Page 73 - 2020 JSOM Winter

TABLE 3 Select Qualitative Feedback From Medics on Devices FIGURE 5 Example of rigid tongue causing difficulty in passing iGel
[Preferred iGel] – iGel is excellent for quick intubation. In most using the manufacturer-recommended technique.
casualties I would choose it as long as no contraindications are
present.
[Preferred iGel] – I had been trained on a cric before and no
training on the iGel but felt more comfortable with the iGel . . .
It is way faster to perform and does not really need training to do.
[Preferred cricothyrotomy] – What I’m use to.
[Preferred iGel] – Less invasive, quick, no equipment needed . . .
Doesn’t take too much space and is not heavy.
[Preferred cricothyrotomy] – More trained & informed. Don’t
know much about the iGel. It is simple but I’d need to know more
about it in tactical environment before I carry it.
[Preferred cricothyrotomy] – Only reason I prefer this is due to the
usability with most facial trauma.
[Preferred cricothyrotomy] – Both – these should not be compared.
They are used for separate things. I like both, we need both. We
need more training on both. The mannequins are not realistic. We
need cadavers for this study. iGel is only for unconscious patient
who is staying unconscious.
[Preferred iGel] – It was easy to lose my landmark on the cric. I felt
the iGel was faster and easier. I would feel confident in being able
to get an airway with it. FIGURE 6 Example of artificial rotation of the airway structures
after aggressive attempts at cannulation via surgical cricothyrotomy.
[Preferred iGel] – Smoother, you don’t run the risk of cutting
wrong.
[Preferred cricothyrotomy] – I don’t know how well the iGel will
hold up to over 100° heat or being in an aid bag . . . Not until
I know it works and withstands a deployment for a medic. It
would be good for aid station but I don’t feel it could replace the
cricothyrotomy. Also, if someone had a swollen throat how would
you access their airway.
[Preferred iGel] – I prefer the iGel for speed & cric for maxillofacial
trauma . . . The speed of application coupled with the lack of
thought necessary to successfully apply it would prove to be useful.

training. With regard to the iGel, none had experience with
it during their initial entry training and most, even those with
SGA training reported, advised us their training occurred using
the King LT or a different type of SGA. In addition to the data
formally collected as part of our study design, we noted other
observations with important implications for airway studies in
the combat medic population. Second, while our study team
felt that the Syndaver represents the most realistic mannequin
on the market, it remains plagued with several shortcomings related to the size and weight of the device options. Future
that medics would likely not experience in real life. Addi- studies should capture this data to better assess the limitations
tionally, these shortcomings could potentially lead them to associated with packing aid bags.
a false sense of security during the procedure aside from the
obvious lack of real human-like, anxiety-provoking behaviors The survey data indicate that the medics preferred (59%) the
(e.g., gagging, biting, changes in mental status, bleeding, etc.). iGel over the cricothyrotomy option (Table 3). While not cap-
While live tissue may better simulate a real-world scenario, tured in our survey design, several of the medics only stated
there are no animals that provide the anatomy that would fit they preferred the cricothyrotomy over the iGel because they
human-designed SGAs. Moreover, it introduces substantial were concerned that even with the iGel, there may be a subset
cost and ethics challenges. In one such example, we noted fre- of casualties that would be candidates for a cricothyrotomy
quent difficulty with the iGel catching on the tongue of the but would not tolerate an iGel. Data highlighting the number
model (Figure 5). The tongue is more rigid than a real casualty of patients that would only be cricothyrotomy candidates in
that would likely tolerate the iGel. However, the video from whom the iGel would not work would be useful in answer-
the manufacturer recommends against placing the fingers into ing that concern, but is unlikely to be forthcoming given data
the patients’ mouth – this will easily allow passage of the iGel limitations in the Department of Defense Trauma Registry
into the airway but also places the medic at danger of bite in- (DoDTR). 2,3,6,8,13 However, previous data suggest that very
juries. We also noted that the airway anatomy on the cricothy- low proportions of patients receive a nasopharyngeal airway
rotomy training would become altered, frequently with slight (NPA) before more invasive options. 2,3 Our survey data also
rotations (Figure 6). None of these movements would likely found that 24% reported a cricothyrotomy procedure or at-
be seen in a real casualty. Moreover, when they would place tempt. We believe that number is likely substantially overre-
the cricothyrotomy tube into a slightly dislodged position, it ported and is related to a misintepretation of the question.
would likely result in either a false passage or laceration of a Given the limited number documented in the DoDTR, that
major vessel. We also did not include in the survey questions number seems substantially high.

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