"...Hi this is the anaesthetics SHO, how can I help?"
"Hi, thank you, we have a lady down here in ED who needs transferring over to ENT at St Mastoid's, and they just need anaesthetics to clear the airway before they go"
These are weird requests
One of the joys, and curses, of anaesthetics is that nobody else really understands what we actually do a lot of the time.
They know that we render people unconscious and do breathing things and central lines, and that we're often nifty with a cannula, but there's a lot of behind the scenes disaster-planning and preparation that we're responsible for that never actually gets witnessed by other specialties.
Airway assessment is a classic example.
It is generally accepted among the medical specialties that anything airway-related is either the remit of ENT or Anaesthetics, and in this instance since ENT are miles away - hello anaesthetics SHO.
Is it safe?
It feels scary being asked to assess someone's airway specifically to make a decision as to whether they need an anaesthetist to go in the ambulance with them.
- What if something changes?
- What if they deteriorate?
- Am I accepting sole responsibility for this patient until they arrive?
- Should I go with them just to be safe?
The reality is that the vast majority of the time it's rather obvious when a patient needs immediate airway support, because they look dreadful and both patient and monitor are making all sorts of unhealthy noises that make your spine tingle.
The more difficult decisions are to be found when the patient is alright at the present moment, but might need some sort of airway intervention in the future, and you have to decide whether this is likely enough to warrant committing an anaesthetist to the back of an ambulance, thereby removing a set of hands from a hospital that very much needs that extra set of hands.
Start with why
The first thing to do is look at the patient, and get a bit of a gut instinct of how you feel about their airway.
Clearly your assessment is going to depend on why they have concerns about the airway - facial burns require slightly a different focus of attention to penetrating neck trauma - so the key is figuring out why they're worried in the first place.
Examples of why they want you to assess the airway
- Foreign body
- Low GCS
- Bleeding after tonsillectomy
- Facial burns
- Neck trauma
- Stridor of unclear cause
A foreign body might move and cause obstruction, facial swelling can increase rapidly and start causing stridor, unexplained stridor needs investigating before sending the patient out into the world.
Think about the trajectory
You're probably only going to lay eyes on this patient once before making a decision about whether they're safe to hop into the ambulance and head over to wherever their source of definitive treatment is.
This means you're taking a snapshot, static picture of what is very much a dynamic process.
Is this patient's airway likely to get worse or better, and how quickly?
- A post-tonsillectomy bleed who has had a trickling ooze for the last eight hours is likely to continue to have a trickly ooze for the half hour that they're in the ambulance, and if they're spitting the blood out into a bowl with no respiratory compromise then they're most likely fine without your help
- A wheezy anaphylaxis patient with a big tongue that started eight minutes ago may well have a very much larger tongue and more oedematous airway in five minutes' time, and neither you nor the patient probably should be going anywhere right now
- The facial burns patient with singed nostril hairs and a slightly darkened tongue may well be absolutely fine right now, but in twenty minutes this could be a very different picture
- No oxygen requirement
- Voice is normal for the patient
- No difficulty swallowing
- No drooling
- Able to spit out any secretions or blood without coughing
- Strong cough when required
- Tongue and lips feel normal size for the patient
- Normal work of breathing
- Fully conscious and not confused
- No added sounds or stridor
- No evidence of nasal hair singing or soot in the mouth in the case of burns
Document for right now
Let's say you assess the patient and determine that at this moment in time they don't need an anaesthetist to do anything.
This is key - you need to make it clear in your documentation that your assessment is in reference to the airway as it appears at that moment in time.
Things might change, and the clinical picture might deteriorate.
Things happen in medicine (and in ambulances) that we don't expect and that are out of our control. This doesn't negate your assessment or render your decision invalid - it just means you need to be very clear about when you made your assessment.
- "Seen at 02:15 - Airway currently not requiring intervention, however please contact anaesthetics team if any clinical change or concerns."
- "Based on clinical assessment at 07:15, patient does not require anaesthetist for transfer to ENT at X hospital"
As always, if you have any concerns at all, a quick phone call to the boss is never a bad idea, even if it's just to say 'I've seen this person, this is my assessment, I'm not concerned, I just wanted to check whether you'd add anything'.
Some specific things to check for
In a trauma patient
- Evidence of facial fractures
- Blood, vomit or teeth in the mouth and airway
- Surgical emphysema
- Distracting wounds
- Neck haematoma
In the case of burns
- Singing of nasal hair
- Facial burns
- Hoarseness or voice change
- Rasping cough
- Head or neck swelling
- Soot in the mouth, nose or saliva