I posted an interview with a master of the awake intubation Dr. Ian Morris as Part 1 on the subject. Ian is an anaesthetist (who also trained and worked as an ED doc) friend, neighbour and mentor who along with Adam Law taught and inspired me to make the awake approach a real option in the ED. We talk about the awake in EM and Critical Care but we tend to discard it as irrelevant given issues of acuity, time and patient cooperation retreating to our comfort zone of an RSI. We have become perhaps too confident of our ability to rescue the failed RSI. My practice has changed significantly over recent years in part because of my belief in deliberate practice. Deliberate practice requires effortful practice opportunities that challenge the clinician to improve their skill set. But be clear I’m not seeking challenge for the sake of increasing my sphincter tone I'm doing it to give my patient's and me safe options. While this begins in the sim lab, the most common reason I do an awake approach these days is for the apnea intolerant patient who I cannot optimally preoxygenate. Gaining expertise in these cases in part deals with the difficult airway paradox I talk about in my vlog so that I can perform awakes with more skill and confidence on patients with known difficult airway pathology.
I recently gave grand rounds at an US institution after which one of the new attendings came up to me saying that they're worried about losing their skills because the residents and fellows perform all the procedures. I guess I'm "lucky" that our program is small and ~70% of my shifts don't have an EM resident but these skill maintenance limitations do have solutions. Other means of practice are possible such as optimizing your topicalization technique by practicing on each other.
Finally I find it fascinating that we spend so much time and worry about the rare CICO scenario not to mention which method we’re gonna use and most important what we're gonna call the technique (FONA, ESA, TTJV, TTSA, etc) of “putting the tube in the hole through the neck” (I propose PTIHTN) and yet relatively little time taking about and doing awakes. Anyway, if you are interested check it out and thanks to EMCrit for giving me the stage.