The impact of human factors on clinical performance during airway emergencies is well recognised [1][2][3][4][5]. Although this includes 'teamwork skills' such as leadership, role allocation and communication, the scope of human factors is much broader than this. As the scientific discipline concerned with understanding and optimising the interactions between humans and other elements of a system, human factors involves considering the impact of aspects of the individual, environment, processes and culture on human performance [6]. The availability and presentation of airway equipment is a key component of the clinical environment in relation to airway management [7].

† Buridan's ass is an illustration of a paradox in philosophy in the conception of free will. It refers to a hypothetical situation wherein an ass that is equally hungry and thirsty is placed midway between a stack of hay and a pail of water. As the paradox assumes the ass will always go to whichever is closer, it will die of both hunger and thirst because it cannot make a rational decision to choose one over the other. See

Object The treatment of morbidly obese individuals with spine trauma presents unique challenges to spine surgeons and trauma staff. This study aims to increase awareness of current limitations in the surgical management of spine trauma in morbidly obese individuals, and to illustrate practical solutions. Methods Six morbidly obese patients were treated surgically for spine trauma over a 2-year period at a single trauma center in Australia. All patients were involved in high-speed motor vehicle accidents and had multisystem injuries. All weighed in excess of 265 pounds (120 kg) with a body mass index ≥ 40 (range 47.8–67.1). Cases were selected according to the considerable challenges they presented in all aspects of their management. Results Best medical and surgical care may be compromised and outcome adversely affected in morbidly obese patients with spine trauma. The time taken to perform all aspects of care is usually extended, often by many hours. Customized orthotics may be required. Imaging quality is often compromised and patients may not fit into scanners. Surgical challenges include patient positioning, surgical access, confirmation of the anatomical level, and obtaining adequate instrument length. Postoperative nursing care, wound healing, and venous thromboembolism prophylaxis are also significant issues. Conclusions Management pathways and hospital guidelines should be developed to optimize the treatment of morbidly obese patients, but innovative solutions may be required for individual cases.

Summary Cervical spine immobilisation can make direct laryngoscopy difficult, which might lead to airway complications. This randomised control trial compared the time to successful intubation using either the Macintosh laryngoscope or the McGrath® Series 5 videolaryngoscope in 128 patients who had cervical immobilisation applied. Intubation difficulty score, Cormack & Lehane laryngoscopic view, intubation failures, changes in cardiovascular variables and the incidence of any complications were recorded. The mean (SD) successful intubation time with the Macintosh laryngoscope was significantly shorter compared with the McGrath laryngoscope, 50.0 (32.6) s vs 82.7 (80.0) s, respectively (p = 0.0003), despite the McGrath laryngoscope's having a lower intubation difficulty score and a superior glottic view. There were five McGrath laryngoscope intubation failures, three owing to difficulty in passing the tracheal tube and two to equipment malfunction. Equipment malfunction is a major concern as a reliable intubating device is vital when faced with an airway crisis.

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of first clinical applications 3-7 , its use in normal airways 8,9 , simulated difficult airways 10-13 and actual difficult airways 14,15 , leading on to trials comparing performance of one videolaryngoscope against another or against the conventional standard Macintosh blade 16 . The prolific data on the burgeoning number of devices can be bewildering to the user. The possible superiority of one VL device over another may not be evident when reviewing the literature, especially for novice videolaryngoscopists with limited experience. We have collated the experiences of several experienced videolaryngoscopists to help guide the assessment and use of these devices. This is not a formal study, therefore the conclusions and recommendations presented should be interpreted in that light. SUMMARYDue to the large number of videolaryngoscopes now available, it might be difficult for novice users to assess the various devices or use them optimally. We have collated the experiences of several airway management experts to assist in the assessment and optimal use of seven commonly used videolaryngoscopes. While all videolaryngoscopes have unique features, they can be broadly divided into those inserted via a midline approach over the tongue and those inserted laterally along the floor of the mouth. Videolaryngoscopes that are placed on the floor of the mouth displace the tongue antero-laterally and flatten the submandibular tissues. They generally require a conventional shaped bougie for tracheal intubation. Videolaryngoscopes that use the midline approach may have an in-built airway conduit for the tracheal tube or may require a 'J-shaped' stylet in the tracheal tube to negotiate the upper airway. This may cause difficulty when the tracheal tube is inserted through the glottis and the tip abuts the anterior wall of the subglottic space. Knowledge of the mechanism used by videolaryngoscopes to achieve laryngoscopy is essential for safe and successful tracheal intubation when using these devices.

Introduction: Peripherally inserted central catheters (PICCs) offer a convenient long-term intravenous access option. Different methods exist for insertion including the use of continuous fluoroscopy for guidance, or bedside insertion techniques. The blind pushing technique is a bedside approach which involves advancing a PICC through the access sheath without imaging guidance, before taking a mobile chest radiograph to confirm tip position. Obtaining optimal position is a critical aim of PICC placement as malpositioned lines have been associated with higher complications including death. We aimed to assess the accuracy of PICC placement by comparing the tip position and complications for lines placed under fluoroscopic guidance to those placed without fluoroscopic guidance. Methods: The Radiology Information System was used to identify 100 continuous PICC insertions in each group (fluoroscopic and blind pushing) between 1 January and 12 May 2019. Patients were excluded if there was a known history of central venous occlusion/stenosis. Results: In the fluoroscopic-guided group, 0% of the lines were malpositioned compared with 60% of the lines placed using the blind pushing technique, P < 0.001. Fluoroscopic-guided PICC insertions were in place for a total of 2446 days and demonstrated 6 complications (2.45 complications per 1000 catheter days). This compared with blind pushing technique PICC insertions which were in place for a total of 1521 days and demonstrated 18 complications (11.83 complications per 1000 catheter days), P = 0.004. Conclusion: The use of fluoroscopy for PICC placement leads to significant improvements in tip accuracy than for PICCs placed using the blind pushing technique. While the use of these imaging resources incurs cost and time, these factors should be balanced in order to offer patients the safest and most accurate method of line insertion.

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