Another ACEP Scientific Assembly has come and gone. As the dust settles, Tech Doc Jason Wagner reviews a few of the shining stars from the exhibit hall floor.
This year, the trend of the ACEP Scientific Assembly exhibit floor seemed to follow the “good enough” tech trend of recent years. For those not familiar with this concept I’ll get you up to speed. A decade or so ago the push in electronic entertainment was HiFi (and not your father’s HiFi). VHS was going to DVD, Sony was pushing the improved DAT audio format, and TVs were going High Definition. And then things started to change a few years ago. I credit the iPod with starting this initiative. Born in 2001 and coming into its own around 2005, the iPod suddenly made your entire music library available in your pocket. The trade-off was reduced audio quality – the music played on MP3 devices is highly compressed. And now we can see that video is following suit as more and more consumers are choosing convenience over quality.
Fortunately for many, medical technology is following the pathway. An example of this is the Ambu A-Scope. This is the disposable bronch reviewed by Dr. Rich Levitan in the September issue. This bronch will never rival the German craftsmanship of a Storz device, but that’s OK, because that’s not what its trying to do. It excels as an affordable replacement for a bronch in the ED where concern for loss, infrequent use, or breakage are the priorities.
For this review, we’ll focus on a few key areas of innovation.
The Difficult Airway Box
The Difficult Airway Company
Those looking for a quick and easy answer to setting up a difficult airway solution in your ED should consider the Difficult Airway Box. The hard-sided Pelican case comes in two varieties, one for adults and pediatrics and one for adults only. The adult-only version contains a jet ventilator, trantracheal catheter, Rusch QuickTrach crichothyroidotomy device, a Bugie, a variety of LMA’s, a King LTS-D rescue device, and a single-use Airtraq. The pediatric addition has all of the above as well as pediatric versions of the transtracheal catheter, crichothyroidotomy kit, and expanded LMA sizes. The kit is the size of a tackle box and fairly light, making it easy for an EP to grab when they’re called upstairs to cover the ICU in a hurry. A benefit of purchasing the kit is that they refill your missing items with a phone call at prices competitive with other vendors. The price for the full kit is $2350 while the Adult-only kit sells for $1850.
Vivid Medical Inc.
In an ED full of expensive devices, few things short of ultrasound are more expensive than fiberoptic airway toys – even cheap solutions are in the $6-9,000 range. Vivid Medical is Trying to change this with the “good-enough” concept. Think of the VividTrac as a poor-man’s GlideScope. It is intended to be used as an indirect intubating device and is roughly the size and shape of a large oral airway. The difference is that you load an ETT along the side like an AirTraq. Oh, and then there is the camera in the tip as well as the USB cable coming out of the back. This USB hooks directly into a PC or – wait for it – even a Mac. The vendor said that while not approved yet, another customer got it to work on an Android device. Sorry iPhone and iPad users, Apple’s locked-down system has put them low on the development priority list. Once placed in the oral-pharynx, you manipulate the handle for the best view of the cords and simply watch the ETT pass through the vocal cords. Image quality is very good for a $65 disposable device. After use you can package it into a biohazard bag and ship them back in bunches of 5-10; Vivid Medical will then recycle both the materials and the battery.
EZ-NG (pictured below)
After one too many nasogastric tubes found their way into the pulmonary tree, my hospital mandated that all NG tubes have a KUB following placement. While often a quick process, there are frequent delays when the pace picks up. Not only does a KUB run a few hundred dollars and cost everyone time, it’s also yet another bit of cumulated radiation for the patient. Enter the EZ-NG, which is attempting to make confirmatory KUBs a thing of the past. It uses a simple straw-like device (pictured) that fits between the NG tube and a syringe. When gastric juices flow into it, the indicator turns bright yellow if the pH is less than or equal to 4.5. According to the vendor, this verifies gastric placement without question (I haven’t had time to verify this myself). With EZ-NG, proper placement can be verified in seconds instead of minutes to hours.
Foreign Body Removal Lighted Forceps
Bionix Medical Technologies
Bionix seems to be the master of the elegently simple innovation. A few years back they had the, “Why didn’t I think of that?” innovation of making clear curettes that you attached a light to, allowing the curette to illuminate the ear. They shortly followed this with a magnifying adaptor that clipped to the end of the curette. This year we see a couple of new innovations from them. The first is a lighted curette with a jointed tip allowing you to flex it in order to facilitate cerumen removal. The second is a curette that again illuminates but has the additional benefit of built-in graspers for foreign bodies. A simple squeeze of the base of the curette opens and closes small pincers on the end. What I love about Bionix is their ability to apply innovative changes to simple little devices that just get the job done.
A Better Mousetrap
EASIEAR (pictured below)
If you’ve been practicing for a while, or have friends who are ENTs, then you realize that curettes have not always been made out of plastic. In fact, back in the day doctors sterilized and – God forbid! – actually reused some equipment. Economies of scale eventually took over and plastic molded speculums flooded the scene. They are cheap and, for the most part, get the job done. But most importantly to many patients, they have a near 0% chance of giving them a cerumen transplant from the homeless guy you used it on last. Developed by a pediatrician, EasiEar claims to one-up plastic curettes in the area of quality. They are disposable, but since they are made of a single continuous strand of metal they have no seam.
Plastic curettes come from a mold and when the mold is separated a small seam is left. This, along with the limitations of how thin the plastic can be while still maintaining adequate rigidity, limits how well the curette functions. The EasiEar has a center wire that runs through a coiled wire providing rigidity, flexibility, and a thin profile. These features have the potential to provide for a better surface for cleaning the ear while making for a more comfortable procedure.
The LMA is a great intermediate or rescue airway device. Even better is an intubating LMA which allows you to pass an endotracheal tube through it for a definitive airway. Traditional LMAs require you to inflate a cuff with air which allows for some complications. The most common of these are cuff failures and the tip of the LMA folding over as you place it. The Intersurgical i-gel LMA tries to fix these two problems by using a malleable soft thermoplastic elastomer instead of an inflatable cuff. Sizes run from 2-90+ kg and allow for ETT intubation via the LMA. The i-gel material certainly has a very supple feel, but whether it creates an equivalent seal to air-filled LMAs is yet to be determined.
I’m an admitted “realistic” Apple fanboy – I love their products but will admit their shortfalls. That said, Apple just released the iPhone 4s. While many view this as a minor update – it maintains the same external format at the previous iPhone – there have been some major changes under the hood. The first is a faster processor, which drastically improves one of the iPhone’s best features: the camera. The iPhone 4 already had arguably the best camera on a cell phone, but being Apple, they weren’t happy with that. Apple increased the resolution from 5 megapixels to 8 at the same time improving the light sensitivity of the sensor and increasing the video resolution from 720p to 1080p. What this means to the average EP is that you no longer need to bring a still or video camera to the ED to capture interesting cases. While this is a boon for EPs, it is a bane to risk management as every Tom, Dick, and Harriet has a way to effortlessly send private patient information to the web for general consumption. Both the photo and video quality are more than enough for publication in print or on online.
While the camera is a nice improvement, the groundbreaking change lies in Siri. This is the voice recognition system built into the iPhone 4s. The voice recognition has many neat features that you can look up online but for EPs Siri means a couple of things. First, mark this date as the first real step towards us telling our computers what to do. For those old enough to recall Star Trek IV you’ll remember Scotty trying to talk to a computer mouse. We laughed in 1986, but mark my words we will see this in our lifetimes. You might say, “That’s all future talk; what can Siri do for me now?” Well, if you have Pages on both your iPhone and a Mac, you can dictate to your phone and it will translate it into typed words. Through the magic of Apple’s online syncing service, iCloud, this dictated document shows up on your desktop version of Pages, allowing you to quickly edit what you have and send it out. For the EP on the go, this can help with letters, patient charts, emails, or even an eleventh-hour submission to Emergency Physicians Monthly.
A Final Message from the Tech Doc:
It’s hard to believe that it’s already been four years since my first article on the Welch-Allyn cordless speculum hit the presses but its true. Four years and many gadgets later, it’s time to move on. It’s time to dedicate some more time to my roles as assistant program director for the EM residency program at Washington University in St. Louis and the director for Augmented Learning. I’ve appreciated the opportunity to write, and thank everyone who read the column. I’ll still be around, and you can follow me as @TheTechDoc on Twitter for occasional short updates on the world of technology as it applies to emergency medicine. Keep pushing the envelope.