Communications Resource Guide: Long-Distance Intubation

When an elderly woman with severe COPD exacerbation arrived at the ED at Northern Cochise Community Hospital in Willcox, AZ, in September 2009, she was aggressively treated with conventional medical therapies and noninvasive ventilatory support, but failed to respond.The treating physician finally decided to perform an emergent intubation using the GlideScope videolaryngoscope and contacted the Tucson Telebation group at the University of Arizona for assistance.

John Sakles, MD, FACEP, professor in the Department of Emergency Medicine at the University, supervised the remotely-performed intubation. Over the telemedicine network, Dr. Sakles watched Dr. Poulsen prepare the patient and administer rapid sequence intubation drugs. Then the monitor view was transferred to the view coming from the GlideScope videolaryngoscope in use by the Willcox team, and the Tucson Telebation team provided real-time intubation guidance as the procedure took place. The intubation went smoothly, and the stabilized patient was flown by helicopter to Tucson for further intensive care management.

The Telebation Program at the University of Arizona is built upon the Southern Arizona Teletrauma and Telepresence Program (SATT), which facilitates the virtual presence of an experienced trauma surgeon using high-quality live audio and video streamed from a dedicated telemedicine network. The Telebation Program piggybacks on the existing Teletrauma network and adds emergency airway assistance to the trauma/critical care consultation.

“The whole goal of the program was to lend intubation assistance to providers in rural areas,” says Sakles. “Prior to video laryngoscopes with direct laryngoscopy, there was no way of supervising or seeing what the operator was doing. With the video laryngoscope, we could see exactly what the operator was seeing, even though he was hundreds of miles away. I could be at the university and watch intubations at any of the seven hospitals we’re linked with and provide real-time feedback to them during an intubation.”

Sakles currently speaks of the program in past tense, since it temporarily came to a halt when the director of telemedicine left to take a position at another facility. “The program is all set up and the physical hardware is there, but we haven’t used it since he left,” he says. “As soon as we get someone to fill the position, we could start up again.”

In addition to the remote hospitals, there is also an EMS component set up and ready to go when the program resumes. “The only test we did was to intubate a manikin in a moving ambulance to make sure the system works,” says Sakles. “We were able to successfully intubate the manikin with a Ranger GlideScope and send it wirelessly to the hospital, but we haven’t had any live patients yet. Unfortunately, the people who work in these rural settings don’t have a lot of experience with airway management because they may only get to intubate a couple of times a month, so they’re the people who can really benefit from having an expert remotely assist them with the intubation.”

Sakles and his colleagues recently published a paper describing the Willcox experience and the actual procedure.¹ In the meantime, the search goes on for a new telemedicine program director, and Sakles hopes the position will be filled soon so they can resume their critically important work.

Reference

1. Sakles JC, et al. Telemedicine and telepresence for prehospital and remote hospital tracheal intubation using a GlideScope videolaryngoscope: A model for tele-intubation. Telemedicine and e-Health 17(3):185-188, April 2011.