics. And when I did it, it was just when I was, you know, when the bougie was coming back around. You know, the bougie had been in place years ago. And then we stopped using it, and then it showed up as a flex.

Guide and in the airway course and.

So on and so forth. And so everybody began to have a bougie. But when I did the pig lab, I realized, watching people, that they couldn't get the tube in, you know, and only then did I begin to teach the bougie is the trick. And so I believe very strongly about having a bougie readily available. And so you can almost go and have lunch once you get the bougie in, you know. And by the way, and the reason I'm talking about this is I had a case, a kid with a hot dog. And we actually, unfortunately, we got to see the autopsy on this child, and the incision was made correctly. It was perfect. The problem was we couldn't get the tube in, you know, and that was because of. Probably because of no Trey Cook, but it's certainly because of no bougie. And had we had the bougie, I'm convinced we would have gotten the trachean. So can't underestimate the bougie. The other thing is training, and I think training, and I think we all struggle with this. But, you know, I tried, and I have to say, I don't think I'm particularly successful, but I tried. I don't believe that these critical procedures. I think if we could do it once a year, that might be okay. But the fact of the matter is this stuff, you know, it gets forgotten very quickly. So one of the things I tried to do is not to have it. Not to have it be a training program where there was a big drum roll, and we had it, you know, once a year, but that the battalion chiefs do it on a local basis, on a more frequent basis, every three or four months. Now, I will say that hasn't been entirely successful. But at the same point, my. At the same time, my point is that you can quite easily train this by grabbing another paramedic and laying them on the table and making sure. And they need to know where to do and how to do it. Number one, they need to know what equipment that they have to do it with. They're very familiar with that. And they also need to know when to do it, which you've touched on already. And one of the cases I did a lot of expert work for, mostly defense, but I ended up doing a lot and EMS also. But one of the cases I had was actually an ER case, and it was an angioedema patient. And the doc, they tried multiple times to Intubate, they waited too long. The patient was hypoxic the whole time. And finally they decided to do a crike, and it wasn't successful. They didn't have a bougie. It was just a disaster, you know, but the, you know, you can't intubate, you can't ventilate. It's not about intubation, it's about ventilation. But once you come to that point, you don't have. It doesn't take very long to decide that it's time to go, you know, so it's really about. And so once you can't do that, you got to head for something else. And then lastly, I think.

Oh, but I just want to emphasize the training, I think. And one of the things, I don't.

Think we're fair to the paramedics. So all of my lieutenants, you know, could be faced with having to make this decision. I don't think it's fair to them to ever ask them to make this decision unless they have a high level of confidence that they can do this. And I think that the high level of confidence, it's intimidating. They might be able to do it just fine, but if they don't have the confidence, they can do it. And we can only get to that confidence level by.

Going over and over and over again with them. And so what I want to happen when I go to my stations and I say, by the way, show me how to do a crike. That there is not a blink of the eye. You know, okay, here's the indication. Here's the equipment we have, and this is how I'm going to do it. And I can lay somebody down on the table and demonstrate that. Enough said. But anyway, I really appreciate what you guys have done. I love this topic.

Great conversation. Go ahead, Casey.

I got two quick things on that. We found the same thing. So we created this very simple kit that has the scalpel and the six zero. And the bougie is already in the airway kit, but there is a red bag that's separate from everything else that's in the airway bag that has those tools. So they're not digging in, in the OB kit or wherever else the scalpel may be. I don't remember when that happened in the. In the time span of this study, but that exists now. And as far as mental reps, we preach that. I preach that you're not going to get enough physical reps on this to be good at it. You have to do, you know, every couple weeks, every Month mental reps. And that's indications, contraindications, equipment needed, and then where do your hands go? And practicing on a partner or practicing on a mannequin, whichever one. Any of those stepwise processes that you take are going to be better than not doing it at all. Is that as good as doing it on a human? Obviously, no. But I do that, you know, regularly for my own emergency department practice, because I don't. It's not like I'm out there doing a ton of these. So we really preach the value of mental reps and walking through it with your partner and talking through it. Not just, oh, I probably should think about strikes, but being intentional and talking through it as if you were, you know, managing one on the scene. So agree 100% on all those points.

Excellent. And I want. I want to go now to Jonathan and Tanner and come to you next. Just. Just so you. FYI. But Jonathan is a great friend. He's been on the podcast several times. He runs a large system and south metro out in Denver. Jonathan, Dr. Efelbaum, go ahead and love to hear your question.

I was so excited to see this pop up as the topic.

So I'm the person with the. The agency that we had a spike in our number of crikes when we moved our program for training to be more aggressive with cadavers and such. But I had a handful of questions for you with your algorithm for your medics. Do you give them the leeway to go straight to crike when they're okay? Because that was something which we had incorporated as well. And we'd gotten some feedback or. Or concern from the receiving facilities, like, well, they didn't even try. I was like, there's no point. Just. You were looking, just looking at doing that side of the question there. Did you happen to. Or were you able to record in the study.

The number of failed airways patients who couldn't be intubated? Maybe it wasn't one of your senior medics. They weren't correct in the field and were transported with a suboptimal airway.

I can't imagine that number is a number that I would be warm and fuzzy to take a look at, but. No, but we know those are there.

Yeah.

For sure. Yeah.

Because that was one thing. Which, because as our program moved forward, we took a lot of flack, a lot of feedback that was unconstructive. And so that was my comparison of, okay, well, where are we at in terms of airways that have not. So I was curious if you had that and then last in your group, did you have any survivors?

We looked at just EMS data. We didn't have hospital access so I hope we did. But I mean there was a large proportion that was in cardiac arrest. The other one of the larger EMS studies that's there was Marcolini and that was early 2000s and they had two of 61.

With neuro intact survival. So I would suspect that number would be low. That's what the small but existing literature tells us.

Yeah, no, I was just curious.

Yeah, we just had EMS data and we just pulled those who got, who had surgical airway documented in the EMS chart. So as far as the Mrs. No, we didn't dig there. That'd be an excellent question to ask. And as far as survivors, we had EMS data only.

Fantastic. Well, thanks so much for doing this. I really appreciate it.

Al, did you want to make a comment before I go to David?

Well, I just wanted to say, you.

Know, in addition to the, and I think folks have sort of touched upon this in addition to the psychomotor or the motor aspect of doing this procedure, it's sort of the cognitive aspect of it I think is an integral part of training is empowering paramedics to feel like hey, you know, you can, we need to make a decision and we need to make that decision early and also not making them feel like there's some sort of Monday morning quarterbacking, retribution, anything like that. I've, I've had paramedics who have performed a surgical airway and definitely were questioned by it. And you know, I think we've all been in that situation where somebody else has questioned what our decision was in a, in a, in a heated moment. And I think it's good for us in medical direction to support our medics through those challenging types of scenarios.

100%. And I'm going to bring in David Miramantes, runs a very small fire department in San Antonio.

I'll teasing aside. But David, you put some links in the chat and love to hear your comment. Go ahead.

So if you can't intubate and you can't ventilate, you creculate. It's that simple. And we do the body lab every year for our guys and we have been here 10 years.

So it is a rare thing in our system. So we do about 600 calls a day and we do one a month.

Ish.

It's pretty rare.

Believe it or not, a lot of times we do it is not trump. It's at the jail because they have the massive sympathomimetic ingestion from a balloon or whatever. And they get Christmas. So we see that many times at the jail, actually. So that's my thing. We use the device I put in the chat. So it's a bougie with the tube and then it has wings that you can use sterile towel clips to clip onto the neck. So that's the best way to do it. We're not using the clips yet, but we're fixing to. But that, that's a good little device and it's only 19 bucks. It's not expensive, so all they need is a scalpel in that.

I'm a, I'm a really big fan of assessing a patient who's at who you think is going to need to potentially be a difficult CoCV type of situation and doing a quick attempt at a super. At a superglottic device. I mean, they're very quick.

You know, you're not in the airway.

For significant amount of time. You're not having significant worsening hypoxia. And I've had cases where we've had patients who had horrible angioedema. And you know, the medics just put.

In an eye gel and they were actually able to ventilate this patient, surprisingly.

And then if you can't, you pull it out and then you go to crike. I'm not a huge fan personally of doing a lot of intubation beforehand.

Excellent. Great comment. So I'm gonna, I'm gonna go now next to my co host Tanner Smita, who I'm sure is chomping at the bit with all this research that I'm sure you have a lot of thoughts in your mind about these types of procedures and the research behind it. So, Tanner, take it away.

Yes, thank you both for, for coming on to present. I have a couple questions for you. I'll give you them all at once so you can comment on whichever ones you want, if any. So first of all, I noticed that if I'm interpreting the chart correctly, the number one indication for Craig in a study was trismus. And so I was wondering, was this before the introduction of paralytic assisted innovation to the system or was this trismus that was unrelieved by paralytic administration? So that's my first one. My second comment, I really like that you reported the time to procedure stratified by whether inhibition was attempted first versus not. And there was almost a 15 minute difference between those two groups of patients, which suggests, you know, 15 minutes of perhaps suboptimal ventilation or perhaps no ventilation at all, which I think we can all assume could have a profound impact on patient outcomes. And so kind of springboarding off that I was wondering, is there any kind of rule that you've presented to your providers that is there a certain number of attempts after which they should proceed to crake if the supraglottic airway fails, or a number of minutes from, from the time of initiation of the first endotracheal inhibition attempt? And then finally, so this is my third question more related to the system in which, in which I practice and do research. And so in West Virginia recently, surgical airways were introduced into the scope of practice of ground paramedics. And so along with that comes the problem of how do we train these people, particularly given the fact that West Virginia encompasses a lot of rural EMS systems that are poorly resourced. They don't have access to cadaver labs or animal labs. So I was wondering, you know, in your practice, and I guess this is an open question to everybody on the call in terms of trainers that are available commercially and are there some 3D printed trainers out there? Are there any that are, you know, cost effective, inexpensive, that we can use to train these rural agencies that just simply don't have access to cadaver labs and, and more kind of advanced training?

I'll take the third one. It just popped up in the chat. There's a link to a relatively inexpensive trainer that's there we use, we have some 3D printed traits that we have wrapped with, you know, coban and, and the like and used for mental reps. You know, I can't really say that.

That, you know, I know what it would be like to manage a service with no access to cadaver labs and then how you balance that risk benefit as far as do you think that training sufficient or not? I don't have the answer to that one. I think that's going to be an individual medical director feel based on, you know, how, how well you think you can do using non cadaver, less expensive methods and whether or not you, you know, cost share or tag team on somebody else coattail ride, whatever, you know, whatever you may need to do. That's, that's a decision that thankfully I'm lucky I have a supportive board and you know, that values training in the clinical side of this. So I'm thankful that I can answer that. As far as the paralytic question, I wish you had been a reviewer because I don't know that we got asked that. I'll, I'LL kick that one to Al. I know that we've had paralytic, paralytic assisted intubations in the service through the duration of the study. I can say yes to that one. As far as these cases individually and whether or not those got paralytics or not in the relationship to Trismas, that's a really good question that actually we probably should know the answer to, and I don't, so I'll just own that one. And then lastly, as far as putting exact time rails and time borders around this or attempt borders that always gets kicked around when you review these cases, should we be more direct, should we clarify more? And I just believe that each one of these situations, when you're talking about two or three a year in our service, we have about 100,000 calls a year respond to about.

70,000 plus or minus. So I believe they're individual situations. I think that if you try to say only after two attempts, you're going to find that one that needed it after zero, if you say, you know, 10 minutes, you're going to find the one that the medic knew in four and is going to be standing there for six minutes waiting to clear your, your time hurdle. I, I believe this is such a complicated decision that, that, that those guardrails are going to limit you more than they're going to help you. There are others on this call that could absolutely have the other opinion and be totally valid. That's just, that's just my own personal opinion there. So, Al, paralytics, do you remember? Yeah, it's a good question.

So there, there were definitely a handful.

Of cases where, especially for Trismans, that paralytics were, were used. I think, as everybody on this call knows, paralytics are high risk, high reward. Right. I mean, if you, if you paralyze this person and now, you know, you're not able to secure the airway, you know, you're basically guaranteeing yourself a crike at that point. So, you know, I think some folks are just a little bit more hesitant in these sort of potential COCV situations to paralyze. But for situations like Trismas, we definitely had multiple cases where the medics did utilize paralytics or, you know, Rob Dixon was on scene and, you know, he assisted the paramedics with that portion of it. And that brings another component to this is sort of, you know, what is our involvement with this procedure, you know, in EMS medical direction in the field when it actually happens. So just more fodder for discussion, I guess.

And There definitely was honestly evolution of our system over this time. We currently teach first look, best look and are very pro paralytic assisted intubation. If we're going to look with a video laryngoscope, some of the, you know, the preliminary data from MedStar and you know, the ED data suggests you know, sedation only intubation is, is fraught with problems. So we don't teach that. So most of our crites now I would say would have probably received paralytics if they were going to be intubated. So we are first look, best look, you know, service with, with, with rock uranium that the other side of this is there was about half of this study period that the paralytic would have been succinylcholine. So from a length of action standpoint when you start to get into some of these times that we had to cry, they may have gotten sucks up front and then cracked with Christmas and the sucks had worn off. So there's a lot of complexity there that could exist. This wasn't, you know, this was a 10 year time with the service that evolved.

So and Casey and Al question I have is now that many of us have vl that's, that's recorded and you know, we are now reviewing all of these. Are you able to discern anything further from these cases now that you have the recordable vl if that's indeed what you're doing?

I hope so. We have record recordable VL that rolled out at MCHD 31 days ago, March 10th. So we've not had a crike, we've not had a crack yet. But we're reviewing 100 of our airways now. It's 100% feedback. So I can't help but think that when we see what, what's in the airway with the VL attempt that we're not going to have at least something more to speak to in that run review. You know, and I will. I want to mention something that Al said that I'm not pushing back on you Al, but I will say that, you know, we do want to support our medics but there is that fine line that we have to walk in these situations where you know that some of that feedback may be next time. You know, let's look at this data, let's look at this timing and could we have pulled the trigger sooner? Did we pull it too late? That's such a tough space to be in when it's such an emotionally charged decision. And no, the medics do not want to get beat up. And I'm the last one that wants to beat them up. But we have had a couple of these in the service. I do remember, you know, more than one where there was, there were learning points and there were spots to improve. So that has to be timing. There has to be relationships built. You can't, you can't not know your medics and walk in and start talking about the crike intricacies and timing and then not be crushed if they don't know you're coming from a place of trust. So that, that's a really, that's a tough piece. I think it's worth mentioning.

Yeah, this, this turned out to be a masterclass here because we're getting a lot of great kind of discussion after, after the paper was discussed. So we're going to head over to Dr. Pepe's webinar. But let me give you guys the last word. Both Al and Casey, you know, you have a lot of people in this webinar. Thousands will listen to it afterwards. What would you tell that agency who doesn't have the resources like Tana was mentioning or hasn't done training in a while? What would be your final words to them here as we head over to Dr. Pepe's webinar? Casey, you want to go first and then Al? Sure.

I would just say you have to dedicate time to teach the why, not just the how, because the why is infinitely more difficult than the how. And you have to make sure that, you know, that the medics know that you have their back and that everybody's on board with this being, you know, one of the more high intensity, difficult, big ticket decisions that we make in all of emergency medicine. So I believe the why here, and I think our paper shows this is we know that we can put the tube in the right place. The bigger question, and some of these questions after the fact, you know, really hammer home that putting the tube through the neck we can do. How do we do it properly with the correct timing is still ripe for, for discussion and further research. And so I would just say make sure we focus on the why as much as the how.

Love it. It's all about relationships with your medics. And I love, I love that comment. Thank you, Casey. L take, Take us away.

Yeah, I mean, don't have much else to add, but, but I'll just say in addition to the why is the when. And we have to understand that our medics are in challenging situations with a lot of cognitive stressors. You know, we've all heard the old adage, the hardest part about doing the crike is making the decision to, to do the crike. And so I think that's an important part of, of their training. And, you know, what we know from just general airway data is that multiple intubation attempts leads to worse outcomes. So I think if you're in a high functioning system and you have some good tools like VL and good airway training, I'm not going to frown upon anybody wanting to attempt to intubate somebody. But if it doesn't work, I think we have to get the ball rolling quickly and make that cognitive jump to the next step. I think that's the piece that oftentimes is missed.

Beautifully said. This was fantastic discussion. As Brett just commented in the chat. Thank you both. Thanks for contributing to the literature as you always have done, and for spreading the knowledge by coming onto the webinar. I appreciate you guys in the link in the chat. On the side is the link to Dr. Pepe's webinar, who's sitting right across the room from me here at FDIC in Indianapolis. Thank you guys so much. And Casey and Al, you guys are always welcome back on our podcast anytime, and we appreciate you guys. Thank you.

Thanks for having us. We appreciate y'.

All. All right.

All right, bye, everybody.