Trick of the Trade: A “Fiberbougie” through a supraglottic airway device (King tube)

Resuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success [3]. Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could be blindly changed over a tube exchanger however it is quite easy to lose the airway completely during this process. We describe a potentially safer and more effective alternative.

Trick of the Trade

After a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide.

Equipment Needed

Disposable bronchoscope
Endotracheal tube
50 mL syringe
Laryngoscope (video or direct)
Trauma shears
Suction
Capnography

fiberbougie through supraglottic device king airway

Left: Demonstrating the technique inserting a single-use bronchoscope through a supraglottic King tube in a simulation patient. Right: Corresponding view of the vocal cords through the King side port in a real patient.

Description of the Trick

Insert a disposable bronchoscope through the airway port of the King airway
Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina
Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina
Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway
Insert the endotracheal tube over the “fiberbougie”
Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords
Confirm placement with capnography and/or with direct visualization and x-ray

Insertion of the endotracheal tube over the “fiberbougie” with video laryngoscopy confirmation with a simulation patient. The inset image was captured from a Glidescope on a real patient during the exchange.

Video Tutorial of the Fiberbougie Technique to Exchange a King Tube

References

April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039. PMID 33684505
Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation Cardiovascular Collapse in Critically Ill Patients: Insights from the INTUBE Study [published online ahead of print, 2022 May 10]. Am J Respir Crit Care Med. 2022. doi:10.1164/rccm.202111-2575OC. PMID 35536310
Burns JB Jr, Branson R, Barnes SL, Tsuei BJ. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):92-95. doi:10.1017/s1049023x00007743. PMID 20405470

By Graham E. Snyder, MD, FACEP|2022-07-05T10:44:02-07:00Jul 6, 2022|Critical Care/ Resus, Tricks of the Trade|

Dear emergency physicians: We see you

The COVID-19 pandemic has placed incredible stress and strain on the personal work lives of emergency physicians. We have endured these almost 2 years of misinformation, PPE shortages, fear, frustration, grief, and death. So much going on in the world politically and socioeconomically, we at ALiEM wanted to share a message that WE SEE YOU. We’re with you, and we’re in this together.

Credits

Thank you for the tireless work on this video by animator Spencer Evans, who is a soon-to-be-emergency physician attending medical school currently at the University of Colorado. Also thanks to the entire ALiEM team for contributing to the message and storyboard, especially Drs. Al’ai Alvarez, Andy Little, Carl Preiksaitis, Chris Belcher, Christian Rose, Felix Ankel, Jason Woods, and Teresa Chan.

By Michelle Lin, MD|2022-03-09T11:05:28-08:00Mar 10, 2022|Academic, Emergency Medicine, Life, Medical Education|

IDEA Series: DIY Suture Kit Station

In medical training there is a lack of simulation based activities including procedural labs. Suturing is a critical skill for trainees to master in the emergency department. However, supervised practice is needed prior to suturing a real patient for the first time. This innovation allows early trainees to master suturing while on shift, using easy to find materials, which increases procedural competency and confidence. This activity allows the teacher to assess and correct the trainees procedural skills prior to attempting to suture a real patient.

Name of innovation

This Do-It-Yourself Suture Kit Station incorporates easy to find materials available in every emergency department, allowing early trainees to master suturing prior to suturing real patients.

Learners targeted

Medical students and early trainees who need suture practice

General group size

One-on-one student training is ideal, but can have multiple students who can practice using multiple suturing stations
If teacher unable to instruct while on shift, trainees can be shown a suture training video and practice alongside the video

Materials needed

Blue chuck pad
Paper/cloth tape
Scalpel
Suture material
Suture kit

More detailed description of the activity and how it was run

Make the DIY Suture Kit Station (see above video):
- Place a thick chuck pad on a flat sturdy surface.
- Apply cloth tape to the entire surface of the chuck, and tape over the chuck. This is now the suturing pad.
- Use a scalpel to make an incision to the pad.
- Use the back blunt end of the scalpel to ‘fluff’ up incision edges to make laceration.
Use a laceration repair kit and suture to close the laceration.
Instruct the trainee on proper suturing technique on the suture station (or show a suture training video)
Have the trainee continue practicing until adequate comfort and proficiency level is achieved
Suture real patient!

Lessons learned, especially with regard to increasing resident and program buy in

Procedural skills require much repetition to gain proficiency. This is best done with video tutorials, supervision, and deliberate practice.
Practicing in a simulated environment greatly improves skill and confidence in real clinical practice.

Educational theory behind the innovation including specifics/styles of teaching involved

Simulation practice increases procedural competency.
Practicing on shift allows trainees to reach the number of repetitions required to gain mastery in suturing, Routt [1] showed that the number of repetitions required to gain proficiency was 41 times.
Competency in suturing is required even when cases are low. Wongkietachorn et al. demonstrated that tutoring suturing improves the trainees’ skillset. A practice suture kit helps improve retention for real-life scenarios [2].

Pearls

This DIY suture pad station technique is easily available and inexpensive.
To improve suturing techniques and enhance skill retention, medical students and early trainees need to learn with guided supervision on simulated task trainers.

References

Routt E, Mansouri Y, de Moll EH, Bernstein DM, Bernardo SG, Levitt J. Teaching the Simple Suture to Medical Students for Long-term Retention of Skill. JAMA Dermatol. 2015 Jul;151(7):761-5. doi: 10.1001/jamadermatol.2015.118. PMID: 25785695.
Wongkietkachorn A, Rhunsiri P, Boonyawong P, Lawanprasert A, Tantiphlachiva K. Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases. J Surg Educ. 2016 May-Jun;73(3):524-8. doi: 10.1016/j.jsurg.2015.12.004. Epub 2016 Feb 20. PMID: 26907573.

By Dimitri Livshits, DO|2021-10-08T10:19:05-07:00Oct 15, 2021|IDEA series, Trauma|

In July 2021, Dr. Vivek Murthy became the first U.S. Surgeon General to declare health misinformation a public health crisis. Specifically, COVID-19 vaccine misinformation and disinformation on social media greatly affects vaccination rates in certain populations. Rapid increases in reliable health information about COVID-19 can be overshadowed by the spread of even greater amounts of misinformation, leading to an ‘infodemic.’

The World Health Organization defines an infodemic as:

“… too much information including false or misleading information in digital and physical environments during a disease outbreak. It causes confusion and risk-taking behaviours that can harm health. It also leads to mistrust in health authorities and undermines the public health response. An infodemic can intensify or lengthen outbreaks when people are unsure about what they need to do to protect their health and the health of people around them.”

INFODEMIC Conference on Social Media and COVID-19 Misinformation

On August 26, 2021, Stanford University’s Department of Emergency Medicine and Ethics, Society, and Technology Hub co-sponsored a unique conference to address this issue, “INFODEMIC: A Stanford Conference on Social Media and COVID-19 Misinformation.” Speakers presented virtually from around the world including experts in social media, health policy, ethics, and medicine. The conference focused on the causes of COVID-19 misinformation and mitigation strategies. Vaccine Confidence, Vaccine Hesitancy, and Vaccine Equity were among the main topics of the meeting. INFODEMIC also featured representatives from Facebook, Google, and Twitter, as well as physician influencers, to discuss the role of social media companies to address misinformation online.

Below are recordings of each of the INFODEMIC conference presentations, presented as podcasts. Video recordings of these presentations are also available to view online. The conference agenda and featured speakers are listed on the Stanford INFODEMIC website.

Podcasts

By Michael Gisondi, MD|2021-10-06T19:40:30-07:00Oct 8, 2021|Academic, COVID19|

In pediatrics, the history and physical examination is paramount. But even the most seasoned professional can have a challenge when facing a wiley 2-year-old. What strategies can you use to get in, get out, get the information you need, and maybe even make a (very small) friend in the meantime?

(more…)

By Aditi Mitra, MD|2019-10-31T13:02:31-07:00Oct 23, 2019|Pediatrics|

Peering into Peer Review: How can you participate in peer review?

As part of the ALiEM Faculty Incubator Program, Dr. Anthony Artino, Deputy Editor of the Journal of Graduate Medical Education (JGME) and Assistant Editor for Academic Medicine participated in a Google Hangout with Drs. Antonia Quinn and Teresa Chan where he provided expert insights into the peer review process. His advice and best practices are summarized below. In this interview, the discussion provides an insider perspective to the peer review process and peer reviewer development. This post is the first half of a longer interview with Dr. Artino with the second half discussing addressing peer review comments.

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By Christine T. Luo, MD PhD|2019-10-31T23:26:32-07:00Sep 13, 2019|Incubators, Professional Development|

Under-represented minorities (URM) in medicine continues to be a problem that many programs, especially in emergency medicine, are addressing head on with intentional, proactive strategies. Diversity matters. This EM Match Advice episode discusses how 3 different residency programs are championing for better representation through a variety of strategies.