Safety and Risk in Airway Management During Bariatric Air Medical Retrieval.

OBJECTIVE: Bariatric anatomy and physiology present added clinical challenges to the provision of safe critical care and patient transport. LifeFlight Retrieval Medicine provides air medical retrieval services in Queensland, Australia, and performs over 6,000 retrieval missions annually using rotary wing, fixed wing, and ground ambulance platforms. METHODS: Bariatric patient retrievals were identified from the LifeFlight Retrieval Medicine electronic patient database. These cases were interrogated to quantify and describe adverse events during patient transport. RESULTS: Over the study period from July 2019 to December 2021 11,096 patient retrievals were completed. Of these patients, 816 (7.3%) had a body weight ≥ 120 kg (range, 120-246 kg; median = 146 kg). Bariatric patients were more likely to be male (70%) and to require critical care interventions than nonbariatric patients (25.9% vs. 19.9%). There was an absolute 1.5% increase of high-interest events during patient retrieval, corresponding to a 1.9-fold increased relative risk. Five hundred eleven of 11,096 patients were intubated by the retrieval team, and 61 of these weighed ≥ 120 kg. Bariatric patients undergoing intubation were of similar age and sex, weighed significantly more, had nonsignificant trends toward poorer airway visualization by Cormack-Lehane laryngoscopic grade, and tended toward reduced first-attempt success compared with nonbariatric patients. Rates of airway adverse events (AAEs) were significantly increased for the bariatric group (30/61, 49.2%) compared with the nonbariatric group (135/450, 30.0%) (χ2 likelihood ratio, P = .004). Postintubation desaturation was the most common AAE and was the only criterion significantly increased when comparing bariatric (26%) versus nonbariatric (12%) patients (χ2 likelihood ratio, P = .005). Using patient weight as a continuous variable, nominal logistic regression revealed a significant effect of increasing weight on AAEs (χ2 = 12.9, P = .0003) with a threshold of 105 kg providing an optimal 88% sensitivity for predicting AAEs. The odds of AAEs were increased significantly for those weighing 105 to 119 kg versus those weighing < 105 kg (odds ratio [OR] = 3.4; 95% confidence interval [CI], 1.6-7.5) and for those weighing ≥ 120 kg versus those weighing < 105 kg (OR = 2.5; 95% CI, 1.4-4.3). There was no difference between those weighing ≥ 120 kg versus those weighing 105 to 119 kg (OR = 0.73; 95% CI, 0.3-1.8). CONCLUSION: Air medical retrieval of bariatric patients is safe despite an increased risk of adverse events. Strategies to optimize emergency anesthesia should be used to maximize safe intubation in bariatric patients.

Ketamine-Induced Spontaneous Breathing Intubation With Airway Topicalization: A Case Report of Airway Obstruction in Retrieval Care.

A LifeFlight Retrieval Medicine air medical team was tasked to a rural facility 200 km away to manage and retrieve a 73-year-old woman with evolving airway obstruction. Resources at the referring site included a general practitioner with anesthetic skills training but no access to otorhinolaryngology (ear, nose, and throat) or flexible fiberoptic airway devices. On arrival of the LifeFlight Retrieval Medicine, the patient became agitated, with deterioration in her airway patency. A clinical diagnosis of Ludwig's angina with evolving airway obstruction was made. Using a technique of ketamine-facilitated, spontaneous breathing tracheal intubation with a video laryngoscope, the retrieval team was able to safely secure the patient's airway before transporting her to a regional hospital with ear, nose, and throat surgical services. Computed tomographic imaging revealed an oropharyngeal abscess with spread into the larynx, which subsequently underwent surgical drainage. This case report outlines the technique of awake laryngoscopy with relevance to the retrieval physician and discusses some of the challenges and potential complications associated with it.

Rural experience for junior doctors: is it time to make it mandatory?

OBJECTIVE: To determine whether rural practice terms for junior doctors result in increased interest in rural practice and whether these terms improve learning experiences, clinical skills and insight into difficulties of rural practice. DESIGN: Semistructured, self-administered survey with questions on respondent demographics, clinical experience during rural practice terms, post-rural experience and personal opinion. SETTING: South East Queensland. PARTICIPANTS: Thirty junior doctors from three tertiary hospitals were approached. The response rate was 100%. MAIN OUTCOME MEASURES: Exploration of junior doctors' rural term experience. RESULTS: Two thirds (67%) of the respondents reported feeling uncomfortable with respect to clinical practice requirements during their rural terms. Half (47%) performed procedures they had only previously performed in simulation environments, and the majority (87%) relied on textbooks or other resources on a daily basis. Two thirds (67%) changed aspects of their usual clinical practice while practising in a rural setting, and 80% reported a change in attitude towards the hardships faced by rural practitioners. The majority of the respondents (87%) enjoyed their rural term, gaining confidence as a result of it, and more than half (53%) reported considering working in rural areas in the future. CONCLUSIONS: The results of this survey suggest that junior doctors on rural rotations are required to perform at a clinical level higher than that required of them in metropolitan hospitals. While their clinical experience appears to result in a greater interest in future rural career possibilities for junior doctors, this survey highlights the requirement to improve support for junior doctors undertaking terms in rural areas.