Nemesis of emesis – training for massive airway contamination

Above from left: Associate Professor Stu Marshall and Dr Tim Leeuwenburg; SALAD kit, Kangaroo Island SALAD sim in Chicago.

An international collaboration has spawned a simulation device to teach the SALAD method of airway decontamination.

“Train as you mean to fight” is a term often used in simulation circles. Perhaps the greatest challenge is dealing with the critically unwell or “dynamic” airway – not just anatomical difficulty, but also physiological difficulty. One of the challenges we rarely train for is that of the massively soiled airway. Fasting, passage of a NG tube and RSI should obviate this, but on occasions the anaesthetist will be faced with massive airway contamination, whether from blood or vomitus.

A collaboration between Milwaukee anaesthetist Dr James DuCanto and numerous clinicians around the world, via social media, has led to the evolution of the SALAD simulation. While the inspiration for developing the SALAD technique remains with Dr DuCanto, the global collaborative has been to run this as an open-source project, in the spirit of free open access medical education (FOAMed).

SALAD (suction-assisted laryngoscopes airway decontamination) is a technique we’ve been teaching to anaesthetists, emergency physicians and pre-hospitalist clinicians on a number of courses. The debut was showcased by James DuCanto and myself in Chicago in 2015 at the smaccUS conference, repeated in Dublin in 2016 and will be part of the dasSMACC event in Berlin in 2017. 

In order to refine the SALAD technique – basically, decontamination of the oropharynx under direct vision while simultaneously passing an ET tube – it was necessary to design a realistic task-trainer. DuCanto’s original device involved a complicated array of water pumps and variable control rheostats to modify flow. Meanwhile, individuals worldwide have modified manikins in order to teach the SALAD technique to their target audiences. I use the “Vomi-quin” on the Critically Ill Airway course at The Alfred hospital in Melbourne, as a simple task-trainer to teach the SALAD technique.

How to make a SALAD sim trainer?

A simple airway trainer is adapted by using off-the-shelf garden hose connectors (see http://kidocs.org/2016/10/portable-vomit-simulator/). A bilge pump, powered by a 12-volt battery, pumps simulated airway contaminant to the oropharynx – typically water-coloured with red or green food dye, although particulate matter can be made up using gelatin or xanthan gum. While the bilge pump can deliver up to 500 litres per hour, flow rates are controlled by an in-line ball-valve.

For added realism, either white vinegar or “Barf-ume” (fake vomit smell available online) can be added to provide a strong olfactory stimulus.  

The entire set-up is contained within a Pelican case, which not only functions as a reservoir for simulated airway contaminant, but also allows airway head, assorted suction catheters, laryngoscopes, ET tubes etcetera to be rapidly bundled away for travel. 

I typically fly in to capital cities to teach and can have the Vomi-quin ready to go within five minutes. Disassembly is rapid and the entire set-up (including sealed-lead acid battery < 100Wh) can be carried on standard commercial aircraft when travelling between airway courses.

Use of the Vomi-quin has led to some interesting perspectives on the utility (or lack thereof) of the standard Yankauer suction catheter, as opposed to alternative devices available on the market.  Practice of airway decontamination in head down, head up, left lateral is useful and the performance characteristics of both direct and video-laryngoscopy can be explored.

So “train as you need to fight”; experiment with the SALAD technique using a Vomi-quin and join the global SALAD SIM open access collaboration online – www.facebook.com/SALADSimulation/ or #SALADsim on twitter.

Dr Tim Leeuwenburg
FACRRM (GP-Anaes)
Kangaroo Island, SA


Suggested links
https://emcrit.org/podcasts/having-a-vomit-salad-with-ducanto/
https://www.facebook.com/SALADSimulation/


This originally appeared in the June 2017 ANZCA Bulletin.