How to make your own airway management SALAD simulator

An evil trick I often play on my advanced EMS students is to wait for them to get complacent on their airway skills practice, when they’ve performed the skill enough times that they are prone to just pay lip service to checking their equipment ... and that’s the day they find their patient copiously vomiting, and the battery disconnected on their suction unit.

I believe that the burned hand teaches best, and failing a skills station because you knew better but took a shortcut anyway is an excellent way to drive that lesson home without killing a patient. I’ll frequently try such tricks as students approach skill mastery, when teachable moments become fewer and farther between. I’ll use the laryngospasm simulator on the airway manikin, or have that respiratory arrest patient present with a foreign body airway obstruction. It keeps my students on their toes.

My only issue was, I couldn’t make the manikin vomit enough. I could squeeze the stomach and make a little simulated vomit ooze slowly up into the oropharynx, but it was nothing like the “massive gastric distension, vomit coming out of the nose, holy crap did this guy eat panel 3 of the Sonic menu?” kind of vomit volcano you sometimes see in the field.

In short, I needed a SALAD simulator.

Dr. Ducanto’s video laryngoscopy training technique

If you’ve been living under a rock and have never heard the term, SALAD stands for suction-assisted laryngoscopic airway decontamination, a technique pioneered and popularized by airway guru James Ducanto, M.D.

Using video laryngoscopy and the suction catheter that bears his name, Dr. Ducanto teaches us how to manage even the most copious secretions and secure an airway with confidence under what would otherwise be impossible conditions. A Google search will yield a plethora of useful articles and YouTube videos on the technique, but you really need to take the man’s class in person. Attendees rave about it.

But while video laryngoscopes are no longer cost prohibitive and Ducanto catheters don’t cost appreciably more than their competitors, the challenge is that you really need a dedicated manikin to practice and teach the technique.

Now there are great tutorials on the web on how to construct a SALAD simulator from a Lifeform airway manikin (and Lifeform even sells the SALAD simulator as a new product), those of us with Laerdal airway manikins have to improvise.

What you’ll need to build a SALAD simulator

I converted my Laerdal Adult Airway Management Trainer (aka, Fred the Head) to a SALAD simulator using Dr. Ducanto’s instructions. Along the way, I discovered a few tweaks that make the conversion easier, cheaper and less messy. With one exception, I bought my parts at the local Lowe’s. Product numbers may be different at your local retailer Here’s what you’ll need to build your own airway management SALAD simulator:

• Set of washing machine hoses (Lowes #551720): $22.98
• 2’ length of ¾” CPVC (hot water) pipe (Lowes #832011): $2.39
• ¾ CPVC female threaded adaptor (Lowes #23754): $1.38
• All-purpose pipe cement (Lowes #23541): $6.93
• ¾ brass threaded male/male hose fitting (Lowes #877064): $4.58
• ¾-1 ½” stainless steel hose clamp (Lowes #80887): $2.28
• ¾” threaded brass hose bibb (Lowes #867976): $6.78
• Plastic drill-powered pump (Lowes #138026): $8.99
• Teflon thread tape (Lowes #456831): $3.98
• Variable speed electric drill (Lowes #619208): $29.98
• 5-gallon plastic carboy with cap (Amazon #45-56Y8-E2FR): $16.39
• Xanthum gun or sodium alginate (1 pound, price varies): $25.00
• Total: $131.66

How to build a SALAD simulator

A little trial and error led me to deviate from Dr. Ducanto’s instructions a bit. I ditched the garden hose quick connects and the clear plastic tubing, as well as the table lamp dimmer and the wireless on/off switch. It ain’t as sexy, but it still works fine. The next iteration of this device will likely include a remote-controlled submersible aquarium pump.

I tried several brands of garden hose quick connects, both plastic and brass, and couldn’t find a setup that didn’t leak. While that may not be an issue on your lawn, it can be in a carpeted classroom.

The clear plastic tubing (and the male/female hose repair connectors necessary to link it all together) can be replaced with washing machine hoses, the kind with a female connector on each end. There’s no need for glue and sealant, other than a dab of PVC cement on the esophagus connector, and silicone threat tape on the vomit container. Here are the steps to build your own SALAD simulator:

1. Cut ¾” CPVC pipe down to 3”
2. Prep surface of pipe and fitting, then using pipe cement, glue ¾” CPVC female adaptor to the 3” length of pipe
3. Using thread tape, screw the ¾ brass threaded male/male hose fitting into the female pipe fitting securely
4. Remove stomach bag from esophagus of the airway simulator. Slip free end of pipe into the clear plastic esophagus of the airway manikin, secure in place with hose clamp (this is totally reversible, you can remove at any time, the hose clamp merely secures the CPVC fitting to the esophagus without leaks)
5. Attach washer hoses to hose fitting on manikin and drill pump
6. Drill out ¾ threaded punch-out in screw cap of carboy, taking care not to damage the threads. Remove the small cap over the vent, drill a small hole for a vent and replace the cap
7. Wrap threads of brass hose bibb with Teflon tape, screw securely into ¾ threaded hole in cap of carboy, fill carboy with required amount of water, replace cap
8. Attach the free end of the hose to the hose bibb. Open the valve and allow gravity to prime the system
9. Secure pump into drill chuck
10. Squeeze the trigger on the drill, and voila! Vomit volcano!

Vomit recipe

Vomit solution can be made with sodium alginate or xanthum gum in the ratio of 5 tsp/gallon, adding food coloring to achieve the desired color. A pound of xanthum gum or alginate powder, depending on consistency, will make anywhere from 16-32 gallons of simulated vomit.

Use a blender and mix gradually. It can be prepared the night before. Sometimes, the alginate or xanthum doesn’t dissolve completely, leaving little clumps that make the vomit even more realistic.

Disassembly and cleanup

Here’s how to disassemble and clean up your SALAD simulator (it takes about five minutes):

1. You can pump the manikin nearly dry by reversing the drill and pumping the water out of the manikin. Empty any remaining vomit solution into the sink or toilet and rinse.
2. Refill your carboy with hot water and bleach solution (2 tbsp/gallon). Dr. Ducanto recommends vinegar cleanup to prevent mold, but it does tend to degrade the pump bearings. I found hot water and bleach to work just as well, and is easier on the pump.
3. Disconnect lungs from your airway simulator, clean and dry separately. Remove the head from the base and place in sink. Using your SALAD setup, now pump your hot bleach water through the manikin until everything that runs out is clear.
4. Carefully disconnect and drain hoses.
5. Allow the manikin head to drain, dry with paper towels. Make sure you removed all vomit – xanthum or alginate will mold.
6. Reattach manikin head to base, reattach lungs to manikin. Dry and store. All materials will fit in the standard airway manikin hard case.

Since I already had a spare drill in the workshop, as well as numerous bottles of sodium alginate just sitting around, the entire conversion only cost me about $75. Try it on your airway management trainer, and take your classroom airway simulations to the next level.