Opinion
Airway management in the emergency department: The UK emergency physician’s view

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Summary

Patients with critical airway problems presenting to the Emergency Department should be managed by clinicians with the skills and experience to ensure the best clinical outcome. Traditionally, airway management is seen as the domain of the anaesthetist. This is usually the case in countries where anaesthetists form part of the receiving team in the hospital. In countries where Emergency Medicine is a specialty in its own right, this clinician may not necessarily be an anaesthetist. In the United Kingdom, the debate continues as to who should manage the critically impaired airway. It is important that this is dictated by the accredited skill set of the clinician rather than the specialty they work in.

Introduction

In the United Kingdom, the specialty of Emergency Medicine has evolved over the last forty years. “Casualty” departments were in existence in the 1960’s and the first full time “Accident & Emergency” consultants were appointed in 1972. Training programmes for the specialty commenced in 1976 and were further rationalised in 1996. There is a College of Emergency Medicine which oversees the training standards for all doctors contemplating a career in Emergency Medicine.

In the early days, the departments merely sorted patients as to which specialty should see them, but the emphasis has now developed beyond simply treating traumatic injury to encompass critical and acute care for a much wider range of problems. The Emergency Physician ultimately holds the responsibility for the care of all patients in the Emergency Department, even if they are to be subsequently admitted to hospital or if specialists are asked to attend and contribute their expertise.

Airway management is still seen as the main role of the anaesthetist and it is still a common belief that if a patient needs tracheal intubation in the Emergency Department (ED) then it should be done by the anaesthetist. However five years since the introduction of the Acute Care Common Stem (ACCS) training programme in the UK, things may be set to change.

Section snippets

UK training

Junior doctor training has undergone significant changes in the last eight years under the UK Government Modernising Medical Careers (MMC) initiative. Prior to this, newly qualified doctors were known as Pre Registration House Officers (PRHO). They had to successfully complete their first year as a doctor, without incident, in order to become fully registered with the General Medical Council to progress to the Senior House Officer (SHO) grade. Doctors used to spend several years as an SHO,

Is this new career structure working?

In 2012 a new breed of EM trainees will become EM Consultants and we shall see what differences ACCS may or may not make to airway management in the ED and to relations with the anaesthetic department. The new EM consultants will have had 12 months of anaesthetic training to RCOA competency levels, worked amongst anaesthetists and skilled assistants in theatres, worked on ICU, been “first on call” for anaesthesia, called to the resuscitation room and will have been called to the wards as part

NAP4 audit

The findings of the 4th National Audit Project (NAP4) of the RCOA and The Difficult Airway Society2 were published in March 2011. It was carried out to investigate how frequently complications in airway management occur and why. It was designed to answer three main questions:

  • What types of airway are used during anaesthesia?

  • How often do major complications, leading to serious harm, occur in association with airway management in anaesthesia, in the ICUs and in the EDs of the UK?

  • What is the nature

Skills attrition

Why then, having been deemed fit to assess emergency airway problems by the RCOA attaining the Basic Level Training Certificate, do such situations arise?

From an EM perspective, becoming deskilled is a significant problem. After a full year in Anaesthesia performing in excess of ten tracheal intubations per day, the EM trainee returns to their spiritual home of the ED to find an intubation rate as low as an average of 6.5 per year.7

There is currently no official recommendation for the

Solutions

The priority should be in vivo experience, but these patients cannot be magically conjured up. It seems that in EM more than any other specialty, being in the right place at the right time is the key. Some trainees are fortunate to be involved in several RSI cases and get invaluable real life experience whilst others do not. It has been suggested that EM trainees request time in theatre, but with the emphasis firmly placed on service provision it is increasingly difficult for trainees to be

Conclusion

The NAP4 study has demonstrated that Emergency Physicians are as capable of performing an RSI as their anaesthetic counterparts.

Management of the critically impaired airway is not just about performing an RSI though. The cases that will present to the ED are by nature more complex and have a higher complication rate than those patients who have an RSI performed in more controlled circumstances. It is imperative that the clinician has the skills and experience to manage any airway problem that

Conflict of interest statement

Neither author has any conflict of interest to declare.

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