Airway control and ensuring adequate respiratory function are priorities in managing any seriously-injured patient. Failure to maintain a patent airway remains a significant cause of preventable death and disability. In these circumstances, emergency tracheal intubation is a potentially life-saving procedure to optimize oxygenation, maintain ventilation and reduce the risk of aspiration. Early tracheal intubation has been promoted and adopted increasingly in many trauma systems. However, much controversy surrounds this practice, particularly in the pre-hospital setting where high complication rates have been reported, and current evidence suggests that tracheal intubation may not be universally beneficial [1]. Airway management of patients with major injuries is challenging, even within hospital. This chapter will review four controversial topics relating to airway management in severely injured patients: Pre-hospital intubation, protection of the cervical spine, the use of cricoid pressure, and the choice of induction drug.

August 2007 marked the start of new programmes for training in accordance with Modernising Medical Careers [1, 2], which provided continuous training for 7 years from the first anaesthetic year to the receipt of a Certificate of Completion of Training (CCT). We were keen to ascertain in what way this change affected clinical training and experience for anaesthetists within the Bristol School of Anaesthesia during the basic training years. We used electronic logbook data [3] to examine the pattern of training, supervision, and clinical experience before and after the Modernising Medical Careers run-through programme. We compared the new registrars, who had trained in the senior house officer (SHO) programme (entering specialty training (ST) year 3 in 2007) with the new cohort of trainees entering the run-through training programme (ST year 1 in 2007) in the Bristol School of Anaesthesia. We examined 20 logbooks, 13 from the SHO group and seven from the ST group. The average number of months spent in basic training was 33 for the SHO group and 26 for the ST group. The total caseload during basic training was 31% higher in the SHO group than the ST group: the median (IQR [range]) number of cases for the SHO and ST groups was 1383 (1175–1560 [794–2269]) and 1050 cases (994–1236 [960–1436]), respectively. The annual caseload was similar in both groups; the median (IQR [range]) number of cases was 523 (432–646 [396–911]) for the SHO group and 525 (497–539 [480–591]) for the ST group. The level of supervision of trainees by consultants increased from 57% in the SHO to 69% in ST group. The number of ASA 3–4 cases was reduced from 16% for the SHO group to 10% in the ST group. The proportion of elective work was 58% in the SHO group and 71% in the ST group. The percentage of cases performed out of hours decreased from 25% in the SHO group to 17% in the ST group. Our data indicate that annual case numbers were maintained when run-through training began. The reduction in the total number of cases that our ST trainees completed during basic training, compared with the previous SHO group, seems to be related to the shorter duration of training rather than the reduction in weekly working hours. Our data imply that the ST group maintained good numbers of well supervised ASA 1 or 2 elective cases during normal working hours. However, it also suggests that there has been a reduction in experience of emergency and higher risk cases. The opportunity to gain further experience was also lost with a shortened training programme. These changes may have implications for both training and service in the intermediate training years and should be taken into consideration by trainers and organisers of service provision. No external funding and no competing interests declared.

This article discusses the background, logistics and safety of ECMO retrieval in New South Wales, Australia. We look at the experiences of a well established, high volume medical retrieval service and the challenges presented during the recent H1N1 swine flu pandemic. In outlining the referral and retrieval process utilised in NSW we hope that other retrieval services can gain from our experience.

An 82-year-old man underwent the routine removal of a common bile duct (CBD) stent by endoscopic retrograde cholangiopancreatography (ERCP). He had been fit and well prior to the procedure, and his past medical history was unremarkable. He had presented 18 months previously with acute cholangitis caused by gallstones.

Over the last 15 years supraglottic airway devices (SADs), most notably the classic laryngeal mask airway (LMA) have revolutionised airway management in anaesthesia. In contrast for resuscitation, both in and outside hospital, facemask ventilation and tracheal intubation remain the mainstays of airway management. However there is evidence that both these techniques have complications and are often poorly performed by inexperienced personnel. Tracheal intubation also has the potential to cause serious harm or death through unrecognised oesophageal intubation.