Controlled drugs have long been carried by clinicians in a leather pouch on the belt. Closed-cell foam inserts surrounded the vials to provide impact and deformation protection to the glass vials. The original pouch was designed to carry Opiates and with the addition of Ketamine these new vials were placed either above or below the foam insert. There was no room to incorporate further vial spaces in the closed cell-foam as wide cushioning margins were needed to provide impact protection. Due to the harsh prehospital environment vial breakage was common and appeared to be related to both loose vials and the ability of the closed-cell foam to flex. Rebuilding the pouch to a larger size had the concerns of greater size, weight and cost and could not solve flex related breakages.

The solution came from pilot Armin Egli who overheard the failings of the controlled drug pouch. His answer was to design and make a rigid plastic insert by 3D printer. This insert fits the vials precisely preventing rattling. The vial insert depths are tailored to the vial sizes to allow ease of vial removal while maintaining maximum protection. As the inserts are rigid the vials can be closely stacked allowing the original pouch to fit all the current vials carried with a spare slot.

There have been no known vial breakages with the new insert and only positive feedback has been heard. This was a reminder that any member of the team may have the solution to a problem and often the most innovative answer comes from an interface between skill sets. The alternative explanation is that a man who can single handedly make a helicopter simulator can make whatever he likes.

By Dr James LeFevre

Auckland HEMS is currently trialling the Storz C-MAC Videolaryngoscope (VL), and we are also aiming to trial this device in the Auckland Adult Emergency Department soon.

There is much debate in the FOAMEd community regarding the place of the VL in Emergency airway management, with often quite polarised views, and the published literature is yet to catch up with the uptake of the various multitude of VL devices.

There are many different Videolaryngoscopes out there, but they generally boil down to two basic types:

Those that use hyperangulated blades to “see around the corner” (such as the Glidescope that is currently available in Auckland ED), and those that use Macintosh-style blades that are connected to a video screen (Such as the Storz C-MAC).

Hyperangulated VL blades often allow superb laryngeal visualisation, with the downside that tube delivery requires a different technique with an angulated stylet, whereas Macintosh-style blades allow for the use of the same tube delivery technique through direct laryngoscopy (looking directly at the larynx) or indirect laryngoscopy (looking at the screen to see the larynx).

Although the literature is still not clear on this issue, it would appear that some patients are more easily intubated with direct laryngoscopy with a standard blade, and others are more easily intubated with a hyperangulated blade, so intuitively it makes sense to have both options available.

The C-MAC we are trialling has a Mac-3, Mac-4, and a hyperangulated D-Blade option. Potential advantages include the ability to turn the screen away from the airway operator whilst using the Mac blade to allow teaching and the resuscitation team to see what sort of actual view is being obtained (sometimes this info just ain’t forthcoming in real time!), allow assistants other than the airway operator to perform suction under visualisation, and has a hyperangulated blade should a poor view be obtained with a standard Mac blade.

Attached below are some FOAM links which discuss the differences between VL and DL, how intubation techniques differ, and some of the pros and cons to each technique. There is also some published literature in the password protected section, happy reading.

Lifeinthefastlane.com on Videolaryngoscopy at:

http://lifeinthefastlane.com/education/ccc/direct-versus-video-laryngoscopy/

http://lifeinthefastlane.com/education/ccc/video-laryngoscopy/

PHARM (Prehospital and Retrieval Medicine) at:

http://prehospitalmed.com/2012/09/07/why-video-will-never-kill-the-direct-laryngoscope-star/

EMCRIT Scott Weingart versus Paul Mayo Debate – Direct versus Video laryngoscopy at:

http://emcrit.org/podcasts/has-video-laryngoscopy-killed-the-dl-star/

Richard Levitan at:

http://www.epmonthly.com/subspecialties/technology/video–direct-laryngoscopy-/

http://www.epmonthly.com/features/current-features/four-secrets-to-video-laryngoscopy-/

Relevant literature:

A Comparison of the C-MAC Video Laryngoscope
to the Macintosh Direct Laryngoscope for Intubation in the Emergency
Department