Webinar Session 4 - HFNO and emergency FONA
Summary
This session is where medical professionals can learn techniques to manage emergencies such as prolonged apneic time and failed intubations. We will be joined with consultants from King's College Hospital and the Princess Royal University Hospital who are experienced in teaching and training optic flow. We will then open up the floor for 10 minutes of discussion. We will have a video demonstration of techniques such as the needle cricothyroidotomy, scalpel techniques and emergency tracheostomy to help understand and get familiar with the procedure. Moreover, strategies will be discussed on how to reduce the risk of such situations and lessons learned from a nap four study to ensure safe and effective resuscitation. This session is imperative for all medical professionals as understanding these techniques is life-saving.
Learning objectives
Learning Objectives:
- Understand the purpose and appropriate use of high flow nasal oxygenation in medical scenarios.
- Describe the process of preoxygenation prior to induction and intubation.
- Explain the role of jaw thrust during intubations and extrication.
- Demonstrate the correct application of mechanical jaw thrust devices.
- Outline the optimal technique for emergency front of neck access in critical situations.
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So my next job is more warm to the next session, which is going to be done by I have worked to two off my colleagues. Both of them are consultant many cities at King's College Hospital. I'm rejects Plant here. James Randi, second cell phone anesthetist with serious interest in every management. He is there a lead at the Princess Royal University Hospital, part off things called Hospital London on. But he is a very real involved in teaching at training on the kitchen user off optic flow on. But he is a monster off that out. So without any further description will handle James Smith. Thank you very much. So, um yes, I'm going to talk about hyponatremia oxygenation or what will soon be turned hyper nasal therapy now that the aim of high phone laser therapy really is to prolong the period of apnea or even potentially at near without the saturation, whilst also naming See 80 Clearance on. This is particularly relevant to this to this, the practical techniques that we've described earlier with video laryngoscopy and fiber optics. Now this is a slight showing from the awake trick. You'll intubation the use of high flow nasal option a shin to prolong that period to change it from a hurried process to a much less relaxed process. And you can see the papers here demonstrate that that's shown in the airway fibrotic intubation guidelines. The combined oh, a vast guidelines in bariatric surgery or s I, um you sit in a respiratory failure. Post cardio thoracic surgery used in buying PAP after hypoxic respiratory failure. It's used in extensive ent surgery, multiple papers on that endoscopy, physicians using in bronchoscopy, a CT and now in you subject, um, ease now prominent ent anesthetist professor. Until Patel has this particular quote, I'll leave that for you to read. Essentially, it's about making something that's hurried much more relaxed and safe the same time so that the stress of it is taken out situation. So this is a slide showing, actually, how long that apneic time convey up to even 70 minutes, with none of his patients de saturating below 90% on these patients who had Mallon Patty three gray three laryngoscopy Ease. If you're thinking about doing a pre oxygenation before your induction, e you, What you want to do is attach the nasal problems in the same way orientation as you would expect to put a nasal found your airway. Okay, so, like this. Okay, So going to attach these now on a very, very soft, very comfortable. And it's the fact that the flow is humidify. That makes the makes it so comfortable. Okay, so if you were to have dry gas is that would make it uncomfortable for the patient. So we're not going to attach this little clip to the patient, so it doesn't actually pull on the face. Okay, on here. Now, we're gonna start up to 49 to a minute on with the patient's mouth closed, you generate the maximum people on with the patient's sitting up. You also try to avoid any compression of the bases with diet. At this point, you're preoxygenated the patient on day after about five minutes of doing this, you have pre oxygenated to the patient sufficiently as if you have been using a face mask for the close circuit in a circle circuit. The next important point is not to use a facemask on top of this already existing. Okay, So what's important about that? First day you wouldn't get a seal when you put the face math gun on show you that you can't get the seal, but also due to the high influx of oxygen. At 70 or 40 minutes, there's nowhere that to go. So it's important to remember not to put a face mask on this contemporaneously so late to imagine now that the patient has being induced with your induction agent. Now lose consciousness. Need to increase the flow rate about 70 and now you need to apply jaw thrust. It's important to apply mechanical drawing class because you need to maintain the airway open as opposed to the airway closed with a tongue that causing the obstruction. During this time, you may have been waiting for the muscle relaxant too rapidly haven't onset and therefore you need to use appropriate dose of rock uranium. Or alternatively, you can attach this and then certainly may in to pull the pre option nation. Once you've achieved that onset time, your muscle relaxant. If you maintain in the jaw pressed on, then perform your endoscopy because during your laryngoscopy you're providing 70 m per minute flowing here. You're providing benefit later e exchange, so see a two is exiting the patient on you're also providing auction a patient on during your laryngoscopy with this are you increase the time before you the onset of high pox yet so this is quite useful. Remember, some of the studies will know mention where the jaw has been applied. Therefore time Teo. That is very important when you're better for such a extent that are, friends in the US have already developed a mechanical device that provides jaw last for this specifically at the time of extra vacation. Once you sufficiently happy the patient's sitting up or whatever left that position you feel that is important to provide it safe. Extrication. It's important always to make sure that they haven't got into lowering your spasm, so I personally a chance the face mask again. Then the street that I have capnographer and missing of the mask before now attached the nasal problems. Now it can attach nasal problems, having an established that the Airways patent on Now I would touch again the doctor flow fry between 40 and 70 liters per minute. Depending on the level of consciousness, I can transfer this patient from the operating data using opta fried because the oxygen delivery on flow is dependent on the pressure in the cylinder. There's no depending on electrical power. The electrical power is only there to eat the water. But so if I have a cylinder with me, that would be the last thing I detached from the common gas out that on the splitter attacks it's the cylinder, and I'll take the patient on this high Flonase option to recovery. In recovery, you'll be able to transition from your portable up to fly, which is dependent on cylinder for its flow to your tushie. You'll have osteo recovery stuff to have primed it, so that is probably probably heated and simply exchange your Optivar a flight heated circuit with your circuits. How many done this? The recovery stuff. We have to titrate the level of that, too, but also maintain the level of CPAP people. They want to have the patient given the normal stage or obstructive sleep apnea. And this can also be continued on the ward, given it if the stuff are properly trained. So, um, I'm glad that you managed to see that, but because this is a joint session with the phone, uh, I'd like Teo first carry on with the next introduction to our esteemed colleague, Doctor Andrew Pool, who is a colleague on consultant anesthetist on also any statist in liver, adult and pediatric transplant surgery. So without further do, we'll continue the next lecture on, then joint questions. Thanks, James. So last but not least for this session, I'm gonna be talking through emergency front of neck access. I've got just a few slides to run through. Then we'll show you a video of the technique itself on then, as James said, will be joining Port Smith for 10 minutes of discussion. So I'm sure you're all pretty familiar with a nap for study, which is over a decade old now. It was the first major national order of airway complications and help us understand that the frequency of major airway difficulties on the use off emergency front of neck access What did it say? Well, the good news relatively good news is the airway events requiring emergency from the neck access A. Thankfully, fairly rare on that estimated the instance of between one in 12,501 in 50,000 during German anesthesia cases of 184 seriously airway events. They were 80 phone or attempts, the majority of which were were in the operating theater. Before we go on, I wonder whether it's worth mentioning. Perhaps the best way to manage it constipate context situations is to try and avoid them happening at all. What strategies can you do to sort of try and reduce this risk? Where one a proper assessment of the airway and effective planning for failure? In some cases, there was a failure to identify the high risk features on a lack of planning for when your plan A failed at to performing effective pre oxygenation of which are high flow is a great benefit. Obviously, if you're thoroughly preoxygenated, it buys you time to run through your information drill at before the onset of high pox at three at limiting the number of attempted intubation repeated laryngoscopy contend a situation which you can can oxygenate but can't intubate into a c I c. O situation. So it's important to recognize that you failed on to move on to the next attempt and forced act before it's it's too late. Making the decision to perform an emergency surgical airway is difficult but it it's something that needs to be active upon before hypothesis sets in. I thought it was a brief. You mentioned that there may be some cases where the chance of failure, both oxygenation and intubation, is so high that you would electively move towards you wouldn't even attempt induction anesthesia. You think about something like awake track your stomach and the best approach. That sort of the gyn's emphasizes the value of a standardized approach. Essentially so. So in terms of the techniques available broadly divided into three needle cricothyroidotomy scalpel techniques on also emergency tracheostomy, although that requires both so especially trained surgeons specialist equipment and it also that takes a little bit longer. The needle techniques could be broadly divided into the narrow techniques using the jet cannula on the white board techniques such as quick track or them milk, a kit, a scalpel. Crack a Toradol. Today you'll be seeing more of it in the video, as I said that the desk or emphasized the value of a standardized approach with simple equipment emphasize training on the importance of human factors in decision making on, I think without further ado will go into their video for this station will be discussed in front of the access, which will be attempted in the college finals situation. This is when they made your best attempt by oxygenation ventilation and they failed on. It's the final step to reverse on prevent caressed brain injury. And ultimately it's represented by this is very by Plan D off the dance with him, which is usually associated with other anticipated difficulties with what's the situation is very rare. It's something that we have to be prepared. What you recognized. There is some debate about the optimal weight in front of access. For the purposes of this weapon, we are going to be demonstrating the desperate committee with using the scalpel beauty. Cheap International Session on You may hear from some international expense have a slightly different approach as agree with knowledge. Other techniques, maybe equally successful in in skilled hands. One of the key observations from the left for study is that there was often delays in recognizing this was kind of oxygen situation and also declaring the wind team on committing to the procedure. We'll start by retracting. They're a diagram showing that should be coming up on your screen now, and also I'll show you when are like, kind of wanted to help keep starting from at the top at the mandible as we go down. The first structure we may encounter deep is the hyoid bone. It's not marked here next to the Adam's Apple, the thyroid cartilage, which is marked here on, then underneath that with the cartilage on the X marks the cracker thyroid memory. We've also marked on the neck the first and the second Tricky Ring and the Sternal Notch. Once the decision to proceed front of access has been made, one of the keys to gaining successful accesses the position of the patient. You need the neck to be hyper extended that can be achieved in a number of ways with sandbags, with my eyes were So, um, actually your patient on the bed, so that is partially hanging off the end of the bed. This will automatically put them into an extended position. So so far we discussed the indications front of neck access. We've discussed the functional and that to me on, we discussed at optimal positioning to achieve achieve a successful outcome. Next, we're going to talk about the equipment and the advantage off that that's guy violence, that you need a relatively limited and simple amount of equipment. And so your knee is a size 10 Scalpel. Governess booty a size six and educate, chewed on a syringe that should be reading available. And you need to check that cuff on your cheek is working before you. So now we're gonna move on demonstrating the technique. Today, we're going to be using this animal model head just to reiterate the Let me we can handle you live the skin away. This is the thyroid cartilage cricoid cartilage. And then, like if I remembering in between So we've got our kids ready and we would obviously have assistant ready to inflate the cheap. So first I'm going to demonstrate the staff twist booty tube technique, which he use when they're a palpable landmarks. So we start with a lower into your hand shake using our index finger. We run down from the thyroid membrane until we identify at quite a fire with membrane on our finger, middle finger and thumb, a stabilizing the trickier. So I'm left handed so you will mirror these maneuvers if you're right handed. So taking this campell. You're stabbed through the quite a thyroid membrane. Then you turn the blade towards the feet and pull this careful towards you. He then swap for your non dominant hand in this case, my right hand and take the bougie called it parallel to the floor and slide the code a tip along side scalpel blade inside. Okay, rotate 90 degrees and passed a cruise down into the trachea. You can then remove the scalpel using a lubricated to size six, and she's gonna pass that booty on using a twisting technique. Pass cheap into the trachea. You're going to remain the BG Yeah, inflate cuff, and then you could attach. You wear a device invented one thing that's very, very important to check. Once you pass the cheap, it is the length of the tree, particularly in a situation every lots of adrenalin flowing. It's very easy to persecute too far in one of the bronchus broncho, which could potentially and, you know, have your life. It's to get oxygenation that improved very quick in the event that there is no palpable landmarks. Then you need to proceed to the second describe technique, which is using a vertical incision. Next, I'm going to demonstrate that a scalpel finger bruise easy technique, which you would use when there are no palpable landmarks. So taking your scalpel, you're going to make a 10 8 10 centimeter incision, starting from the stone or notch and going up towards the chin using your fingers. You're thinking toe blunt. Dissect through you until you have palpable land marks on the cheek. Here, having blunt dissected well, now proceed with a stab twist. Bruise easy technique as before, having palpated the cracker thyroid membrane. We'll perform the staff twist so that they're sharp with the blade is facing the feet as before and pull the blade towards us. We then stopped for a non dominant hand and taking the booty, holding it parallel to the floor and again sliding the codeine tip along the blade into the trachea. Now rotate to be in line with the Creon and passed the booty down. You commended rental Rachel Cheap. Same way described with previous, I say hopefully secured the airway successfully. It's important to take a deep breath when you drain them, wear off, take stock of the situation and make a definitive way management also congratulate your team that helped you on. Think of an appropriate time and place for a day, right? Nothing. So I've just got a couple more slide so immediately after you've successfully achieved from the neck access. Essentially want to secure the tube. I think we're gonna doctor that had a little bit. Check the capnographer. You'll need a chest X ray to look for any complications, and you want to organize a plan for definitive airway management moving forward and obviously debrief the team in terms of complications. They sort of more immediate ones, obviously. Failure toe. Locate the tube in the trachea, bleeding from the multiple vascular structures that's surrounding the trachea. A something was gonna need to deal deal with fairly quickly on. Then there are there's more delayed complications that may take some time to develop pneumothorax, mediastinum or suffer jail injuries, particularly if there's been a posterior damage to the trick. Here. Subcutaneous emphysema may happen, particularly if if they've been attempts a high sort of high pressure oxygen on. I think I just finished by saying there's no substitute for hands on practice, so we encourage everyone to take every opportunity to practice whenever they can. So that's the end of me talking. Hopefully, we're going to go over enjoying Doctor James Dean's more Who's Who's down in Portsmouth. He's one of the airway leads on, has a special interest in front of neck access, and I understand is no mean windsurfer. So, James, can you hear us? Okay. Yeah. You find Thanks. It's real nice to be picking up with you. Pleasure. How's the course going? You have a lovely day today. It was lots of action in the background. People are currently practicing their front of access on sheet sheet. Larynx is which is great accident. And again, thanks for joining us. And hopefully we're gonna get a few questions up when I'm on. It is, But I guess we could start first of all, but by sort of asking, what would you do next? So weight successfully achieved emergency front of neck access. We've got a size six tube in the cricothyroid membrane. So what would your approach beat managing things from there on? I mean, I think there are some very immediate things, and then there's more things you could do. A more Leslie place. I think you mentioned your to death, and I think with our enthusiasm to get achy been, it's very easy to end up too far. There was actually coming up in in recent weeks. A obstructed airways ended up in emergency surgical scalpel through the technique emergency front, like access in our, um, hum. And interestingly, the attempts to reaction eight the patient after successful to facing were compromised because of right main broken intubation. So this's a recognized problem and does happen. I think the other thing is, is a scalp techniques you can expect bleeding on from our point of using these just what we do in practice, you get goals and put pressure on. So there's the two things that need to be done immediately in terms or what to do next. You mentioned a surgical review. Really? A head and neck surgeon Tear a get hemostasis is the first thing on secondly, some kind of multi disagree discussion to see whether or not it's reasonable to keep with the tube in remembering, or whether or not tracking surgical track us to me. And it is the is the right thing to do next. It's slightly depend very much depends on the exact circumstances that led to the inspector next area? Absolutely. I suppose the other scenario is, if you're in a a center that doesn't have access to either head or neck or Max Wax that, would that would, That would sort of complicate things. You may be less like toe transfer the patient to somewhere, as he say, and sort of damage control, getting, getting immediate control, your bleeding. So so That's another. Another thing. I think it was another. Another question that's come in regarding front of neck access. Is there a role for the use of ultrasound? An emergency front of neck access? Do you have a hernia on that? So my thoughts were because ultrasound is firstly practicing regular practicing front ultrasound is really, really good to improve your own personal familiarity with your that's me of the Net and get comfortable with the neck. So is a really useful thing to practice. It may be used pre emptively. Teo, depending on the anatomy, elected to lead you to identify correctly the correct remembering or even in very difficult Lexapro or two prior to no induction to actually just identify the airway tube itself difficult Next with large neck masses there could be quite significant on deviation of the airway to one side or a lover. So, actually, sometimes it's just a question of finding out where in the neck is the airway itself. If you actually ended up in a sort of a way crisis, it's like, depends on exact scenario. Often airway crises off quite insidious affairs that that, you know, patients may often remain quite toxic, but no arrest for many minutes, actually, with the immediate value is golf sounds. Certainly I think you're doing ultrasounds, so identify neck and at midway through, attempt to rescue the airway from the from the top end. It's totally reasonable. I mean, the other thing is, is that if you're if you're if you're using, can you can you can track your to me as an option Realtor time puncture of the airway tube? Do you kind of try to me, It's a It's a very reasonable thing that I couldn't get myself a couple of times. Yeah, absolutely thanks. James and the other James here in the studio with me, there's there's another question. Why, to some patients still dissection on a high flow nasal oxygen post induction with their system Fundamental um, precepts that you need to establish if you want to expect successful maintenance of saturation using opta play. Firstly, the airway needs to be patient. So whether that be, you're using a video language scope to lift up the tongue and epiglottis whilst muscle left was kicking in a fast patient. That may be a way to keep the airway or whether using your thrust, whether the patient is awake and they're having an awake, fiberoptic nasal intubation, they can stick their tongue out and they're awake, them maintaining their own airway that way. But there needs to be a pathway for that high flow to be passing through. Next up is that Is there sufficient flow to generate a peep? If the patient's mouth is open, the people will be compromised. So Azzam break it difficult to ask patients to close their mouth, but it will generate more people is the one thing. And then the next final thing, I would say is, is that if the patient's body habitus or physiology is such that there is embarrassment of the basis of the lung due to either body mass index or infection, there will be atelectasis or physiological shot going on on the maximum people. Congenital rate with the mouth closed in Optivar O is approximately seven a half centimeters of water. So if that people and if I take one, given the fact it's a higher than your peak and spread your flow rate, it's guaranteed one cannot overcome physiological shot because of basic collect. It's an embarrassment off the basis. Then you cannot expect to maintain sets. Ah, high level consistently for a prolonged period now saying that and no patellar manage to do that for 70 minutes in rather large patients who had compromised airways. But you do have to choose your patient right on that. I always have my patients at least 30 degrees head up, pre and per interpretation on post extra patient. I'm James in Port Smith. I think you wanted to mention something about the use of high flow in in patients with threatened airway. So So Upper airway, impending upper airway obstruction. Just just I was just thinking myself that one of the one of things that I'm most most pleased about having off for is that is the scenario the stretchiness patient twos. I pox. They're tired, anxious and your face with a sort of fairly time urge and requirement to secure their airway. And actually, our experience is being important is where we see quite a few of these patients had next centers that we actually putting up to flow on these scenarios. In most cases, it can substantially improve the work of breathing of these patients personally by some degree of airways things opening. They often seem to be able to their then relax and oxygenation improves a lot of things that improve and suddenly advise you time and you yourself and then relax and take your time to secure airway. When otherwise, it's pretty stressful, messy experience. And obviously, if you're if you're forming awake information on these patients, it is a complete game changer that your nell, my experiences. You doing that any space in patients who got SATs are close to 100% rather than a much more worrying and 91 or 92% with an exhausted Yeah, and I think the video that brand showed a liver of the acute hepatitis was it was a great example of that. Say stretch. It is patient, but the sets were maintained throughout using using thrive. And I guess we get in with a couple of sort of technical questions that have come through. Uh, how easy is it to rotate the scalpel after stabbing like a thyroid memory? I guess I would say you probably have to feel you have to have a go in practice. You will expect some resistance. Andi Other question was, What length would you expect the endotracheal tube to be in the skin? I think we've touched on that couple of times. It's just important to have a listen to double check the tube length, perhaps with the chest X ray. It's hard to give an exact figure. I don't if anyone else going to think anything that what? Why would That is good practice. Teo. You've got the emergency interests change catheter set within which there is an angle piece, which will allow you to attach that to a size six and put bronchoscope through that to make sure your positioning is correct and not too much into the right bronchus. So that's an objective way of finding out whether you what your position is in with your cracker thorough does meet you. Yeah, right. I think so in the session there. So I'm sure you're looking forward to the international section, which is interactive. But first, we have an interview with Dr Helgi A Hanson who's on the council of the Royal College. Beneath this on his interview will be about education in anesthesia. I just like to say add again. All thanks to James for for dialing and from Portsmouth. Much. Appreciate it. Thank you, everybody. And thank you for joining us today. I hope you're enjoying the King's virtual workshop. So far. My knee was poor Willis. I'm the national sales manager at VeriFone for GlideScope. And we've got this. Is that the lunch time slot we've got? We've got a real special glad guest, which I'm gonna hand over to now. So let let doctor huggy answer and introduced himself on. So the floor is yours. Hello? Money's held your hands on on one of the consultants at Imperial College. Health Care. I'm also on the College Council of the Roll College of the Mist. But I'm give making well, completely talking from my own experience and done on hope to talk about Airway management's a little bit. Yeah, we really appreciate time since the day I'll be so thank you very much for taking the time out. It's mostly like to re talk about is the guidance, but never say we training. And I understand you were involved in kind of right in these guidelines as such, but we really wanted we we really want to do them, tend to pick your brain's about it and get your experience kind of the past 12 months. And what made what the future looks like for for training in an answer, easier. And so it gets straightened from the question. So I need to smoke questions, which I guess we've been receiving in the field problem from novices. Anything from consultants as well. So what That has the curve it pandemic had one depart instability to undertake numbers training the co bit pandemic? Is that a massive impact on the anesthesia? Chaining for several reasons, and some of those reasons are actually included in the B J article. So we've had our trainees reading point. We've had consultants redeployed. I became a Nintendo care consultant or four months of the start of this year, which was actually a really interesting experience. Um, but also, the fact that the patients are sick with a communicable disease makes us want to have the most experienced person, um, doing the interview patients. So the opportunity for allowing novices to do these critical intubations is actually much less there than it would have been in the past. Also, people like me were taken up to the item you and taking away from the from from the, uh, the theater floor where we were doing routine operations, and the UK cancelled suedes of operations nationally that the novice in the cities would have been doing their intubations on. So all of this has has amounted to much less training opportunity in really life for these trainings. And my heart really goes up to them that they had such a difficult year other than what we would normally be able to give them. Yeah. No, exactly. Yeah, we've been looking at the guidance. Not a lot of stuff we've been hearing about this several strategies that they're being employed to kind of optimize trailing off, know it's in theater. So these were the first being video endoscopy on how this confusing alternative to direct laryngoscopy. Can you elaborate on necessarily be used in your trust in your practice you've been seeing. But the l's maybe replace that will be used instead of four. How is that assisted? So I have to say in our trust, everything a Attard has both the video laryngoscope on do a, uh, obviously the normal Macintosh laryngoscope. So using the video lowering laryngoscope is it's not a fast it is there and it's available, and we use it all the time. I use it on several of my lists. Generally, if I'm working on my own, I'll just use whatever my ODP gives me because I'm flying, working with both. But actually what I really enjoy about a little video laryngoscope so and I'm not being paid by Gladys scope for this or anything like that s o s so on. But I love all the laryngoscope so equally on. But what I love about it is being able to teach people so easily while I can still see. And one of the big, uh, anxieties that the teacher has is that we can actually see what the training is seeing with the direct laryngoscopy, whereas with the video laryngoscope We can see exactly what they're seeing on. We can go. Okay, that that that thing there, that thing there is the is the larynx. And that's where you need to put your tube on day. So it's actually a really fantastic teaching tool. And in fact, white Recently I did a bariatric list with, uh I think four or five patients on it on Dad A medical students, which student with me who had never interpreted anyone. And I have to say, by the end of the list, the first one he he was quite shocked up being made to intubate. First of all, you thought he was just gonna be watching. No, sorry, this is a doing less not a not a watching us here on by the end of the list, he was actually really good or intubating. And this is where the video laryngoscopy comes into. It's it's four, and it's a fantastic teaching tool, know and just makes it quite easy and allows the teacher to feel calmer about allowing the student too, to do that thing. Yeah, Yeah. Then that said, um well, what What technique to use when you're using a bit of video and just group. Obviously it's It's a mile. What brand? What you say. But well, in the guidelines, they talk about the content, screen away. Some of the consultants in see and look at the screen visually and then on the novice has to look direct. That's always got to use a Macintosh later. Is that kind of what you do? Is well or so I would probably start with the video laryngoscope because you get most of the technique from that with easy view from the slightly anxious teacher in the corner going No, don't do it like that. Um, on bend, Move on to the direct laryngoscope. Yeah, okay. Do you have any fears of be Skilling with video Learned describes? I have sent a publicly before that I'm slightly sad by the fact that the video lowering escape make my life so much easier because intubation is this special thing that makes this could do and nobody else could do on D actually is much easier to teach. Using a very video laryngoscope on DMA oh so intubations Aires ear with the video laryngoscope compared teo the direct during sleep. However, I think there is still a place for direct laryngoscopy on. There are some information's where you start with the video laryngoscope and just because of the anatomy, the way this way, when there's a short distance between the base of the tongue and the on the larynx. And, uh, there are just times when a direct laryngoscope better on go I I sometimes do switch from the video doing step to your door. It's lowering step, but not very often. And looking at we discussed the strategy. So video laryngoscopy is one of them. The other strategy is looking at different locations. Where where are you? Trading could be conducted? Um, in your experience where? You know what? What if you don't overcome this? And where have you come back? The training, because honestly elected has gone down. We have about a year and be it. It s o in my hospital. I'm probably quite lucky in some ways, that sent Mary's is a very emergency hospital and actually are overall intubating activity hasn't gone down that much. Even the height of Kobe. It it did for the first copay, but second code that we actually did quite a lot of emergency operations on our trainees got most of the experience is that they need it. But I think it's really important to remember that we can do a lot of this with simulation. Um, Andi. There are some very, very realistic simulators, and they can certainly teach you the techniques. And then it just after that it becomes, ah, state of mind that every consultant who was working in the building, if they have a teaching opportunity, it's It's your duty really to make sure that people know that there is a teaching or jundi around on. But for some of the numbers, trainers trainees to be able to come into your theater and do the intubation with that that leads. I'm really nicely to that kind of Next question, I guess, because we're looking obviously training with Bill in theaters. I guess the next question is out of here to trailing. So we've got kind of the one thing to discuss and kind of reading elements to this, which I put down is what what is the value and workshops is where this is. The value in Virtual slash hybrid conferences or workshops are and then also finally helping the use social media you quickly and such mean. It's fun as a training that form to it. You can get promote, new training. And so I guess it's kind of re questions in there. What's your thoughts on the on the value of each of them. So I think my thoughts about using other forms of training probably encapsulated by what we did before our first Crovitz surged. So we if you can cast your mind back, it feels like a very long time ago February 2020. A lot of water has passed under the bridge, but, um, but we we had this thing that was about to come on. But nobody had really seen that many cases by then, Um, and and so we did quite a lot of training during that that area when we were training people in using the BP, but also using the ppd with intubations. And we changed the way we we did the interpretations. Not sure whether that was the right thing to do in the end, because the safest way of doing stuff is to do the stuff that you've already learned, rather than trying to learn a new technique But essentially, we used on awful lot of simulation during that time, which was highly successful on day, and it made us a lot pretty much pretty aware off what we needed to do on. There is no reason why we can't use that sort of simulator. Um Morphea Quint before our trainees on on day, I would encourage all of us to do so. Yeah, What's your sports? I guess I'm kind of on the virtual side of these workshops. Needs to come out. I would work similar to this one today at King's and and you might have seen it to the guys and say Thomases Workshop. So and then there were days. I mean, it was it had some great benefits, but it's obviously, you know, you've got a much wider audience, but then you miss you losing that kind of physical interaction of hands on experience on. So I guess, what's your ports on? Virtually. You think it's going to stay around and you tell me I think it does. I think it's an amazing opportunity is an amazing thought that, you know, there are what 2000 people registered for this workshop on on Dnep for in a wildest dreams. Would we have had a conference on something like this with 2000 delegates? And it's on be pretty expensive to hold and things like that. And yet on dirt, be for most people, it would would be impossible to come to a one day conference, um, from the other side of the world. And I think it's just uncredible opportunity too big to be able to do this and to be able to spread the learning further and wider than we have a before. Um, personally, I think that we're likely to continue, um, using virtual ways of doing things. And I think the hybrids probably has the greatest potential off, for instance, having a electric the answer with a television style audience. But this is being that live teo the world as well. And this although you don't get your your hands on experience yourself, there's a lot of what Once you've heard a little bit of hands on experience, there's a lot you can gain from watching other people do it. And actually one of my hobby horses and one of my pact hates in in anesthesia and actually in anything is If, for instance, if a train he's been struggling with the procedure. And I'm bailing the maps on day rather than watching me do the procedure and usually getting it in because I'm normally quite good at tennis. These have been doing it for 22 years, so it should be fairly good at it. They get distracted by something else and go and do something else. Nothing. Hang on. You know, Are you trying to learn something or not? And and you gain a massive amounts of experience from watching other people do something. And I love watching my colleagues and and every time I see one of my colleagues in these tights, I I learned something new. Eso Why you can't do that Virtually. I see no reason. Yeah, well, that's on it. It's sharing. Best practice isn't wouldn't trust, which you might not usually interact with mean, I guess, even though all the experts New world in your trust, you get all these techniques. But then if you can kind of spread out not internationally, with globally as well get difficult, and tricks work through all that as well. So it's it's one touch that because I AM and it gets it leaves kind of final bullet when you talk about was the social media side of things as well and how we commute allies that training, you know, a lot of people. I mean, there's a lot of kind of big here being big doctors out there that she know. Tim cook yourself. There are thousands of followers, and it puts a great content out there. Um says yes that when you see the value in in social media in kind of a reaction to it and an instant thing twitches to need one isn't mean. It's it's for it's for us, but And yeah, so So I apologize for all the trash that efforts on my social media accounts as well. But people seem to like it, and maybe that's the That's the key here is that, um, you have Teo pick people up doing it for entertainment as well. On diffuse have a very dry social media presence that with very dry mountain, Then people switch it off, whereas it if it's interesting and engaging and short, then people will watch it or or read it. And actually, while you're scrolling a doomed scrolling the various things that are on your timeline and you see something educational just having that 15 seconds of education. Actually it and it meant up, and you end up with a lot of educational opportunities from those little tip. It's that get done on social media and on their their certainly evidence already from very studies that apologies for the most like they're They're certainly evidence from from very studies that the the, uh had promoting something on social media actually increases engagement and increases learning on. But there's no point producing educational content if people aren't learning from it. We're doing it for learning, not for teaching and being able to access social media for that is immensely bug a boo for Lent. Yeah, number expel sense. Yeah. And of course, you want to put the the old picture of the beach on there. All your five k run. Well, it's just we've got to be done. People like to Europe is, um, a little There you go. Yeah. You actually expect that? Um I don't find it disturbing the roughness that we were nearly a time there now, So, um, I guess that the rest of the guidance is looking kind of the national strategies, and this is looking at the future. And I guess we kind of already took touched on this. Um, but like the noise, the government's stepped around over it and heat help teaching throughout Kobe for novices. So where do you see the future of this house? You know, as the printer goes back to normal as we start open back up is that many of these structures are going to keep We're going. You know what? We're going to keep what we're not going to keep, you know, Where's the future off training for numbness is so I'm gonna firmly sit in the middle here and say that the strategy, um, post Provent strategy is going to be a mix of what we did before and what we what we did urine co bit. Um and I'm very, very glad, but certainly at the moment we're in a low as far astray of its concerned on. I hope they're e dearly that we never have a surgeon over again. And I'm actually slightly optimistic that we might not on go Oh, when now, looking at the post craving future on. But I wouldn't want to change everything back to the way we did it before. I think some of the online novice course this increased attendance and increased learning. Therefore, um, Andi made it very easy for those who couldn't make it to Teo. Watch it later on, catch up on. But I think a lot of that. A lot of the simulation that we did well stay. But I do think that there is absolutely no substitute for doing it and realize yourself with somebody watching over you. And I think that's that's the important thing here. We cannot do away without realize training with realize a niece, this real like patients and really life teachers. Yeah, I think that's it. And I just hope that you guys enjoy the rest of the rest of the workshop. And thanks very much for asking me to do this little 15 minute thing.