EMS Adoption of Glidescope

The EMS planned adoption of Glidescope Ranger and GlideScope AVL has been gathering momentum recently. There is a synergy as well with Military usage which has become institutionalized within branches of the US Military based on the widespread educational activity and general popularity of Video Laryngoscopy.
USB recording for GlideScope ALV monitor system is now a reality and can be obtained for EMS. This addition makes video file management very simple and will allow the EMS Medical Director to keep a very current convenient quality file and teaching file.
Dr Ken Rothfield working with Howard County EMS has been a leader in proving that addition of video laryngoscopy teaching to EMS Fire and Rescue teams improves performance to 96% overall success rates.
Video and especially recording video make it possible to learn and grow the skills of a department while operations are sustained.
Look for exciting new products from Verathon in the coming year .
Highlight Glidescope 2
This mighty Glidescope is a great addition to any EMS or Hospital Glidescope system.
Keep tuned in.

Telemedicine and the New ASA Airway Algorithm

                         

 The adoption of the electronic Medical Record and the adoption of Telemedicine Promises to improve health care , greatly improve Patient Participation in Health care planning , and reduce cost of quality care at once.

  Avera Health in Sioux Falls South Dakota provides a glimpse of the future for this new technology.
The E-ICU , The E-ER, The E-Pharmacy links a large and increasing number of hospitals in the adjacent 7 states into a network that provides Quality care standards and Clinical support via an ever expanding IT framework.

 Dr Don Kosiak is the Medical Services leader of this innovative E-Care  Medical activity and leads the ATA special interest subgroup.  Mr Jay Weems , the Executive Director of the services , reports that the 24/7 telehealth service has resulted in a measured 18% decrease in Ambulance and Helicopter transfers to major hospitals which results in smaller hospitals being enabled to safely provide higher levels of care using protocols and monitoring from the center hospital.

The service is in the initial stages of using Telemedicine directed airway management techniques which promise to bring Video laryngoscopy to a new level of sophistication by allowing "big Hospital" guidance on a real time basis.  The combination of these techniques with the benefits of the new revised  ASA difficult Airway Algorithm which features Video laryngoscopy prominently in the planning of airway intervention is an extremely powerful combination.

Take the time to study the new ASA thinking as soon as possible.

Airway Geometry

The GlideScope Ranger

"New" ASA Difficult Airway Guidelines 2012

The long awaited new ASA airway management guidelines incorporate the Video laryngoscope for the first time. GlideScope is the most widely used device of this kind. GlideScope  led development of this practice change.
1. The Algorithm features Video Laryngoscopy as a potential first choice in the initial assessment phase.
2. Then the Video laryngoscope is the first mentioned option for " alternate approaches to intubation" where rescue is required.
The primary ASA table is presented here .

DIFFICULT AIRWAY ALGORITHM

1.  Assess the likelihood and clinical impact of basic management problems:

•  Difficulty with patient cooperation or consent

•  Difficult mask ventilation

•  Difficult supraglottic airway placement

•  Difficult laryngoscopy

•  Difficult intubation

•  Difficult surgical airway access

2.  Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management.

3.  Consider the relative merits and feasibility of basic management choices:

•  Awake intubation vs. intubation after induction of general anesthesia

•  Non-invasive technique vs. invasive techniques for the initial approach to intubation

•  Video-assisted laryngoscopy as an initial approach to intubation

•  Preservation vs. ablation of spontaneous ventilation

 

Alternative approaches to intubation  include:
  Video laryngoscopy, alternative laryngoscope blades, SGAs like  the LMA, light wand, flexible laryngoscopes and others.

The document is very detailed and is required reading for aspiring  "Airway Managers".
Anesthesiology  Feb 2013  vol. 118, No. 2.

     The ascent of video laryngoscopy over the lifetime of the GlideScope has been particularly gratifying and is leading many to advocate the use of Video Laryngoscopy as a first line management tool. The variety of valid opinion will continue to grow and care givers will continue to "customize their approach " based on the skills and equipment available. There is however, an emerging standard that builds on the wisdom of the ASA Difficult Airway Algorithm and in Canada the CAS Difficult Airway study group Algorithm which requires that skills and equipment be available in the following key areas.

1. The Direct Laryngoscopy approach
2. Video Laryngoscopy
3. Flexible scope technology application
4. Supraglottic airway use and skill
5. Direct surgical airway capability applied in extreme situations
6. Supportive adjuncts such as the Verathon Stylet, the Bougie, the Endotracheal tube exchange catheter,  optical stylets, and oral /  nasal airways.
 
    The use of these pieces of equipment in combined approaches may feature the GlideScope and a Flexible scope  or an Airway exchange catheter together in some circumstances. The power of the new devices can only be fully realized when practitioner skills span the full range of airway offerings. What we are seeing now, is the maturation of  the teaching systems such as -simulation workshops, clinical resource optimization exercises on manikins, airway rotations with deliberate planning to be certain that the output of trainees is standardized at a high level, and team competitions that challenge ones skills in a friendly but serious manner.
 
  Truly an impressive amount of progress !

Historical Verathon Approved JEMS Video

http://airway.jems.com/2011/05/advancing-technology-the-glidescope

Worlds First True Video Laryngoscope - GlideScope

The proverbial home workshop that has created so many new products and procedures was also pivotal in the creation of the "World's  first True Video Laryngoscope , the GlideScope."

   The first GlideScope  video laryngoscope: defined as a video camera mounted on a rigid laryngoscope blade with no fiberoptic components, exploited the development of the CMOS security cameras developed in the late 1990s. The GlideScope , circa 2000, was a  disposable Direct Laryngoscope blade heat modified to incorporate a video camera and LED epoxied onto the under surface, at the point of angulation,  to place the viewer in the pharynx with a panoramic view of the glottis. This proved to be a powerful tool.

Overview of the GlideScope history

SUMMARY OF THE INVENTION
THE PROBLEM


Placement of a tube into the trachea during surgery or lung failure permits mechanically-
controlled ventilation of a paralysed, sedated patient. Anesthesia and induced respiratory failure make the patient totally reliant on the caregiver to adequately maintain ventilation, otherwise severe brain damage or death may occur. A condition known as “airway anxiety” exists because the classic 1895 innovation of direct laryngoscopy, updated by MacIntosh in 1943, may fail to adequately show the entrance to the airway in as many as 10% of patients. This situation can hinder timely intubation during critical treatment or lead to esophageal tube placement – a situation that often produces deadly results.

GLIDESCOPE® -THE FIRST VIDEO CAMERA LARYNGOSCOPE

  Dr. John Pacey has conceived and developed a unique device – the GlideScope® video laryngoscope –which solves the problem described above in more than 99% of treatment cases. The device greatly improves the ability to see the airway entrance at the larynx, resulting in a high probability of “first pass” success for the caregiver. To achieve this reliability the GlideScope® “sees around the corner” behind the tongue via a video camera positioned in the pharynx, which looks directly toward the larynx. Extensive experimentation and discovery by Dr. Pacey, along with analysis of lateral view MRI images (see Appendix), found that the solution requires a specific 60 degree angle on the blade of the device. Also important was the discovery that having a special camera placed 6 cm back from the larynx provided a clearer and more panoramic view of the critical area. This panoramic view countered the belief of others that the optimal site for the camera was in the vicinity of the blade tip. The GlideScope® is provided with a low cost lighting solution that exploits the low temperature and power consumption of illuminating light emitting diodes. These LEDs replace a $5000 Xenon light source seen on classic endoscopic systems. Typical fibre-optic systems cost $50,000 and are fragile, whereas the rugged GlideScope® system costs approximately $10,000 and requires little maintenance. Additionally, the GlideScope® has a patented heating system for the camera lens to prevent the typical fogging problems that have plagued endoscopes over the years. Device start-up is rapid and requires pressing only a single button, contrasting with older systems that require white balance and tuning. These additional configuration tasks often frustrated users at times when seconds meant the difference between life and death. 

   The GlideScope® also presents an enormous advantage for training due to the fact that it has a method of use familiar to those trained on older types of laryngoscopes. However, in contrast with these direct laryngoscope models, which often require between 200 and 400 uses to master, the GlideScope® requires only two to ten uses to do so. Modern trainees are also particularly adept with the use of video technology, and the new capability of recording GlideScope® video allows medical directors to monitor quality of care and provide real video for training. The telemedicine GlideScope® now under testing also allows coaching from an emergency department hub. Dr.Pacey’s vision of a field telemedicine airway device using Wi-Fi or 3G connectivity is an important intellectual first.

    The streaming video connection can now be made to smart phone handheld devices for further convenience. The GlideScope® has proven to be a "skill-levelling” device that has been successfully used by fire personnel, EMS, police EMS, respiratory technologists, nurse anesthetists, medical students, and military corpsmen, often in adverse situations. There is a developing consensus that the advent of video laryngoscopy will replace the 100 year old direct laryngoscope technology for all airway management, mostly due to ease of use and the substantial increase in patient safety. The measure of its success is evidenced by its adoption on a global scale by respected and hard-working medical professionals who swear by this important Canadian innovation.

Dr John Allen Pacey MD FRCSc
Vascular and General Surgery
Vancouver , Canada