Set the scene: ACLS course, airway management

5 in the room: 1) Instructor 2) nervous RN 3) competent RT 4) arrogant surgeon 5) exuberant med student

Instructor: And after we conclude the didactic portion of airway management, would be a good time for questions, and practicing the skills. We have a model here, along with several airways that you should all be familiar. In particular, I think everyone should be comfortable with an oropharyngeal airway and an LMA.

Student, waving his hand frantically

Instructor: yes?

Student: (all looking very panicky) Well, I know it’s not part of the core curriculum, but I was really hoping you could teach us about the combitube and maybe nasal intubation, and also emergency cricothyroidectomies. Because you never know when you might need to know these things. And what meds would you use during an intubation? Can you tell me?

Instructor: we could address those towards the end- if we have time – but…

Surgeon: I could show you how to do a cric, it’s good to be prepared. You may have to save a life at some point. I have done a few in my time. Here, it’s easy…. You start by locating the cricothyroid membrane… <fade as they walk over to the model>

Nurse: (quietly) cricothyroidectomy? combitube? What? They aren’t on the curriculum, are they? I mean, I’ve heard of them, but I have been nursing for 15 years now and I have never had to know what these are.

RT: sorry? what? I can’t hear you?

Nurse: (a bit louder, but still barely audible) It’s just that I’m not interested in learning things that simply aren’t relevant to nurses. I just want to practice those manoeuvres we were talking about earlier.

RT shrugs as he still can’t hear….

Instructor: I think those are good questions, but our nurse here has a good point. These are beyond the scope of our current course.

Surgeon: Just a second, he’s almost got this . That’s right… a little lower… Now expect some bleeding… more than you would think…

Instructor: Ok, that’s great. But let’s stick to the lma and the oropharyngeal airway. We need to master those?

Surgeon: No one needs to practice those… They are self-evident. You can’t mess them up. This is key stuff here….

RT: Well, actually, there are some subtleties, and it might be best if those who haven’t used them got familiar with them first.

Instructor: Right, so as I was saying….

Surgeon: look, if no one is going to listen to me, I don’t have time for this crap. I’m only here because of licensing requirements. I’m going to answer a page… <storms off>

Med student: Ok, that was awesome! Can we talk about the drugs now?

Nurse: Would it be ok if I tried the LMA?

Instructor: So, as I was saying… let’s try to stick to the core materials. The first thing you need to know is how to assess an airway and when to use an adjunct. You won’t always need an airway, but when you come across a patient who isn’t breathing, what’s the first thing to do?

<med student waves hand eagerly>

Instructor: let’s hear from someone else for a bit. Nurse?

Nurse: I would call a code. Then start on vitals. The code team should arrive rapidly, with a code leader.

Instructor: That’s great, calling for help. But let’s say you are the code leader?

Nurse: Well, the code leader is never the nurse. i don’t want to be the code leader.

Instructor: But the purpose of this course is to ensure you all have adequate skills.

<nurse looks over at the RT, kind of helplessly>

<med student still excitedly trying to get attention>

RT: I’d love to be the code leader! RT to the rescue for a change! I would sweep in and first assess LOC – are they conscious? Then when I find out they aren’t they need an airway, perfect 2 seconds flat and done. Are they breathing? No. Bag them through the ETT I just put in. Next – do they have a pulse? No start CPR! Yes? Transfer to ICU while bagging! And DONE.

Instructor – a little bit flustered. Ok – but you can’t do everything yourself. being a code leader involves delegating to others and overseeing the process. So instead of intubating the patient yourself, what could you have done? and let’s talk about how to assess the airway.

Surgeon walks back in

Surgeon: Are we still on airways?

Med student: I want to be the hero!