DuCanto’s SALAD

[VentMonkey]

I wanted to know if anyone’s agency out there practices either, or both, techniques.

If so, how do you like it/ them? What don’t you like about either item or technique? What do you find easiest? Are they truly as helpful as they appear to be.

I have a lot of respect for Jim DuCanto and folks like him. IMO, he’s attempting to help revolutionize the prehospital airway management playing field for the astute providers.

I really want to pitch both techniques to my program and I’m looking for some feedback, thanks.

 

[DesertMedic66]

The SALAD technique is utilized by Air Methods for all of their new hire training/orientation. They use the DuCanto cath and have a SALAD manikin.

 

[NomadicMedic]

I made a salad manikin and we teach/use it, along with DuCanto caths.

 

[VFlutter]

Like said it is an Air Methods standard so we use the SALAD technique and DuCanto catheter. The DuCanto catheter is awesome and I think better than similar large bore yaunkers like the BigStick. The SALAD technique is very useful and has saved me a few times.

I usually lead with my suction and follow with my camera until i identify if there is vomit/blood then suction and pull out or bury the suction to the left. If they do not need continuous suction then I just pull the yaunker. With the DuCanto it can be a lot of stuff in the mouth, especially smaller people and kids, and hard to pass your tube.

The ability to intubate with the DuCanto, pass a bougie, and then tube is amazing and for great those traumatic airways when you can suction just enough to get a brief glimpse of the cords.

DuCanto, Pocket Bougie, and C-Mac makes me a very confident intubator in almost any situation.

 

[StCEMT]

Honestly, we dont practice any method. A bougie is required and that's the extent of it. I am going to try to put some various airway stuff together to see if we can't update our intubation SOG a bit.

I have had one airway this happened on this year right as I had VL and ETT in hand. Fortunately it was watery and not chunky, but I like the idea of having the tools to use DuCanto's method as a more flexible approach.

 

[VentMonkey]

I made a salad manikin and we teach/use it, along with DuCanto caths.

I’d love to build a “vomikin”.

I think I’m to the point where I don’t think things such as the SALAD technique, DuCanto’s catheter, bougies, and the like should be optional for any prehospital advanced airway manager.

Anyone who disagrees should stick to routine blind airway placement. They have no business performing endotracheal intubation.

 

[NomadicMedic]

I’d love to build a “vomikin”.

I think I’m to the point where I don’t think things such as the SALAD technique, DuCanto’s catheter, bougies, and the like should be optional for any prehospital advanced airway manager.

Anyone who disagrees should stick to routine blind airway placement. They have no business performing endotracheal intubation.

I found a cheap, used airway manikin and then I started messin' about with hoses and pumps. I'll post some pics when I get back from a couple of days off.

 

[Carlos Danger]

I think the suction catheter looks cool, definitely an improvement.

But as far the "SALAD technique", I don't know……I was taught to replace the Yankauer with an ETT and shove it in the esophagus during heavy vomiting many years ago, so it isn't really a new idea.

And just like always using a bougie, I'm not sure leading with the suction for every intubation is necessarily a good idea. You don't need a bougie or suction in the vast majority of intubations, so it just seems like we are adding extra steps to something that instead we should be trying to simplify.

 

[VFlutter]

And just like always using a bougie, I'm not sure leading with the suction for every intubation is necessarily a good idea. You don't need a bougie or suction in the vast majority of intubations, so it just seems like we are adding extra steps to something that instead we should be trying to simplify.

Agree to a certain extent however personally I train for the worst possible scenario, Anatomically difficult airway with massive airway contaminate, and develop that muscle memory. It is easy enough to ditch the suction or not use the bougie for basic intubations but i rather be comfortable using all of the above when i truly need it.

 

[NPO]

I pitched the DuCanto catheter to my department last month and they agreed to make the switch. The guy heading up our clinical department was aware of the SALAD technique, but not very familiar with it. After we had all agreed to switch to the new catheters we decided to roll them out and do a SALAD training all at once during our 1st Quarter in-service. I am going to build a vomikin for the training.

I may even suggest the Bougie-to-Go and make it a two-fer to try and increase the willingness of people to use the bougie. I think some of the negative stigma still applies.

 

[NomadicMedic]

I think the suction catheter looks cool, definitely an improvement.

But as far the "SALAD technique", I don't know……I was taught to replace the Yankauer with an ETT and shove it in the esophagus during heavy vomiting many years ago, so it isn't really a new idea.

And just like always using a bougie, I'm not sure leading with the suction for every intubation is necessarily a good idea. You don't need a bougie or suction in the vast majority of intubations, so it just seems like we are adding extra steps to something that instead we should be trying to simplify.

I think teaching a solid technique that can be used in a stepwise fashion makes sense. I see too many providers revert back to old/bad habits as soon as things start to go sideways. Why not teach to always lead with suction and always use a Bougie? For occasional intubators, it makes sense to stack the deck in their favor.

 

[Carlos Danger]

I think teaching a solid technique that can be used in a stepwise fashion makes sense. I see too many providers revert back to old/bad habits as soon as things start to go sideways. Why not teach to always lead with suction and always use a Bougie? For occasional intubators, it makes sense to stack the deck in their favor.

I agree that we should try to stack the deck in favor of the occasional intubator, which is exactly why I don't support the idea of adding extra, unnecessary steps to the procedure. By using a bougie and suction on every intubation, you are literally requiring tools and steps that are not necessary the large majority of the time. How is that helpful?

Here's the thing: Among new or occasional intubators, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. Another common difficulty is in visualizing the glottis but not being able to pass the ETT. Both of these problems can be mitigated by using good progressive laryngoscopic technique along with external laryngeal manipulation. Because the problem of anatomic visualization (getting a view of the glottis) is a far more common one than massive airway contamination, I think the best use of your right hand is ELM, rather than suctioning a pharynx that has nothing in it to suction.

As far as the bougie: Even though I don't share the opinion, I can definitely see why so many people think using a bougie on every tube is a good idea. A bougie does, objectively, make many intubations easier. How can that be a bad thing? For two reasons: First, it *usually* simply isn't necessary, so it adds an unnecessary step. Second: Again, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. This is usually a technique problem, which should be addressed rather than covered up with another tool. The bougie does indeed make proper airway instrumentation and axis manipulation less important, which is a good thing if you are legitimately having trouble with an airway. It might not be the best thing though, if you are trying to improve your laryngoscopy technique. Requiring new intubators to use the bougie on every intubation because some intubations are difficult is like requiring someone learning IV's to use a vein finder or ultrasound on every IV start, because some IV starts are difficult.

IMO, prehospital airway management training and protocols should focus on preparation, solid, basic technique (positioning, progressive laryngoscopy, ELM), and quick, smooth transition to use of a bougie or suction when necessary. I also advocate for NOT using a stylet in the ETT.

 

[CANMAN]

I agree that we should try to stack the deck in favor of the occasional intubator, which is exactly why I don't support the idea of adding extra, unnecessary steps to the procedure. By using a bougie and suction on every intubation, you are literally requiring tools and steps that are not necessary the large majority of the time. How is that helpful?

Here's the thing: Among new or occasional intubators, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. Another common difficulty is in visualizing the glottis but not being able to pass the ETT. Both of these problems can be mitigated by using good progressive laryngoscopic technique along with external laryngeal manipulation. Because the problem of anatomic visualization (getting a view of the glottis) is a far more common one than massive airway contamination, I think the best use of your right hand is ELM, rather than suctioning a pharynx that has nothing in it to suction.

As far as the bougie: Even though I don't share the opinion, I can definitely see why so many people think using a bougie on every tube is a good idea. A bougie does, objectively, make many intubations easier. How can that be a bad thing? For two reasons: First, it *usually* simply isn't necessary, so it adds an unnecessary step. Second: Again, the large majority of difficulty with intubation comes from not properly recognizing or visualizing the anatomy. This is usually a technique problem, which should be addressed rather than covered up with another tool. The bougie does indeed make proper airway instrumentation and axis manipulation less important, which is a good thing if you are legitimately having trouble with an airway. It might not be the best thing though, if you are trying to improve your laryngoscopy technique. Requiring new intubators to use the bougie on every intubation because some intubations are difficult is like requiring someone learning IV's to use a vein finder or ultrasound on every IV start, because some IV starts are difficult.

IMO, prehospital airway management training and protocols should focus on preparation, solid, basic technique (positioning, progressive laryngoscopy, ELM), and quick, smooth transition to use of a bougie or suction when necessary. I also advocate for NOT using a stylet in the ETT.

Agree with both posts 110%. We actually focus on teaching these exact things in the cadaver lab for the CCEMT-P program I instruct for. I think now a days there are too many people coming up with a "new technique" or something fancy to rework a procedure, and a lot of people who already may struggle doing the basics well now feel like they have to implement this "cool" stuff. You guys must be seeing some really nasty stuff on the regular, because I can't remember the last time in my flight career, time in the trauma bay, or frankly the last EMS call at my ground part-time job where I wasn't able to control the airway, and/or intubate with just standard equipment, preparation, and technique. I think everything mentioned in Remi's post will do far more for people's airway management skills they trying to pull off something fancy in an already bad situation. We see some pretty nasty airways in the trauma center I have to rotate in, and every single person ends up getting an airway without SALAD or these DuCanto's. While I think they appear to be a better device and pull more volume, we just don't have them and things go down just fine when needed and performed by experienced airway managers.

 

[Tigger]

https://emcrit.org/emcrit/failed-airway-algorithm-2018/

Food for thought at least.

For me, I use the bougie every time. I don't get enough tubes to get particularly comfortable with any method, so the idea of having a "backup" plan does not make sense to me as I will no doubt be less comfortable with that procedure in the event it is needed. So, I work a single procedure that will get safely and efficiently allow me to intubate nearly all of the time. If that makes things somewhat more complicated and overkill, I am ok with that. I simply do not get the reps in on difficult airways to have a separate difficult airway procedure. Apparently Weingart calls that "single skill mastery" in the above, who knew. I treat every intubation like it is going to be super hard, and yes, sometimes it is annoying to have railroad a tube over a bougie when I have a grade 4 view. If the hands are available, I just have someone give me the tube and I place it.

As for the Ducanto, it is awesome. It really is. Getting chunky vomit out is a pain and the Ducanto does make it easier. I trained to connect a 9.0 tube to suction at one point for this reason, turns out using the Ducanto is much more elegant. As for the SALAD technique, it does work but I would struggle to call it easy or as effective as it looks. I find keeping it in the esophagus is very difficult while intubating, it has a tendency to slip out. Never mind if chest compressions are occurring, you need someone to hold it in their for you, which the ELM person can certainly do.

 

[VFlutter]

I can't remember the last time in my flight career, time in the trauma bay, or frankly the last EMS call at my ground part-time job where I wasn't able to control the airway, and/or intubate with just standard equipment, preparation, and technique. I think everything mentioned in Remi's post will do far more for people's airway management skills they trying to pull off something fancy in an already bad situation

In my short HEMS career I have seen my fair share of massive hemoptysis, La Forte fractures w/ significant bleeding, pediatric airways, self inflicted GSW through the mouth, etc that I believe would have been significantly harder or failed with standard techniques. Personally, it works for me and I have the first pass success / lack of complications that support it. To each their own.

 

[Carlos Danger]

In my short HEMS career I have seen my fair share of massive hemoptysis, La Forte fractures w/ significant bleeding, pediatric airways, self inflicted GSW through the mouth, etc that I believe would have been significantly harder or failed with standard techniques. Personally, it works for me and I have the first pass success / lack of complications that support it. To each their own.

No one is saying that you’ll never run into a fluid-filled airway. Just that it makes no sense to suction a dry airway, especially when it prevents the use of other helpful techniques (ELM).

 

[NPO]

I think the point is just to have the technique in your belt. There's no need to SALAD every airway, but having all of our equitpment at hand and ready, and making the decision to SALAD or intubate with your first look is beneficial.

No one is saying that you’ll never run into a fluid-filled airway. Just that it makes no sense to suction a dry airway, especially when it prevents the use of other helpful techniques (ELM).

 

[Carlos Danger]

I think the point is just to have the technique in your belt. There's no need to SALAD every airway, but having all of our equitpment at hand and ready, and making the decision to SALAD or intubate with your first look is beneficial.

I don’t think that’s what they teach, though. Many folks are saying they lead with the suction on every intubation. It’s the dumbest thing I’ve ever heard of.

 

[NPO]

That won't be how we teach it at my agency. More as a tool of needed type of thing.

I don’t think that’s what they teach, though. Many folks are saying they lead with the suction on every intubation. It’s the dumbest thing I’ve ever heard of.

 

[CANMAN]

In my short HEMS career I have seen my fair share of massive hemoptysis, La Forte fractures w/ significant bleeding, pediatric airways, self inflicted GSW through the mouth, etc that I believe would have been significantly harder or failed with standard techniques. Personally, it works for me and I have the first pass success / lack of complications that support it. To each their own.

To each their own like you said. If it works for you then keep on with what you're doing I guess. I'm curious though, after flying for a pediatric team for many years why you think this technique would be of benefit in pediatric airways? The last thing I want to do when managing a peds airway with an already limited view, based on limited size of mouth opening it to jam more stuff in there before I get the best view I can obtain.....