Google Glass in Airway Management

By Michael Macias 

I have no affiliation with Google, this story is simply a figment of my imagination and a hope for furthering technologic innovation in emergency medicine.

Let's imagine a scenario together. It's 2 AM, you are moonlighting and its been quite the bore of a night. You're managing the local inebriated folk who don't really want to be here but managed to be at the wrong place at the wrong time. 

The bat phone rings. Hypotensive, obtunded, pale and diaphoretic patient. ETA 5 minutes. A surge of fear tinged with excitement travels up the nape of your neck as you soak in the situation. You activate your staff rapidly and you prep the resuscitation room. You arm yourself with your Google Glass. Your screen appears in the right hand corner, your heart rate populates, 90 bpm. Not bad you tell yourself. Your in the zone. You open your intubation checklist and your necessary tasks pan through your visual field as your ready you pre oxygenation equipment, suction, your laryngoscope...bougie at the bedside. You call out your meds to the nurse in the room and they are drawn up. Your single audio earpiece is playing Clair de Lune subtly in the background because that helps you stay focused and calm. Heart rate now at a comfortable 72. 

Information starts pouring in from the paramedic video feed to your direct visual field. Vitals, accucheck, IV access obtained, non-rebreather in place. A live view of the patient shows you current management in the ambulance, and you begin to establish in your mind potential issues you may face when the patient arrives. You agree with the management thus far and have nothing to communicate to them other than, 'see you in a few.' They pull into the ambulance bay. 

The ambulance bay doors slide open and the commotion begins. 3 paramedics glide into the resus bay with the sick patient. He's pale, profusely diaphoretic, with a large girthed neck but you already knew this. His breaths are rapid and shallow and he is leaned over to his right with no apparent appreciation of the severity of his condition. You attempt to arouse first by voice, but he required a forceful sternal rub to even open his eyes. He does not do much more than that. His respiratory compromise is fairly imminent. Your heart rate begins to trend up as the gravity of the situation appears more real. He is hooked up to monitors as you function as the leader of the room, delving out tasks to your team, obtaining further access, placing a nasal cannula under his non-rebreather in preparation for apneic oxygenation. As his monitors are hooked up his vitals populate on the right side of your visual field. He is tachycardic to 120s, his systolic BP is 85, RR 30, O2 saturation 96% on 100% FIO2, febrile to 102. Sepsis is on your mind.

You begin you fluid bolus wide open, push dose pressors at the bedside and move to the head of the bed to prepare for intubation. You assess his airway and know it will be difficult. Your heart rate and the patient's begin to even out in the 120s and you begin to lose your focus as the acutely septic, acidotic and dying patient sits in front of you. Deep breaths, focused on your goal, focused on the skills you know you have. Make a move. 

You push your ketamine and succinylcholine and 60 seconds later take your first look. Advancing the Mac 4 blade down along the base of the tongue and into the pharynx. Epiglottis. Grade 3 view. Take your time you say to your self, you have your eyes on his vitals in your Glass screen. SBP 90s, saturation 96%. You call for the bougie since your view is poor and slowly advance the coude tip down into the pharynx, past the epiglottis, your tip pointed anteriorly feeling for tracheal rings. Your tip stops, you can't advance. Thud in your chest, a sense of panic, cognition begins to cloud. Calm down, sats still appear great thanks to your ongoing apneic oxygenation through the nasal cannula. Plus Merry Christmas Mr. Lawrence is playing on your ear bud now, why should you let the stress beat you. Inhale, hold...exhale. You slowly rotate the bougie and sure enough after 90 degree rotation the bougie slowly advances forward. Railroad tube, ETCO2 confirmed. Tube secured. Ventilator rate set. Saturation 100%, never dropped below 92.

Success. At least with the airway. Your Glass screen now moves on to the next screen, with the next checklist regarding management of the septic patient...and off you go.

Interesting thought here on the utility and integration of technology both into the management of the difficult airway and possibly future applicability with regards to delivering key information (vitals/labs) to providers in vivo while they work in order to optimize work flow an efficiency and avoid missed steps in management. This post was stimulated by a recent article in the pediatric anesthesia literature on the use of google glass for airway assessment and management and the new hype for wearable medical technology.

At many institutions there are macro systems in place or forms to record difficult airway management however these are not accurate portrayals of the true problems faced during difficult intubations. Was it a technique problem? Was the wrong tool used? Was it a positioning problem? Was the operator under too much stress? (Assessed by heart rate monitor, head/eye movements) These questions and others could be answered with a system such as Google Glass implemented in both academic and non academic settings. Furthermore, the idea of in vivo vitals and checklist monitoring in line with the sight of the airway operator makes the idea even more enticing. 

Interestingly, Google Glass has already begun to make its way into the realm of medicine. Bill Kelly and David Spiro, founders of Reeldx.com, use real patient videos obtained through Google Glass for various applications with an emphasis on both medical eduction and enhancing the patient-physician relationship. Harvard Medicine is also delving into the Google Glass realm and the idea of delivery of in-vivo patient information directly to the visual field of the care provider is already a possibility. Consultant at home and you need them to lay eyes on your patient immediately? That will be possible with Google Glass as well. Learn more about what Harvard is doing here. I also found a great google hangout, examining the feasibility and issues faced in the development of wearable technology in the medical field at Digital Disruption.

Emergency medicine has become a field with a strong focus on quality improvement that reaches from clinical management to operational efficiency. As leaders in airway management, enhancing the ability to gather data from difficult airways is in line with this current theme and I hope to begin to see further discussion regarding this topic as this technology or similar devices become more wide spread. Emergency Medicine leaders and innovators out there, this is your calling. 

 Original Article: The use of Google Glass in airway assessment and management.

Visit airwaycam.com to to take a look at the 'pre-Google Glass' era and true innovator of the airway camera Dr. Richard Levitan.