|Year : 2020 | Volume
| Issue : 3 | Page : 119-126
A magical journey into knowledge creation in emergency difficult airway access – Defining the destination, reserving your seats on the magic carpet
Department of Otolaryngology-Head and Neck Surgery, St John's Medical College and Hospital, Bengaluru, Karnataka, India
|Date of Submission||21-Nov-2020|
|Date of Acceptance||30-Nov-2020|
|Date of Web Publication||25-Dec-2020|
Prof. Arumugam Ramesh
Department of Otolaryngology-Head and Neck Surgery, St John's Medical College and Hospital, Koramangala, Bengaluru - 560 034, Karnataka
Source of Support: None, Conflict of Interest: None
The aim of this article is to ignite the minds of readers and empower them to create new knowledge in relation to 'emergency difficult airway access'. It starts with a structured description of a challenging healthcare situation in emergency airway access in a resource-limited setting. Questions in nine domains relevant to healthcare are addressed. The reader is encouraged to create their own questions using the Population/Intervention/Comparison/Outcome format. The concepts of hypothesis framing, variables and conceptual framework are explained based on the research questions. Framing objectives from a research question is explained in the given context. The relevance of each category of question and its implications for practice, policy and advocacy are explained in detail. The writing is contextual and enquiry based. This is the first of a series of four articles. The articles to follow will deal with designing the study, data analysis and applying/expanding knowledge. The aim of the series is to empower readers to create product/process/paradigm/positioning innovations in emergency difficult airway access for better care of humanity.
Keywords: Ignited minds, knowledge creation, research question
|How to cite this article:|
Ramesh A. A magical journey into knowledge creation in emergency difficult airway access – Defining the destination, reserving your seats on the magic carpet. Airway 2020;3:119-26
|How to cite this URL:|
Ramesh A. A magical journey into knowledge creation in emergency difficult airway access – Defining the destination, reserving your seats on the magic carpet. Airway [serial online] 2020 [cited 2021 Jun 17];3:119-26. Available from: https://www.arwy.org/text.asp?2020/3/3/119/304856
| Introduction|| |
The intention of this series of four articles is to create a pathway for knowledge creation in managing emergency situations where securing airway access is difficult. The process of knowledge creation is an exhilarating experience. The minds of scientists engaged in discovery and invention are ignited with the passion to create new knowledge.,, There is mystery, thrill and delight when new knowledge is created, hence the term 'magical journey'. In this context, knowledge creation is defined as innovative products, process, paradigms or positioning of existing models of care to solve challenging situations. I have adopted a story-telling style, for we all love stories. There is a flavour of 'One Thousand and One Nights' (Alf Laylah wa-Laylah). I pray your minds get ignited if not yet and/or more ignited for those whose minds already are. The overall intention is for India to become a primary knowledge creator rather than a knowledge consumer.
Creating new knowledge requires a new method of thinking. From our early childhood, we are trained more in knowledge consumption than creation. This denies us the access to knowledge creation. On completing this series, you will begin to re-wire your thought pathways. A new way of thinking will emerge. You will start seeing situations in a transformed way like you have never seen before. That is the awakening of your long-suppressed ability to think and create.,,,, Though I am focusing on a very specific area – 'Difficult airway access in emergency' – the process can be applied to any situation. It is recommended that the reader follows the step-wise process as described to acquire this ability.
So, let the magic begin …..
| The Beginning: Defining Challenging Situations in Difficult Airway Access in Emergency Scenarios|| |
So, let us begin at the very beginning …
It is 2 am on a New Year day. Dr Abhay is woken up by the emergency room staff. Chanchal, a 30-year-old male riding a motor bike in an inebriated state, allegedly crashed into a tractor. Madhu, his sober girlfriend who was pillion-riding, was thrown forward and her neck hit the handle of the motor bike. Chanchal had bilateral mandibular ramus fracture with restricted mouth opening due to pain. There was no evidence of intracranial injury. Though Madhu had no external neck injury, she was barely able to breathe. Dr Abhay has been working for 2 years in this remote district hospital located in a hilly terrain. Prior to this, he had trained as a postgraduate resident and a senior resident at a regional medical college. This is the first time he has had to independently manage a situation like this. People of Madhu's village have assembled outside the emergency room. The nearest city with a medical college hospital is a 2-h drive across a difficult hilly terrain. Drawing on all his courage and with a prayer on his lips, he prepared to manage the situation. He had observed a few similar situations during his residency, but had never managed one independently. He had witnessed fibreoptic intubation on one occasion and emergency cricothyroidotomy on another, neither of which he was confident of performing. A curse crossed his mind for he had been requesting the District Health Officer to procure a fibreoptic bronchoscope for the previous 6 months. It was considered a non-essential item and refused. The otorhinolaryngologist and the general surgeon were both down with mild COVID illness and admitted to the medical college hospital. Dr Abhay tried to secure Chanchal's airway using a supraglottic airway device (SAD). He could not get a good fit and the patient started desaturating. An emergency tracheostomy was attempted but was unsuccessful as Dr Abhay had never performed one before. Madhu was fortunate for the SAD fitted well. However, ventilation through the SAD resulted in high airway pressures. Both were shifted in an ambulance to the nearest medical college hospital with Dr Abhay accompanying. Half an hour into the journey, Chanchal arrested and could not be resuscitated. Madhu ended up with irreversible hypoxic brain injury and was bedridden for a lifetime. Dr Abhay narrowly escaped being manhandled by the relatives as he was travelling in the ambulance escorting the patients during the event. Nevertheless, he had to face a departmental enquiry. Though absolved of negligence, the enquiry concluded that he was grossly underskilled. He was demoted and transferred to a Primary Health Centre. The incident left a painful scar and in a year's time, he resigned from the job. He now does freelance practice and is very careful in his selection of cases. He shies away at the slightest hint of a difficult airway and asserts his right to select cases in elective situations. All difficult airways are referred to the medical college hospital.
A close examination of the scenario uncovers the following set of challenges:
- Why was Dr Abhay unaware of the number of such cases that come to his hospital? (It could have assisted him in convincing the authorities for investing in emergency airway access systems such as fibreoptic bronchoscopes or videolaryngoscopes.)
- Why are standards for training in emergency airway access (in terms of time to access airway in various emergency situations) not incorporated into anaesthesia certification examinations? (If time ranges for securing airway in various situations were available, Dr Abhay could have made a more prudent decision in Chanchal before inserting an SAD.)
- Why did the Health Ministry lack data on the status of trained anaesthesiologists capable of accessing difficult airways in emergency situations leading to death/irreversible brain hypoxia in district hospitals? (The lack of trained personnel and consequences thereby would have been visible for initiating action.)
- Chanchal was stable till an attempt was made to access his airway. Was Dr Abhay aware of the complications or shortcomings of an SAD? (A controlled trial of SAD in Indian settings would have provided information to make a better decision.)
- Why did Dr Abhay not highlight the cost-effectiveness (lives saved for money spent) to the concerned authorities for convincing them to invest in emergency airway access systems? (A health economic study in the Indian context would have highlighted the incremental cost-effectiveness ratio for Dr Abhay to make a strong case, which would have protected him from demotion.)
- Why did Dr Abhay not anticipate the possibility of a paraglottic haematoma in Madhu, which is the common reason for high airway pressure requirement in blunt neck injuries? (If a point-of-care decision-making algorithm was available on Dr Abhay's smartphone, he could probably have attempted a cricothyroidotomy.)
- Could airway access training using a simulation device with embedded training algorithms for optimal positioning and transport in the medical college have reduced the risk of death or irreversible hypoxic brain injury? (Data on adverse event reduction by simulation-based training would have convinced education authorities to invest in this technology.)
- Did Dr Abhay have estimates of time required to access difficult airways in various situations based on his training? (If there were data on correlation coefficient estimates between the number of difficult airways managed in the emergency and time to secure airway, probably he would have waited in Chanchal's case till he reached the medical college hospital.)
- Why did Dr Abhay lack a powerful strategy to convince health authorities to invest in fibreoptic devices to access airway in emergency situations? (An in-depth interview with health policymakers would have assisted in creating a 'Grounded theory' on perceptions of hospital managers on investing in expensive but cost-effective technology. This 'Grounded theory' can give access into the thought process of hospital managers. This access can assist airway managers transform the thinking of hospital managers and influence their decisions.)
In a simple and logical manner, we must elaborate a challenging situation and ask relevant questions. This is the first step in knowledge creation. Now these questions, though appearing natural and spontaneous, have a particular thinking process working in the background. We will explain this and refine the questions.
Why was Dr Abhay unaware of the number of such cases that come to his hospital?
These types of questions are classified as 'Description questions'. We usually observe and ask what is the proportion of cases seen in a particular setting. In the present situation, a prior knowledge of this, displayed as a dashboard in the hospital, could have highlighted the importance of preparedness to deal with such situations. This question can be further refined as:
Here, we have introduced the concept of outcome/event and population which are components of research questions. They are self-explanatory.
Why are standards for training in emergency airway access (in terms of time to access airway in various emergency situations) not incorporated in anaesthesia certification examinations?
This question addresses the range of a parameter (here, time to access airway in various emergency situations). We call these 'Lab range questions'. Here, we examine the range of a relevant quantitative parameter. If the doctor had an estimate of time taken to secure and stabilise the airway in various emergency situations, he would have waited in Chanchal's case till reaching the medical college hospital. A refined version of this question is:
Why did the Health Ministry lack data on the status of trained anaesthesiologists capable of accessing difficult airways in emergency situations leading to death/irreversible brain hypoxia in all district hospitals?
Here, we step back and look at the larger issue of lack of trained personnel in the region/state/nation/world. This highlights the otherwise invisible healthcare lacunae. 'Incidence/Prevalence questions' is the term used for this category of questions. Incidence is applicable, if new events are measured, like deaths prevented by ensuring training to manage difficult airways in a region/state/nation/world. The answer to this question will give accurate estimates for policymakers to understand the burden of the adverse event. A more accurate way to frame this question is:
Chanchal was stable till an attempt was made to access his airway. Was Dr Abhay aware of the complications or shortcomings of SADs?
In this situation, we question the efficacy of one intervention over another, or not intervening at all. A scientific approach with adequate controls is required to prove the efficacy and safety of treatments. Such questions are classified as 'Therapy questions'. There is a need to examine the appropriateness of various conventional treatment modalities and revise them based on the needs of the Indian context. A more accurate way to frame this question is:
Why did Dr Abhay not highlight the cost-effectiveness (lives saved for money spent) to the concerned authorities for convincing them to invest in emergency airway access systems?
Cost determines policy. Questions such as this address the need to measure costs in healthcare. Costing is an elaborate exercise involving measurement of all facets of expenditure. 'Cost questions' are an important category of questions that we must ask in challenging healthcare situations. A more accurate way to frame this question is:
Why did Dr Abhay not anticipate the possibility of a paraglottic haematoma in Madhu, which is the common reason for high airway pressure requirement in blunt neck injuries?
Asking questions such as this emphasise the need to have reliable prediction tools: tools for predicting adverse events in a given case and tools based on the collective past experience of practitioners based on refined decision-making. Here, we explore the domain of creating systems or devices that can diagnose/screen/predict events. After creating such tools, they have to be validated in real-life settings. 'New Test question' is the term for this type of question. A more accurate way to frame this question is:
Could airway access training using simulation device-embedded training algorithms for optimal positioning and transport in the medical college have reduced the risk of death or irreversible hypoxic brain injury?
Measuring and reducing risk factors aids in preventing adverse events. What are the odds of death or irreversible hypoxic brain injury when you have personnel with hands-on training using advanced simulation systems in comparison to those trained using conventional observation in real emergencies? Here, we examine the possibility of reducing adverse events by training graduates using advanced simulation systems. Hence, they are termed 'Risk Measurement questions'. A more accurate way to frame this question is:
Did Dr Abhay have estimates of time required to access difficult airways in various situations based on his training?
The ability to calculate a measure based on another is a useful guide in practice. Correlation between age and tracheal size assists in selecting the correct endotracheal tube. Correlation coefficients are mathematical constructs that assist in correlating two relevant numbers. Hence, they are termed 'Correlation questions'. A more accurate way to frame this question is:
Why did Dr Abhay lack a powerful strategy to convince health authorities to invest in fibreoptic devices to access airway in emergency situations?
We are limited by our thinking. If we have an in-depth knowledge of the thought process of another person, then we possess the ability to transform them. Questions that explore the thought process of another person are termed 'Beliefs/Perceptions/Experiences question'. A more accurate way to frame this question is:
Defining the objectives: Reserving your seats on the magic carpet
Accurate framing of a research question, followed by distilling objectives, is the crucial step in the magical journey of knowledge creation. Unfocussed objectives are a result of inaccurate questions. It is like getting into any bus parked in the bus station. This is fine as long as you want to go somewhere. This translates to faculty writing some paper for fulfilling the publication requirements to procure promotion. There is no passion in it. Whereas creating a new product/process/paradigm/positioning to make healthcare affordable, accessible and equitable is a lifelong mission and quite exciting. A correctly framed objective, derived from an accurate question, is similar to booking your ticket for a pre-decided destination to accomplish a specific goal.
There are two skills required to distill objectives from a research question. First, create a conceptual framework and then design your question for statistical testing (hypothesis framing). In creating a conceptual framework, the larger picture is visualised to enable us to understand if we are clear about what we want to create. So, we define:
- The outcome/event: In our context, death/irreversible brain injury
- Target population: People presenting in emergency with open mandibular fracture
- Two interventions/risk factors if relevant and confounders: Residents trained using conventional methods and simulators are the two interventions. The confounder here may be various causes for difficult airway seen during conventional training. If the resident is not exposed to different types of challenging cases then it may appear that conventional method is less effective than simulator-based training.
Designing the question for statistical testing involves defining all the variables accurately for correct statistical tests to be chosen (hypothesis framing). I will avoid discussing null, alternate, one-sided and two-sided hypothesis to ensure the mental well-being of our readers. Nevertheless, these concepts will be explained in a practical way over the series of articles to follow. Variables can be broadly classified as categorical and numerical.
Categorical variables are those which can be categorised into two or more mutually exclusive groups as described below.
- Death/irreversible brain hypoxia (in incidence/prevalence question)
- SAD versus fibreoptic-guided intubation (therapy question)
- Residents trained using conventional observation training and those trained using advanced simulators (risk measurement question)
Numerical variables can be represented on a metric scale and depicted as numbers:
- Time taken to secure a stable airway (in lab range question and correlation question)
- Probability of securing the airway using an SAD (new test question)
- Time spent on accessing difficult airway using advanced simulation systems and conventional training (in lab range question and correlation question).
Once we are focused and clear in stating the research question, the objectives can be framed effortlessly. The objectives are framed beginning with 'To', as they give a clear direction for action. [Table 1] shows rephrasing of the research question to an objective. Note the rearrangement of outcome/event and population verbatim. You can use the template to frame objectives relevant in your area of interest.
|Table 1: Method to rephrase the research question and frame objectives based on Population, Intervention, Comparator and Outcome components|
Click here to view
Utilising these templates and accurately defining the population, outcome/event, interventions and risk factors is the key to getting started in the right direction. In the next article titled, A Magical Journey into Knowledge Creation in Emergency Difficult Airway Access - Planning your Journey with Research Genie, we will discuss various data patterns that fit the objectives. You will also be introduced to the 'Research Genie' - at your service in the magical journey of knowledge creation in emergency difficult airway access. Till then, frame objectives relevant to your areas of interest.
The author would like to acknowledge Dr George D'Souza, Dean, St John's Medical College and Hospital, for administrative support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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