Welcome back! Today’s podcast episode is the next installment in our series on prehospital airway management. Today I review the MSMAID acronym and how we can apply it to our endeavors in EMS. This is a great acronym….and I’m not even an acronym type of guy. I love teaching them though, because they help us organize our thoughts. This one can be useful, certainly in a hectic emergency airway situation.
Airway management is a system. One that we typically don’t “systematize” very well in EMS. The majority of the airways that we manage are crash airways. In other words, we are inheriting a patient with a failed airway and have to rapidly secure it. We’re used to walking into a respiratory or cardiac arrest situation and chaotically slapping together a patent airway. This is a reason why, nationwide, our advanced airway management statistics are abysmal. We need to systematize our airway management strategies to position ourselves as clinicians to succeed, not just get lucky.
In addition to these crash airways, there is a large population of patients that we deal with that can and will benefit from preemptive airway management. This is a relatively new concept to the 911 medic. Pharmacologically assisted airway management scenarios are not something we have traditionally performed frequently. But more and more systems around the country are adopting RSI/DSI interventions into their scope of practice. Having a system in place for those patients is mandatory. If you are administering a drug that will, by design, stop your patient’s breathing, I assure you that you will want to have your system in place to respond to any possibility. MSMAID is an acronym that will help you be prepared.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We need to systematize our airway management strategies to position ourselves as clinicians to succeed, not just get lucky.[/pullquote]
MSMAID stands for Machine, Suction, Monitor, Airway, IV, Drugs. Â It is an acronym that has been used in the anesthesia world for quite some time. As professionals that daily deal with advanced airway management, we can certainly learn some lessons from them. MSMAID is used in the anesthesia environment to prepare. To dot the i’s and cross the t’s. These providers have seen thousands of airways and understand that even the best assessment of airway difficulty doesn’t guarantee anything. Often it’s not known what it will take to secure a patient’s airway until the moment that laryngoscope is inserted. MSMAID puts you in a strong position to respond to any airway you might encounter.Â
M – Machine
- Machine represents our means by which we deliver our positive pressure ventilation. In the OR, machine is the anesthesia machine or ventilator. Out in the EMS world machine often is our BVM. Or possibly a vent if you’re lucky. But regardless of device we want to prepare our machine, check its function, and assign the task of managing ventilations.
S – Suction
- Have your suction ready. Have it put together. Test it. And place it a position easily accessible to the provider managing the airway. Regardless of type of device you must test it. If it’s a powered suction unit, turn it on, ensure it is drawing enough vacuum to be effective. Take a quick look at your suction catheter. Often there will be differences between brands. For instance, some suction catheters require the operator to occlude a port to initiate suction, while others do not. Ensure you know how to use your device. If it’s a handheld manual power unit, make sure it has all of its pieces assembled, you know how to operate it, and that it’s ready to go. You must have suction to be prepared to respond to your patient’s airway needs.
M – Monitor
- Monitor stands for our ability to monitor our patient during the airway procedure. Often this is our all-in-one cardiac monitor that includes NIBP, SPO2, ETCO2, as well as the ability to monitor the ECG. We require the ability to monitor the ventilation, oxygenation, and profusion of our patient in real-time. Make sure your device is turned on, functioning, and that the person monitoring it knows how to utilize it and interpret the data. Ideally, as preoxygenation and ventilatory management will be a consideration in most scenarios, we will be utilizing not only SPO2 but ETCO2 in our prep mode. Have someone prepared to switch from the nasal ETCO2 cannula to the in-line ETT adapter, if necessary. Also assign the task of monitoring SPO2, (as well as other physiological metrics) during the procedure, if you have bodies available to do so. In addition to our technological means of monitoring, don’t forget your trusty ole’ stethoscope.
A – Airway
- Be prepared to succeed. Be prepared to fail. One of the biggest mistakes I see EMS providers make (one of the biggest mistakes I used to make) is not being prepared to manage that patient’s airway if everything goes to hell. I’d always have everything I needed to manage that airway if it went right the first time. But if something didn’t work, I would often be scrambling to respond. By that I simply mean have every airway option at your disposal to get a patent airway established. OPA, NPA, supraglottic devices, multiple ETT sizes, stylette, bougie, multiple laryngoscope blades, video laryngoscope options, surgical airway kit… Have these things, all of these things that you have at your disposal, easily accessible and prepared to deploy at a second’s notice. Planning to fail is a part of any good airway algorithm.
I – IV
- Make sure you have IV access. Make sure you have multiple options available. Make sure these options are patent. Flush them…run the fluids. Observe for signs of extravasation. The time you want to discover your IV is infiltrated is before you initiate your intervention, not during. Also have your IO option out and ready to use. Make sure you have patent access….nothing more to say here.
D – Drugs
- Everybody likes drugs. Better living through pharmacology, right? In this case we need to have all of our meds ready. If this is simply a sedation for intubation, have your sedative of choice dosed and ready to go. If this is a full blown RSI/DSI, you’ll need your induction and paralytic agents. In addition to these needs, you will most definitely need pain management options, if you have an alive patient anyway. So have your analgesia drawn up, ready to premedicate and postmedicate. Also have any reversal agents that might apply to your pharm strategy ready to go. Have fluids ready to respond to any hypotensive side effects these drugs may cause.
Ok, that is MSMAID. I know, another damn acronym to stick into your mental data bank. But this acronym has great applications. Airway management is something we struggle with in the EMS world. Everyday another article talks about taking more and more airway procedures away from medics. I propose that our failure to succeed at advanced airway management has more to do with a lack of training and failure to prepare, than it does with the appropriateness of the procedures to the prehospital environment. Our patients can most certainly benefit from aggressive airway management….from a trained and prepared provider. MSMAID will position you to respond to and secure any airway you might encounter.
Thanks again for stopping by. Hope you enjoyed the episode. Hope this broadened your thoughts regarding airway management. Please let me know what you think. If you liked it, please share it! Facebook, Twitter, share it with your friends and coworkers. Also subscribe to the podcast on iTunes and leave a rating and review. It helps. Thanks again and talk to you again soon. – Derrick