Jim Ducanto, MD: Pre-hospital Airway & SALAD (8/22/23)

Has really taken over the EMS world by storm. Most of us, if not all of us, use his catheter. He's taught us a salad technique, et cetera. And I wanted to ask him to come to the show today to talk about some airway publications. I love to continue talking about the best airway evidence that we have out there. So, Jim, without any further ado, thanks for joining us. Sorry for pulling out of what you were doing, but thanks so much.

Oh, heavens to Betsy, that's fine. Thanks for inviting me, Peter. I'm glad to be part of your podcast today.

So, yeah. So, Jim, so we have had a number of guests on talking about prehospital intubation airway. We obviously all use supraglottics and so forth. So I wanted to see if you could just. And again, if you don't have any specific papers to talk about, that's fine. But I know that you're always combing the literature. You're involved in a lot of this evidence. If you can give us your take on the most recent and best airway evidence out there or just kind of wax poetic on just you being you.

Well, just this morning I was looking over the literature as I was sitting at a breakfast counter, and I was surprised to find a few inclusions in the salad technique in chapters and books, more so than in papers. Although recently.

I have a few friends out there in EMS who are medical directors. One of them published a case report of the use of something called the CDuck, which I had a hand in creating in the aeromedical network. And basically what they reported was the utility of using a handheld portable suction device.

Is that me or is that you?

Sorry, Peter, can you hear me?

So the handheld suction device in this case made a substantial difference in the care of a patient who suffered a grand mal seizure in the presence of the EMS clinicians. As far as any further publications, I'm just sort of kind of sitting back here and I will occasionally just look at the citic, the papers that cite either my original simulation study in 2015 or in the summary article that I published with Chris Root and several other individuals back in 2020. I don't have any.

Jim. Yeah, so I think this would be good because there are some people on this call who maybe don't know what we're talking about, don't have an idea of your background. So I would love for you just to maybe give a quick background on yourself and then talk about. Talk about salad use in, you know, an airway that does not need any tube. Talk about salad with use of. With an eye gel or just salad in general, because I think that, you know, a lot of people are kind of transitioning over to that. So if you can give some history on that, that'd be good.

Oh, most certainly. So, guys, I'm Dr. Jim Decanto. I'm an anesthesiologist in Milwaukee, and I've always had an interest in education simulation. An innovation I came up with in early 2014, late 2013, was to. I've been hacking mannequins for many, many years. And the hack that I created in late 2013, early 2014, was actually to make the mannequin regurgitate. And I had made friends with the director of innovation for a suction company in Los Angeles called Score three or four years before that. And I invited them to a meeting to present alongside me in a workshop at the Society for airway management in 2010. And he coached me as to how to perform a good simulation of airway contamination. Quite literally, if you're going to demonstrate a clinical suction device, you have to create a clinical scenario of regurgitation. So my innovation was I created this simulation, and then I found a way to make it easy to set up and perform. I invited colleagues from ems, emergency medicine, critical care, and anesthesia into the fold. And at the University of Wisconsin and Madison Sim center, we had a few wonderful meetings where we kind of hammered out how to do the simulation and how to. What the techniques were to when the simulation. Because when you have a simulation where the mannequin is completely full of an airway contaminant, a simulated airway contaminant, I call it SAC.

In a younger generation might laugh at that word. But the simulated airway contaminant, there's a certain formula as to how to approach the fully, fully, fully, fully contaminated airway. And so what we developed was a cadence of approaching the airway with a suction in the right hand held upside down like, shaped like a laryngoscope to clear the airway and then use the suction itself as a tool to create space in the oropharynx and the hypopharynx by pushing and lifting like a laryngoscope to ease the insertion of a laryngoscope. A few years later, it came. It dawned on me, how can I make basic life support better with this technique? And it was a little bit difficult for me to do that because I'm an anesthesiologist, and either I put a supraglottic in patients, or I put a tracheal tube in them, or I give them sedation. I don't do EMS stuff.

And it dawned on me. If I put the suction in the left hand and have it like a laryngoscope, it would assist the insertion of the supraglottic airway because it goes in, it decontaminates. You push and you lift. And now the supraglottic, in the case of an eye gel or what have you, it just drops in all the way to the hypopharynx in one move. The obstacle to.

Optimal supraglottic use is you have to create the space at the base of tongue, lift the tongue and epiglottis off of the posterior pharyngeal wall to permit the device to slip along the posterior pharyngeal wall under the laryngeal complex and have the tip sit in the upper esophageal sphincter area. A simple jaw thrust doesn't do it very well in patients who have been given a general anesthetic. Oftentimes an anesthesiologist will actually have to put their fingers into the mouth of a patient in order to make the device seat. Well, that's not an option for you guys because oftentimes you're dealing with patients who haven't been giving an anesthetic. They just happen to be unconscious, and they still have reflexes and they will bite your finger. You're not going to put your fingers in somebody's mouth in the type of scenario that you work in. So what we need for supragonic insertion is we need a supragonic insertion tool. Now, you're allowed to use a laryngoscope in most places in the United States, as well as apparently the United Kingdom. In the London, paramedics are allowed to use laryngoscopes to place Igels. You're allowed to use a laryngoscope to do that. But as long as we're talking about using a rigid suction catheter to create oropharyngeal and hypopharyngeal space in essentially a decontamination and a push and a lift, it's the optimal way to place a supraglottic. Okay, next little chapter in airway decontamination with resuscitation is if I'm in a position where they say, all right, Dr. Jim, look, we don't have all this stuff. You're going to have to bag mask the patient with an oral airway and I'm going to do CPR in the 32 cycle.

With the knowledge that we do have regurgitation during CPR and I'm stuck at the head of the bed, I'm thinking to myself, well, you know, I could hold this mask over the patient's mouth while the CPR is going, but they're really kind of not getting anything unless you've got a high flow nasal cannula irrigating the nasopharynx with high flow oxygen. Why don't I, before I put in the positive pressure breath, actually put a suction catheter down alongside the oral airway. And it doesn't have to be a rigid suction catheter, but that's what you have it, that's what you use. Why don't I suction the airway before I face mask ventilate if we're going to do the 30 to 2 cycle? Hmm. Well, you know, are you going to wait to hear the gurgling to see that you're forcing aspiration? And I'm not saying that you have to do that every single cycle, but I think that we need to raise the concept in people's minds that if you're going to do BLS based cpr, we should be able to do airway decontamination before we put in the positive pressure breaths. Okay, so that's where I kind of want to stop talking for a moment, Peter, and let you kind of guide us through what it is that you think is important when it comes to this topic.

Well, I think that you hit on it early on, which is that we should be leading with suction.

Yeah.

It'S funny to hear that. I guess it's not really funny. I think, you know, look, among us, everybody here, whether you're a physician or not, you would love to make a positive impact on current and future medicine. For me to have done that with something that I consider pretty simple, well, I guess that that's a great good thing, especially since it's simple, because it means it's generally applicable to all levels of caregivers, from basic, from the first responders all the way to the top levels, to the physicians, all the way to the first responders. So what I'll have to say about salad is when I give seminars to EMS groups, the first thing I single out is I said, all right, who among you is an EMT Basic? Who among you are the lowest level providers in this group? They identify themselves and they look sort of like, sort of like, I don't know, they just sort of like have a dejected look on their face sometimes. They says, okay, we're going to focus on you first. Going to have you do this where first of all, we're going to have you do everything that everybody else is going to do. You're going to intubate these mannequins. What I want to do is I want to focus on you first because this is absolutely, completely essential. If you're asked to do anything, you will be asked to use your BLS procedures, which include the insertion of a supraglottic airway, at least in the Midwest. Apparently in other parts of the United States, you have to be a paramedic provider to place a superglottic. Apparently in Wisconsin, you can be literally a first responder in most parts of the state and put these things in, by the way. And I think there's a pilot project in New York state to let EMT basics place the superglotics, which is what they should do. But I focus on the basics, okay? Now, this is not to disrespect anybody at a higher level, but what you have to do is you have to basically understand that the people who are going to do the work, they need to be given the confidence, they need to be given the encouragement, they need to be given the excitement, the energy to do this stuff, because you don't want them to look at a nasty situation where the mouth is full of blood or vomit and turn around and say, you know what? Not today. I'm not going to deal with it. You want them to say, oh, yeah, I know what this is and I know how to fix it. I don't like it one bit, but I'm going to come in here, I'm going to do the best job I can do. That's the attitude we need to instill as teachers and as leaders.

So let me ask you, though, how many agencies out there still using the Yang Kaur and how many agencies that you have gone to to visit actually have a mannequin that could provide regurgitation? I have. You know, I have in all my agencies here in South Florida. I had to call the trauma center. You know, Candice, I'm not sure she's on today. She's got the mannequin. She drove it over to Davie Fire to Coral Springs. We already have one in Palm Beach County. But it's my sense that not many people are doing it. And I would love to hear from the people in the group like Jonathan, do you guys have the Soiled mannequin. The airway mannequin. Do you guys do that currently in South Metro in Colorado?

We do, but we're also using the decanto section.

Right. So I guess the question is how many people out there.

Are able to do this kind of training? Oh, there's Candice. Hi, Candace. Can I pick on you first? If I can pick on you for a second? How many agencies have called you out to do this type of training?

So we wrote a grant to actually get some airway mannequins. We have eight now that are available to all of our EMS agencies in Broward County. So they check them out on a regular basis. So we either do a train the trainer, we can go to any of the stations or agencies, or they can check out the mannequins and use it on their own. So we've had all 18 agencies use it, and then we bring it to the first Air First Care conference as well.

Are you still using Yank hours?

I think there's several that are, or some agencies carry multiple devices. So I always challenge the medics to check their truck and what actual devices they have so that they can check both.

Okay, let me first pick on Angus across the state, and then I'll go to Marv across the country. Angus, is your sense that across the state, as a state medical director, that this simple technique of lead with suction, whether it's supraglottic or ET tube is being utilized?

I'm sorry, Peter. I'm multitasking. Was there something directed at me?

Yeah, I just was curious what your thought was on how many agencies across the state are practicing on the use of suction of the soiled airway.

In terms of the actual sort of salad technique, I do not know, because everybody has sort of the ability to do their own protocols. I have not seen that we've even actually gotten very many sets of protocols uploaded into the shared thing on Mobilize, though. That's a good point. It would be great for more people to upload their protocol books there.

Yeah, you're right. Yeah. So I guess the reason I'm harping on this, Jim, and everybody here is because.

I would say that we're pretty proactive here. But some of these minor things, like using a better catheter, using a better technique, it takes a lot longer for that kind of thing to make it into a training session. And so I had the pleasure of speaking to Marv this week. Marv, you're the airway guy. What's your take on.

The skill set in Ems, with respect to what we can do better.

Yeah. Thanks, Peter. By the way, I'm honored to be on with Jim. Hi, Jim.

How are you?

We have shared many stages together. Of course, I've shared them longer than anybody. But anyway, seriously. So we have Mr. Puke, which is what we call him. We don't have standardization in all our agencies on the, on the suction device, the anchor is still too common. The Kando is sort of running the race. Well, as you know, we do all BLS is Igel. We train every quarter, even if it's only for 15 minutes. On IGEL, we try to train that suction is first and eye gel is second.

And of course, the als. Peter has seen some of our videos. Most recently I sent him a 10 month old that was unfortunately nursing mom who'd been sucking on her fentanyl, which was a very sad story. But it shows a video. It shows the intubation, the clarification, and even the NG tube after the intubation. So we're trying to change that. It's not one particular action, it's a series of actions that combine to achieve what you need to achieve. We also try to train that if the Igel is working in a CPR case.

And you're able to provide whatever additional suction that you work in again on an as need basis. So I know Jim agrees. I also know that we're not as good as we need to be. You know, we'd like to think we have got the best of something, which we always don't.

So.

But thank you. But I do think that the concept of a process rather than a procedure is the key.

So Jim, let me kind of pitch off Marv's comments and I'm gonna give you a scenario. And you know Marv. Marv has some great videos, but I'm gonna give you a scenario.

You know, we have, in some of our agencies, we have dsi. Okay. So we give the ketamine, we give the rock, and then we go for the tube. You know, interestingly, we've looked at our data and we want to publish this. That.

A lot of our folks, we actually allow them to just give the ketamine, evaluate what's going on. And oftentimes they're not even giving the rock. But the scenario that I really wanted to ask you about here, you gave the ketamine, you oxygenated them, you had the three minute.