When are ‘human factors’ not ‘human factors’ in can't intubate can't oxygenate scenarios? When they are ‘human’ factors

<span class="paragraphSection">Editor—Timmermann and colleagues<a href="#aex018-B1" class="reflinks">¹</a> raise valid concerns about the recommendation by the Difficult Airway Society (DAS) to use a scalpel cricothyroidotomy as the sole technique in a can't intubate can't oxygenate (CICO) scenario.<a href="#aex018-B2" class="reflinks">²</a> However, their argument falls short on a number of levels. First, although the Fourth National Audit Project (NAP4) has its drawbacks, it is the best snapshot ever created of current anaesthetic practice with respect to complications of airway management.<a href="#aex018-B3" class="reflinks">³</a> NAP4 tells us what is happening now, in the real world, not in a hypothetical reality where 'dedicated training programme(s)' have been instituted. In the real world, anaesthetists cause morbidity and mortality with a cannula technique. In addition, advocating cannula use because it can be practised on real patients is to obfuscate the issue. Awake fibreoptic intubations, which in some institutions are relatively rare themselves, do not need transtracheal blocks because the airway can be anaesthetized with less invasive means. Nor is the pre-emptive use of cannula cricothyroidotomy likely to catch on. Second, a 'human factors' approach to the CICO problem needs to move beyond the human/anaesthetist viewpoint and look at the wider picture. The authors concentrate on the anaesthetic practitioner in terms of familiarity, training, and pre-emptive use. Human factors is the science of improving human performance and well-being by examining all the effectors of human performance. A 'scalpel only' technique, when viewed using a human factors approach, has a number of benefits, as follows. <ul><li class="roman-lower">Task. Equipment can be minimized and standardized, with no need to decide between 'the Enk Oxygen Flow Modulator (Cook Medical, Bloomington, IN, USA), the Rapid-O2 (Meditech Systems Ltd, Shaftesbury, UK), or the Ventrain (Dolphys Medical BV, Eindhoven, The Netherlands)'.</li><li class="roman-lower">Person. In the crisis, there is no need for the anaesthetist to waste time making a decision between cannula and surgical cricothyroidotomy. Precious training time can be focused on the one technique.</li><li class="roman-lower">Team. In the crisis, the team will know what equipment to get. There is no need to wonder whether the anaesthetist has chosen the correct technique for this patient. Precious team training time can be focused on the one technique</li><li class="roman-lower">Organization. The organization can use implementation of the DAS guidelines as part of its governance procedures. The anaesthetic department can use the DAS guidelines to make a case for equipment and training.</li><li class="roman-lower">Socio-cultural. The adoption of a sole technique means that future reviews of difficult airway management can focus on best practice with the scalpel technique.</li></ul></span>

http://ift.tt/2kVNNyf