@dasairway guidelines out USE A VIDEOLARYNGOSCOPE DEFAULT Videolaryngoscopy is now the recommended norm Some folk will need to make changes. We recently published a narrative review which discusses the challenges and myths around VL and gives guidance on default VL implementation from those who have done it associationofanaesthetists-p… @BJAJournals @Anaes_Journal @Fionafionakel 1/2

“Hello, my name is” introductions & badges need updating to include full name, title & role bmj.com/content/bmj/388/bmj.… Choices choices

It’s interesting that this case - which rests with the decision to sedate rather than anaesthetise (which is judged here to be safer) judiciary.uk/prevention-of-f… Comes in the same week as this case -in which the criticism is of the decision to undertake general anaesthesia instead of deep sedation (which is judged here to be safer) judiciary.uk/prevention-of-f… Both key to recommendations to prevent future deaths Albeit both may be right…. ….medicine is complex and requires careful, often time sensitive, high stakes decisions and actions. Anyone telling you otherwise doesn’t understand and hasn’t done it.

Responding to a tweet I’ll offer this VIDEOLARYNGOSCOPY PROBLEMS….and rebuttals ‘Unavailable’ -yes if you haven’t got it you can’t use it (resource constrained settings) -but in a high income setting unavailability of VL is an OPERATIONAL CHOICE ‘Failure’ -In the recent DEVICE study DL failed more often than VL ‘DL succeeds when VL fails’ -there are large case series of VL rescuing failed DL but none of the opposite -it uncommon at best (and dare I say it) when it occurs often due to poor VL technique ‘VL reduces DL skills’ -if this is true (and I’m not sure it is) I’m not sure it bothers me much, it is a very clinician focussed rather than patient-centred view (cf the LMA reduces FM skills, DL reduces blind nasal skills) -and VL of course is the best way to teach DL skills ‘Capnography more important’ -capnography is vital in determining correct/incorrect tube positioning but has nothing to do with the act of intubation ‘The burden of proof lies with those who want change’ -ok, that proof is widely published, it just needs to be implemented -if VL existed and DL was invented there is about zero chance anyone would adopt it DL is ‘tried and true’ -tell it to the families of patients who have died unnecessarily of oesophageal intubation (One more in NZ media last week, another in UK about to go to inquest) To counter the quote at the top of the slide (which once again is clinician-centred and hints at “heroic healthcare”) ‘Intubation is a potentially dangerous service we provide for our patients, which we should perform in the most effective, reliable and safe way we can. The evidence for each of those three goals lies with VL’ (happy to add refs if requested)

Thanks for asking As some one who has worked in the NHS for 35 yrs and examined its working throughout that time my list of what needs changing would start with Stop breaking the system by defunding it in the name of efficiency. It is way beyond the point at which trying to cut things can improve efficiency. It is doing the opposite. Now not enough diagnostic centres, not enough doctors, not enough beds (numerous reports - ask @NuffieldTrust or @TheKingsFund or @HealthFdn) The rest are relative minutiae but areas to address include * understanding that promotion of the private sector as a realistic alternative to the NHS is flawed. The private sector can do sone things well (low risk procedural stuff) but is no substitute for real NHS hospitals with the full gamut of services (staff, systems, space) associationofanaesthetists-p… *don’t dumb down medicine. There appears to be a concerted effort to suggest that medicine has become less complex, easier to learn, answers available on google etc and as a consequence medicine can be taught over a shorter period and the role substituted by others who are notably less trained/qualified. The truth is that medicine has become more complex, delivered to ever older more complex and more comorbid patients with ever higher expectations (most of which are actually met). associationofanaesthetists-p… This all happens in the framework of an environment in which litigation (certainly costs and numbers to an extent) is mushrooming. associationofanaesthetists-p… While there may be value in working in new ways the lie that doctors can be replaced by less qualified alternatives because the job has become easier is misplaced, disingenuous and dangerous (as well as quite likely being cost-ineffective). There is a danger these systems will be brought in without testing of efficacy, safety or cost effectiveness. rcoa.ac.uk/sites/default/fil… bjanaesthesia.org.uk/article… * IT systems that are slow, outmoded, inefficient and don’t talk to eachother. Wasting thousands of hours of clinicians time every day. Hope that is enough for now. At the core it is FUNDING. No point in reform without funding.

COVID & ICU Intensive care capacity cannot be measured by counting BEDs. It, at the very least, requires Staff, Space, Systems & Stuff Delighted to see this out today. bmj.com/content/385/bmj-2023… A narrative discussing -how the pandemic unfolded in ICUs in the UK (asymmetrically & dynamically) -the response by ICU teams (immediate, selfless & prolonged) -the differences in the March 2020 & Jan 2021 waves (both overwhelming but for different reasons & with differing solutions) -the impact on ICU staff (profound & persistent) While the focus is on ICU the message applies to much of secondary care, which we try to make clear. A pleasure to write with & learn from @charlot_summers & @Kevin_Fong @bmj_latest