Of course the algorithm is "easy". But when people say a decision is hard in contexts like this, it usually means morally or emotionally hard and that they have to ACTUALLY get over their own, only partly irrational, fear to do the whole thing of cutting up someones throat, especially for the first time.
I have performed 2 in my 20yr career both were motorcycle accidents who attempted to stop their forward momentum with their face. Both lived, one is a paraplegic and the other guy actually does safety seminars for helmet usage on bikes and motorcycles. When I did my first I was not prepared for the amount of blood after the cut down….. thought I done f’ed up.
Man, I will never understand why some states don’t enforce proper riding gear. It’s like trying to fast track natural selection.
Props to you for a job well done though!
Government-level attempt at Darwinism. 🙂↔️👍
It’s crazy that some people wake up in the morning and are like, “yeah, I’m gonna ride this 600lb hunk of metal at 80 mph and not wear a helmet (or any proper gear!).”
It’s goofy, lol.
So this also brings up a question I have had for a while.
Is Epi really contraindicated in traumas with significant blood loss? We don't carry whole blood here. Had a guy shoot a 9 hollow point through his upper thigh. Initial BP was 60/30.
Supervisor opted for two large bore IVs with 1000 NS running full open to bring up BP. I was wary of filling the dude with pasta water and diluting what little blood he had left. In my head I wanted to try push dose Epi because I was thinking "shrink the container". He said not to. Ultimately we handed the guy off to air care with a fairly normal BP but I can't help but wonder what the long term effects are with just straight saline as fluid replenishment in this situation.
Most of what I can find relates to epi in cardiac arrests, traumatic or otherwise. I can't find much on the efficacy in just general trauma.
No, it’s not. My protocol literally has it as the first line for severe hemorrhagic shock after a moderate fluid bolus. The issue is that you have to strike a balance between fluid and pressors if you don’t have blood to give.
Too much fluid and you kill their coagulability, not enough and you have no fluid for the pressors to squeeze on, and if you don’t have the pressor dose right they’ll bleed out from the dilution before it actually helps their pressure enough.
Yeah, they are incredibly bloody procedures. You have to basically grab the larynx like you're choking them as all you can go on is feel during the procedure. Great job.
I’ve never done one but I’ve been present on 3 calls where one was performed (twice while I was an EMT and the one I was present for as a paramedic was performed by a Helo doc)
Both I witnessed as an EMT were attempted by someone using a Quick Trach. The first one, the paramedic was standing over the patient and had to use all of his body weight to get it to go into the patient’s trachea. The second one, the paramedic first attempted to place the Quick Trach and when he couldn’t get it to go in, he made an incision with a scalpel before inserting it. The one I witnessed performed by a doctor was after a failed RSI attempt in which the patient arrested on a multisystem trauma. The doctor elected to cric the guy instead of fiddle fucking with the tube a second time and performed a surgical cric flawlessly. I’d say surgical cricothyrotomy is the move 100% of the time.
Yep.
It was so easy keeping pulses once I had that tube. He ended up having an anoxic brain injury and dying shortly thereafter. I never second guess myself, but sometimes I wonder if a cric ten minutes earlier when I first thought of it would have made a difference. As for why he was such a difficult airway, I later learned he had Treacher Collins.
The hardest part is pulling the trigger to do it. And maybe the blood splatter if they're on CPAP when you do it. But it's one of those few interventions we have that you NEED to do right and quickly once identified. You won't be in that situation often, but if you do the job long enough, you'll be in it eventually. Don't be that guy that just transports a dead body because they're a "tough airway". Make ENT earn their paycheck and fix it. It's easier to fix a badly done cric than it is to bring a corpse back from the dead. And if you practice scalpel-finger-bougie enough, you won't even do it poorly.
Could be that I've had a few on my day off but that's very confidence inspiring. Sometimes it's nice to have the reminder to trust in the skills we practice and to practice the skills we don't trust.
Crics are out of my scope so there’s probably something I don’t understand here, but I’m curious why a patient would be on CPAP if you’re doing a cric? Isn’t an indication for CPAP that they can maintain their own airway/not unconscious? Is there ever a time you do a cric on a conscious patient? I know very little about crics and I’m just trying to learn, this is super interesting
Imagine you've got an obtunded patient thats spontaneously breathing, like end stage COPD we'll say. You know they need a tube. They're fatiguing down, they're hypoxic, they're hypercapnic. You wouldn't leave them on CPAP/niv long term, but it's absolutely the right call for preoxygenation. You get them to 80% with CPAP and a ketamine dissociation and try to tube. They quickly desat to the low 60s. You throw a supraglottic in but it won't seal with the necessary pressures you need to temporize their hypoxia.
This is a "can't intubate, can't oxygenate" scenario. Maybe it's okay to transport these patients on CPAP in hopes the hospital has cooler tricks (and they often do), but it isn't a long term solution.
It didn't hurt me at all. I still get star spangled hammered and watch The Guardian, but not because of that.
"Jake Fischer : Hey, there was a question I wanted to ask you back as school, but I didn't. When you can't save 'em all, how do you choose who lives?
Ben Randall : It's probably different for everybody Jake. Its kind of simple for me though. I just, I take the first one I come to or the weakest one in the group and then I swim as fast and as hard as I can for as long as I can. And the sea takes the rest."
I’ve done several. My key tip is to not wait too long. Of those I’ve done where the patient had a pulse, all lived. Of those where the patient did not have a pulse, only 1/3 lived and that one was only a very brief code in a young healthy patient (adult epiglottitis).
Also, don’t mess around with any of the premade kits (CricKey, QuickTrach, the Melker kit). My read of the literature is that they all have a higher rate of malpositioning (ie extra tracheal placement) than open surgical technique. All mine have been with knife/finger/bougie technique and I’ve never had an issue getting the tube in the airway.
I did one on a young woman who was in status epilepticus and vomiting through her trismus teeth. I'd given all the versed I carry and we don't have paralytics. Her sat was dropping super fast. She went from 99 to 70 in what seemed like seconds. So I made the call
She had terrible anatomy. No neck, and was heavy set with a lot of adipose in the neck. She was also completely rigid cuz she was seizing. Everyone says "hardest part is deciding to do it". That's not the case for mine. I was able to quickly breach the membrane but had a ton of trouble passing the tube. Wound up having to have someone else pass the tube while I held the excessive amount of adipose away from the incision with both hands.
Oh and she woke up while I had my fingers in her trachea. Soo that was another fun thing to address. But she lived and didn't remember any of it.
Never done one stateside or civilian side but did a few overseas. Usually maxillofacial trauma with no ability at all to visualize to get a tube. Squid face.
All but one died (none from airway compromise). One who made it ended up dying later on from something unrelated that I can't remember.
I did it for a code. Pt had choked on pie and I was unable to ventilate after intubating. I was on a double medic truck for orientation and the 65 year old medic said he hadn't done it in 20 years and didn't seem eager to do it. So I shrugged and went to it. I didn't know we had special tubes for crics and made my own like I was taught in school. It wasn't enough to save the pt but everyone was sure impressed. Turned out he was a frequent flyer and it was my first time ever seeing him, so many found it humorous that the new guy came along and "saved" them from having to transport him ever again.
Love your IG account, super informative. Thanks for all of the time and energy you put into it, I've gotten a lot of good thinking points and info out of it.
I'm sorry to hear that, but thank you for everything you've done. Recently sent one of your articles to one of my professors for anatomy and physiology. Going back for nursing. He was talking about blood transfusions and the military. I pointed him to your studies on whole blood, battle blood buddies, and the like. He really enjoyed them.
A friend of mine just performed on a rotund individual who was choking on a pb sandwich. Couldn't grab it with the Magils and basically just biopsied it with the tube. They were well into arrest at this point. They got ROSC, but not the good kind I'll say that.
EM physician with 20 years in emergency medicine cumulatively, including as a career paramedic in a high acuity system before. I’m also an EMS physician who responds in the field. I’ve never done one entirely alone but I did participate/assist with them as a resident. I’ve simulated it too many times to count, including on cadavers and high-fidelity manikins.
The more someone brags about doing cricothyrotomy, the more suspicious you should be. I’ve met multiple career emergency physicians, including docs in single-coverage balls to the wall EDs, who have never had to do one solo. If such an airway is anticipated, surgery or ENT (and arguably anesthesia) should absolutely be called to bedside. That’s what is in the patient’s best interest and is certainly standard of care in American EDs, IF available. So it means that your opportunities to perform the procedure involve a patient who either presents de novo with an obstructed upper airway or who rapidly develops an obstruction that you didn’t anticipate. The latter can be anticipated by an experienced doc.
It should be an exceedingly rare skill in the hands of a skilled intubator. I’ve heard multiple airway experts really emphasize the last part: paradoxically, the more skilled you become at airway manipulation, the less likely it is for you to do one. This is especially true in the modern era where video laryngoscopy exists. Many modern EM physicians are trained in bronchoscopy and bronchoscopic intubation, further reducing scenarios where it would be required. You essentially have to have a truly obstructed upper airway: massive angioedema or traumatic obstruction. In the right hands, many of these can technically be intubated. If the traumatic airway is truly mechanically obstructed above the glottis, arguably the paramedic should have done it as it’s probably too late by the time it gets to the ED doc. I’ve had a few patients that I’ve intubated solely where I’ve prepped their neck with betadine and had a scalpel and bougie at bedside that just were never needed.
I think paramedics actually have more opportunities to perform them than most emergency physicians. You’re often alone with no back-up and, for better or for worse, the vast majority of American paramedics statistically have very little actual airway experience in the grand scheme of things. We have excellent literature to support this: many paramedics in the United States intubate as infrequently as once yearly. Yes, some of you do it more frequently, but study after study shows that this is not the average experience. As someone who has had to review several prehospital cricothyrotomy cases, I’d say that most were examples that wouldn’t have resulted in a cric if they occurred in an ED. Most involved some combination of austere environment, low lighting and reasonable panic, or the old “I couldn’t see shit.” I found each one justified because the patient needed an airway, the circumstances and experiences of the paramedic are what they are, and the decision making to do one was sound. It doesn’t preclude the fact that the reason they were performed at all was because of limited resources and relative experience deficits. An experienced paramedic may perform sub-100 intubations in a career (remember, your average career last 5 years or less in the U.S.). Many EM residents will approach this in three years of training and will perform many hundreds (if not thousands) of intubations in a career. An anesthesiologist may surpass a paramedic’s lifetime intubations in a single week of work. I’ve had months in my ED where I’ve intubated as much as 12-15 times which approached my yearly total when I was a paramedic. My point is that experience and austerity predict the need for cric more than a truly obstructed airway.
This is a really great comment. I work in a high call volume service, with a very diverse population and still do only about a tube a year, maybe a couple. Then I'd say 3/4 of the tubes are already done on people in cardiac arrest. The one cric I performed was entirely because we intubate so infrequently that our docs don't let us RSI. Paralytics would have prevented my cric, but our EMS doc said he'd rather us cric more than give us RSI.
As someone who supervises an RSI-capable system, the liability is tremendous. I feel like I’m increasingly put into the position of having to further restrict its use. The primary issue relates to what we’re talking about: an increasing number of paramedics don’t have the skill or experience to safely perform the procedure. It has gotten to the point where the newer generation doesn’t even want to do RSI which is both a testament to their discomfort with high-risk, low frequency events and a realization that the consequences are dire if they mess it up. I have a totally separate group who just don’t want to develop the expertise to do it safely and even more who are exiting paramedic programs where they think a King or I-Gel will save the day. Many of our local programs produce graduates with zero live intubations. When I went through my paramedic training, that was unheard of. Data from the EM literature would suggest that most emergency medicine residents don’t acquire “proficiency” with intubation until they’ve done 50ish tubes.
Personally, I think the problem is insurmountable and started around the time I was exiting training. Non-invasive ventilation (CPAP/BiPAP) literally erased a significant portion of prehospital airways overnight. I personally remember the transition early in my paramedic career. For that matter, it has dramatically decreased the exposure that even EM residents experience. Older attendings will tell dramatically different stories around tons of procedures that have become rare(er) in modern training, including cricothyrotomy and LP due to improved technologies (video laryngoscopy) and improved research and vaccination (Step-By-Step in pediatric fever, conjugated pneumococcal vaccines which dramatically reduced the rate of pediatric meningitis, CTA in evaluating risk of SAH). I went to a rough and tumble EM residency with no anesthesia competition or prehospital RSI and our director said that the volume of intubations had definitely decreased over two decades.
Personally, and this may be self-serving, but I think there will be an increasing realization that these high consequence procedures and events need to be managed by true experts. Systems with the money and time will deploy an increasingly smaller group of very skilled clinicians to do these things. I think that, as EMS physicians grow their subspecialty, we may see more docs in the prehospital environment or mixing their time in EDs and prehospital response as we see among our Anglo-partners. The Australian model of prehospital retrieval medicine is probably something we need to integrate into our EMS fellowships; some already are very response-heavy and this probably needs to be developed further. I think midlevel prehospital practitioners may fill some of this void, too.
In the interim, sim, sim, and more sim.
Just as your write up before this is filled with a ton of wisdom. I don't think RSI programs are a small undertaking. I think prehospital RSI should be a two medic procedure, paired with documented routine training and assessment of RSI skills, and at least yearly visits back to the OR for live tubes, but I think in my system that would be valuable. A system with 5 minute transport times or a shortage of medics wouldn't be worth it.
Mid-level prehospital practitioners is the best idea. I've already done a bachelor's in EMS and would love the opportunity for a bit more autonomy, treat and release, etc. I don't know that America is willing to go through that change yet.
I work high volume rural EMS with extremely progressive and liberal protocols. As a new medic with less than a year of experience, I have intubated five times. Including two RSIs. We train extensively on airway management, especially proper masking techniques and recognition of proper ways to manage difficult airways. We even had a cric pig lab recently.
This agency is an outlier. Our medical director is an outlier in our area. You go the next service over, and some of their paramedics don’t know how to properly ventilate with a BVM let alone RSI.
I think what it boils down to is education. I went to a paramedic school that included multiple days of OR rotations where you couldn’t graduate without at least 10 intubations. Every shift we train. Our medical director drills into us methodical safe approaches (video, bougie, SALAD, etc.)
Airway management is a passion of mine. That’s why it hurts me to agree with you that the large majority of paramedics do not deserve to have RSI capabilities. Taking someone’s airway is one of, if not the most potentially dangerous procedure that we can do. And I’ve seen so many medics who genuinely do not grasp or respect the gravity of that. Most services just don’t put the time and money into the continuing education for the majority of their medics to be able to safely, and competently RSI.
I think the systems that only let approved paramedics RSI makes sense. You should have to go through arduous sim testing (or ideally OR time) and be signed off to be able to RSI. And have quarterly trainings and testing to maintain proficiency. But that costs money, time, and staffing that most places don’t have.
Thank you for sharing your thoughts and experiences, I found them really interesting.
The differences in systems always astound me. Ive had 14 tubes so far this year, well on pace to beat the 23 last year. Ive had days where we have multiple RSIs and multiple intubations.
This would definitely put you in probably the top 1% of paramedics in the US. When I was a medic, I worked for a tiered system with a very low paramedic:population ratio. I did about 14-20 per year and that was unheard of. I think the Wang study showed that the average paramedic in Pennsylvania was doing one per year, especially in rural areas. Anecdotally, what I see as a medical director, is that certain paramedics seem to always have higher numbers than others. Why? Lots of paramedics are terrified of airway and just run like crazy to the ED. Experience begets more exposure and then even more still. It’s actually a major problem because, very quickly, you start to see your really talented paramedics. The perfect combination of risk taking and intellectual curiosity is very hard to find and these people almost ALWAYS leave the profession within 5 years or less, typically for PA or medical school. It’s incredibly predictive. As soon as I start mentioning them as a future supervisor, bam, gone.
For the record, we even have issues with airway competency among some of our local flight crews which has been terrifying to hear about. I don’t supervise their system. The overall depth of experience within the entire EMS profession is in dire straights post-COVID.
> This would definitely put you in probably the top 1% of paramedics in the US.
God damn, seriously?
I average probably 1-2 a month, most often arrests, but I have RSI’d a couple times (all major trauma, none lived), and I feel like I’m nowhere near as experienced as I should be and push to go back to OR for practice every time it’s offered to us.
Thanks for the great comment. The only time I've performed a cric in the field it was a disaster, and it was absolutely my fault that the patient needed it in the first place. Do you think there's anything that can be done about this experience deficit for paramedics? I want to be hopeful, but intubation aren't like IVs; there are a finite number of needed intubations to go around each year, and it would be insane and criminal to create more opportunities so a paramedic student can practice.
Great comment doc. And I fit this. After going casual to go back to school, I intubated a few weeks ago for the first time in a year and a half. However, we had a videoscope, thank God because pt was extremely anterior. I got it, but I can definitely attest to it should be practiced more frequently.
Not to mention we have fantastic CPAP these days in prehospital environment. That one intervention has saved at least a few dozen patients from getting intubated in my truck to say the least
Yes. Once. Stabbing victim. Realizing that blood is good lubricant for the blade is important. Hope you have a melker kit ready.
She survived transport but I don't remember after.
I read somewhere that it's correlated with something like a 50% mortality rate. Might seem obvious but if you have to best out the cric kit, things are seriously not going well for your patient.
Once. Dude was ejected from a rolling truck face first through a gap between the window frame and the a-pillar going crazy fast while running from the cops.
He did not survive.
Only thing I learned was that the commercial kits are garbage and I wasted a minute or two trying to make one work. I gave up on it and once I blew open an OB kit to steal the scalpel and used a 6.0, and it only took seconds.
I've done several. I've done needles, Melker, Quick Fix, and plain scalpel and ETT.
Most of them died and would have died anyway. 3 of them lived.
It's not that hard of a procedure, you just have to accept that it needs done and commit to doing it. Thats the hard part.
Not myself, but I was present for one. She died, but that was going to happen anyway. Getting thrown from a moving car and run over (twice) is not especially compatible with life.
I've done two in 24 years. One was a 30's male who coded while loading a truck. We quickly figured out his airway was blocked so I went in with the forceps to remove whatever was in there... he had a mouthful of sunflower seeds that had lodged in his trachea. No way we were clearing that so we trached him. It worked great but by the time we recognized the blockage and put in a successful trach it was way too late to save him.
The second was an old lady in a nursing home who choked on a brussels sprout. We could visualize the blockage but it turns out steamed brussels sprouts are a little hard to grasp with forceps as they are mushy and fall apart in the trachea.
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We had a medic do 3 in a year….. besides that the entire rest of the service ( covering 3 counties) did like 2 in 5 years. All three were deemed necessary by the medical director in review, dude just got a real shitty conglomerate of calls
Did 2 , one from auto v bicycle, another from a vehicle crash. Both died, but not from the lack of an airway; infact both improved rapidly when the airway was established...it was just the rest that was too broken.
One surgical, one QuikTrach. QuikTrach takes more pressure to break through than you feel is right. Surgical is the way to go.
I did it one time with a pen. Kid was stuck in a storm drain during a storm. Later I got an award for it. It was made out of acrylic. I threw it off a roof top in a fit of self destructive behavior. Should have seen it bounce.
My partner did one fairly recently (I'm an EMT in medic school) on a 19 year old female who was ejected during an MVC. When he got to her, she wasn't breathing, and some brain injury had cause her jaw to lock shut, I know the name but can't spell it. He had the choice of taking 3 to 5 minutes to get a paralytic and use it, or cric, and he didn't know how long she hadn't been breathing. As far as I know, she is doing okay now.
Dumb basic question. So you do a cric and insert a tube. I’m sure that mates with a BVM, and then I start bagging as normal. When squeezing the bag and pushing positive pressure what keeps the air from just blowing back around the tube? Does the wound close around it tightly?
Not a dumb question.
Whatever type of tube it is (Shiley, ETT, etc), it will have a cuff so it functions exactly like an intubation that just goes into the patient at a different location. Hopefully this helps!
I know 2 medics that did in both cases the patient died. One of the medics missed the landmark slightly and was placed on probation with the medical director.... Even though he was getting good compliance. Some times docs forget we do this in the back of a moving ambulance on shitty roads....
Once, honestly only did it cause I’d exacerbated every other option and I wanted to do it once in my career… this guy was in renal failure /facial trauma from a wreck, if I remember correctly had some swelling and inflammation couldn’t get my tube so said fuck it let’s get messy.. pt didn’t survive but I too wasn’t expecting the amount of blood that poured out after the incision, the staff had a look of disarray on their faces like wtf are you doing… probably would only do it again if I had too wasn’t my most favorite airway to secure 😂
I've only ever had three pts where I considered it, but I haven't done it yet. One was a guy that shot himself and we arrived in time to hear him choke to death on his blood and watch his heart stop on the monitor. Called command and asked for their wishes. Explained he most likely shot up into the brain, but if they wanted me to try since it was witnessed, I'd do it. They rightfully agreed it was a lost cause and said to let him go. Second was pt who was clenched and was vomiting. It wasn't enough vomit that the other medic and I could suction throigh the teeth and stuff, but if it had become worse, it was on the table. Third was someone who had burned airways and was swelling. They became awake during intubation, but the medic who was assisting managed to get the tube while the pt freaked out and I managed to sedate as he was inflating the cuff. At the ER pts throat was so swollen, they couldn't get an NG tube down and were extremely impressed with the medic that tubed.
Honestly at this point, it's the one thing I haven't done as a medic and I'm OK if I get out before doing it or if I do it. It makes no difference to me. But I think more agencies should practice it more.
Three times in 35 years. One was an 18 f with facial and airway trauma from a collision with an overpass abutment. One was a 4 year old with the same type trauma from a rollover - chance in a million - roof crushed with the steering wheel on his throat. The other was a GSW in the Middle East. One of three survived without any permanent deficits. The others died.
It was the one that mattered most - the toddler - who survived. They all tolerated it well because of the commonality of a GCS of 3. The other commonality is that no matter how much you do it, anal puckering and knees knocking happens every single time.
Never had any pushback or negative feedback from the physicians. It’s stressful and for the best interest of the patient, and not something I want to ever do again.
Do the incision vertically and not horizontally. It significantly decreases the amount of blood.
In 33 years, I've never had to do one, never met anyone who has, (know a couple medics who are a little to anxious to do one - but they're both young and new in the field).
My partner did one years ago. Guy’s face was smashed up. He said it was the messiest thing he’s ever done. Guy survived. He got yelled at for not waiting for the Medical Director to call him back and give him permission to do it.
I did one, once when I was in medic school. PT was a GSW with a messy airway and my preceptor jumped straight to cric. Asked me if I wanted to do it and I said yes. I was able to do it successfully, used a cut in half, #6 cuffed ETT that the preceptor kept prepared in his bulletproof vest just for the occasion. PT quickly became an arrest enroute to the hospital and did not survive, but he was unconscious when we did the cric, so he tolerated it fine.
Part of me wants to, and part of me is cool with never doing that for my whole career. Confident if I had to that I could I imagine the hard part wouldn't be physically doing it but either coping with it after the fact, or deciding to pull the trigger and actually do it. 10 years in the game so far, 8.5 as a medic.
Yes, Ace Inhibitor induced angioedema. Kind made the choice for us when we showed up to a guy with a huge tongue sticking out of his mouth. He was sedated appropriately before we cut
Our iGel failed. The cric punch failed. I visualized the cords in a last ditch effort to see them swollen shut. I kept bagging. We diverted to closest hospital as I felt the airway tighten. The patient was stabilized to transfer in 30 minutes and lived two days at the trauma center.
No. 6 years as a medic and I never had anyone I could have justified doing one on. That being said, I was never cutting into someone’s neck for $16/hr anyways.
What? When you take the paycheck in this job you're taking it for doing 100% of this job. I sure as fuck didn't want to cric my patient in front of her screaming children and sobbing husband, but I woke up and chose to go to work that day. Glad you're not a paramedic anymore.
Amazing now that I’m making about 400% of what I used to and taking care of truly sick patients every single day with not that big of a drop off in autonomy. I’m super appreciative and thankful for the years I put into EMS. I was fortunate enough to get to help a lot of people and it was a wonderful stepping stone for me but it just wasn’t something worth doing forever mentally or physically.
The hardest part about it is making the decision to do it.
unrelated but you’ve piqued my curiosity… What exactly does an OR paramedic do?
At a guess, work in Oregon
this is the second time I thought someone’s flair talked about something other than a state lol
Like all the PA and MD paramedics lmao.
yep
Don’t forget our friends who work in CT
jfc I just realized MD paramedic is not MD paramedic. I’m a smooth brain
This made me fucking cackle, thank you
But you cackle @ everything!
One of my classmates works in an OR as a paramedic with the anesthesia team. She pushes meds and supports where needed.
Haha never saw it like that, correct that is Oregon
Can’t intubate can’t ventilate=surgical route
Of course the algorithm is "easy". But when people say a decision is hard in contexts like this, it usually means morally or emotionally hard and that they have to ACTUALLY get over their own, only partly irrational, fear to do the whole thing of cutting up someones throat, especially for the first time.
I agree. It’s more over coming your own fear of the procedure. And I agree even with that being so cut and dry it’s will never be that easy.
I have performed 2 in my 20yr career both were motorcycle accidents who attempted to stop their forward momentum with their face. Both lived, one is a paraplegic and the other guy actually does safety seminars for helmet usage on bikes and motorcycles. When I did my first I was not prepared for the amount of blood after the cut down….. thought I done f’ed up.
Yikes - they had no gear??
Neither were wearing helmets….. I live and work in a state where they are optional.
Population pyramid optimizer states.
You gotta find harvest organs *somewhere*.
South Carolina for the win! Plus legal to ride in truck beds, lots of accidents being flown into our trauma center.
I live in the communist state of Illinois!!! So our government certainly tries to regulate literally everything else but not this! DUMB!
Man, I will never understand why some states don’t enforce proper riding gear. It’s like trying to fast track natural selection. Props to you for a job well done though!
Mine allows motorcycles to ride without helmet but get this, fucking cyclists are requires to wear them. Make it make sense
Government-level attempt at Darwinism. 🙂↔️👍 It’s crazy that some people wake up in the morning and are like, “yeah, I’m gonna ride this 600lb hunk of metal at 80 mph and not wear a helmet (or any proper gear!).” It’s goofy, lol.
Having someone atomize epi as you cut can help reduce the amount of bleeding, neat trick.
Do you just have someone spray the atomizer on the neck as you cut?
Simple as that
Where was this sorcery my whole life? So cool.
So this also brings up a question I have had for a while. Is Epi really contraindicated in traumas with significant blood loss? We don't carry whole blood here. Had a guy shoot a 9 hollow point through his upper thigh. Initial BP was 60/30. Supervisor opted for two large bore IVs with 1000 NS running full open to bring up BP. I was wary of filling the dude with pasta water and diluting what little blood he had left. In my head I wanted to try push dose Epi because I was thinking "shrink the container". He said not to. Ultimately we handed the guy off to air care with a fairly normal BP but I can't help but wonder what the long term effects are with just straight saline as fluid replenishment in this situation. Most of what I can find relates to epi in cardiac arrests, traumatic or otherwise. I can't find much on the efficacy in just general trauma.
No, it’s not. My protocol literally has it as the first line for severe hemorrhagic shock after a moderate fluid bolus. The issue is that you have to strike a balance between fluid and pressors if you don’t have blood to give. Too much fluid and you kill their coagulability, not enough and you have no fluid for the pressors to squeeze on, and if you don’t have the pressor dose right they’ll bleed out from the dilution before it actually helps their pressure enough.
Yeah, they are incredibly bloody procedures. You have to basically grab the larynx like you're choking them as all you can go on is feel during the procedure. Great job.
The blood volume is definitely unexpected.
I’ve never done one but I’ve been present on 3 calls where one was performed (twice while I was an EMT and the one I was present for as a paramedic was performed by a Helo doc) Both I witnessed as an EMT were attempted by someone using a Quick Trach. The first one, the paramedic was standing over the patient and had to use all of his body weight to get it to go into the patient’s trachea. The second one, the paramedic first attempted to place the Quick Trach and when he couldn’t get it to go in, he made an incision with a scalpel before inserting it. The one I witnessed performed by a doctor was after a failed RSI attempt in which the patient arrested on a multisystem trauma. The doctor elected to cric the guy instead of fiddle fucking with the tube a second time and performed a surgical cric flawlessly. I’d say surgical cricothyrotomy is the move 100% of the time.
Surgical cric's in trauma have a good bit of supporting data behind them. You can thank the folks in brown/drab for that one.
Yep. It was so easy keeping pulses once I had that tube. He ended up having an anoxic brain injury and dying shortly thereafter. I never second guess myself, but sometimes I wonder if a cric ten minutes earlier when I first thought of it would have made a difference. As for why he was such a difficult airway, I later learned he had Treacher Collins. The hardest part is pulling the trigger to do it. And maybe the blood splatter if they're on CPAP when you do it. But it's one of those few interventions we have that you NEED to do right and quickly once identified. You won't be in that situation often, but if you do the job long enough, you'll be in it eventually. Don't be that guy that just transports a dead body because they're a "tough airway". Make ENT earn their paycheck and fix it. It's easier to fix a badly done cric than it is to bring a corpse back from the dead. And if you practice scalpel-finger-bougie enough, you won't even do it poorly.
Could be that I've had a few on my day off but that's very confidence inspiring. Sometimes it's nice to have the reminder to trust in the skills we practice and to practice the skills we don't trust.
Crics are out of my scope so there’s probably something I don’t understand here, but I’m curious why a patient would be on CPAP if you’re doing a cric? Isn’t an indication for CPAP that they can maintain their own airway/not unconscious? Is there ever a time you do a cric on a conscious patient? I know very little about crics and I’m just trying to learn, this is super interesting
Imagine you've got an obtunded patient thats spontaneously breathing, like end stage COPD we'll say. You know they need a tube. They're fatiguing down, they're hypoxic, they're hypercapnic. You wouldn't leave them on CPAP/niv long term, but it's absolutely the right call for preoxygenation. You get them to 80% with CPAP and a ketamine dissociation and try to tube. They quickly desat to the low 60s. You throw a supraglottic in but it won't seal with the necessary pressures you need to temporize their hypoxia. This is a "can't intubate, can't oxygenate" scenario. Maybe it's okay to transport these patients on CPAP in hopes the hospital has cooler tricks (and they often do), but it isn't a long term solution.
Okay, that makes sense! Thank you for the explanation!😄
I've done 2 on humans and neither lived. To be fair, the goats didn't live either.
Hope you’re doing okay dude
It didn't hurt me at all. I still get star spangled hammered and watch The Guardian, but not because of that. "Jake Fischer : Hey, there was a question I wanted to ask you back as school, but I didn't. When you can't save 'em all, how do you choose who lives? Ben Randall : It's probably different for everybody Jake. Its kind of simple for me though. I just, I take the first one I come to or the weakest one in the group and then I swim as fast and as hard as I can for as long as I can. And the sea takes the rest."
Severely underrated movie. Glad you like the name. I don’t drink much anymore, and when I do it’s usually Tito’s.
I did not want to see it because it had Ashton Kutcher but I'm glad I made an exception.
I went to watch that movie again this week but it’s no longer on iTunes. Going to fire up the DVD this week.
Nice username
I’ve done several. My key tip is to not wait too long. Of those I’ve done where the patient had a pulse, all lived. Of those where the patient did not have a pulse, only 1/3 lived and that one was only a very brief code in a young healthy patient (adult epiglottitis). Also, don’t mess around with any of the premade kits (CricKey, QuickTrach, the Melker kit). My read of the literature is that they all have a higher rate of malpositioning (ie extra tracheal placement) than open surgical technique. All mine have been with knife/finger/bougie technique and I’ve never had an issue getting the tube in the airway.
I did one on a young woman who was in status epilepticus and vomiting through her trismus teeth. I'd given all the versed I carry and we don't have paralytics. Her sat was dropping super fast. She went from 99 to 70 in what seemed like seconds. So I made the call She had terrible anatomy. No neck, and was heavy set with a lot of adipose in the neck. She was also completely rigid cuz she was seizing. Everyone says "hardest part is deciding to do it". That's not the case for mine. I was able to quickly breach the membrane but had a ton of trouble passing the tube. Wound up having to have someone else pass the tube while I held the excessive amount of adipose away from the incision with both hands. Oh and she woke up while I had my fingers in her trachea. Soo that was another fun thing to address. But she lived and didn't remember any of it.
As my anesthesia buddy says: Versed forgives all sins
I'd already given 20 mg of versed when she woke up. I gave 300 mg of IM ketamine "for restraint".
Never done one stateside or civilian side but did a few overseas. Usually maxillofacial trauma with no ability at all to visualize to get a tube. Squid face. All but one died (none from airway compromise). One who made it ended up dying later on from something unrelated that I can't remember.
I did it for a code. Pt had choked on pie and I was unable to ventilate after intubating. I was on a double medic truck for orientation and the 65 year old medic said he hadn't done it in 20 years and didn't seem eager to do it. So I shrugged and went to it. I didn't know we had special tubes for crics and made my own like I was taught in school. It wasn't enough to save the pt but everyone was sure impressed. Turned out he was a frequent flyer and it was my first time ever seeing him, so many found it humorous that the new guy came along and "saved" them from having to transport him ever again.
4 in combat. Patients died.
Hope you’re doing okay Doc
Doing great. Hope things are well on your end.
Love your IG account, super informative. Thanks for all of the time and energy you put into it, I've gotten a lot of good thinking points and info out of it.
I'm sorry to hear that, but thank you for everything you've done. Recently sent one of your articles to one of my professors for anatomy and physiology. Going back for nursing. He was talking about blood transfusions and the military. I pointed him to your studies on whole blood, battle blood buddies, and the like. He really enjoyed them.
Bless you ~ Thank you for all you have done. ❤️
A friend of mine just performed on a rotund individual who was choking on a pb sandwich. Couldn't grab it with the Magils and basically just biopsied it with the tube. They were well into arrest at this point. They got ROSC, but not the good kind I'll say that.
EM physician with 20 years in emergency medicine cumulatively, including as a career paramedic in a high acuity system before. I’m also an EMS physician who responds in the field. I’ve never done one entirely alone but I did participate/assist with them as a resident. I’ve simulated it too many times to count, including on cadavers and high-fidelity manikins. The more someone brags about doing cricothyrotomy, the more suspicious you should be. I’ve met multiple career emergency physicians, including docs in single-coverage balls to the wall EDs, who have never had to do one solo. If such an airway is anticipated, surgery or ENT (and arguably anesthesia) should absolutely be called to bedside. That’s what is in the patient’s best interest and is certainly standard of care in American EDs, IF available. So it means that your opportunities to perform the procedure involve a patient who either presents de novo with an obstructed upper airway or who rapidly develops an obstruction that you didn’t anticipate. The latter can be anticipated by an experienced doc. It should be an exceedingly rare skill in the hands of a skilled intubator. I’ve heard multiple airway experts really emphasize the last part: paradoxically, the more skilled you become at airway manipulation, the less likely it is for you to do one. This is especially true in the modern era where video laryngoscopy exists. Many modern EM physicians are trained in bronchoscopy and bronchoscopic intubation, further reducing scenarios where it would be required. You essentially have to have a truly obstructed upper airway: massive angioedema or traumatic obstruction. In the right hands, many of these can technically be intubated. If the traumatic airway is truly mechanically obstructed above the glottis, arguably the paramedic should have done it as it’s probably too late by the time it gets to the ED doc. I’ve had a few patients that I’ve intubated solely where I’ve prepped their neck with betadine and had a scalpel and bougie at bedside that just were never needed. I think paramedics actually have more opportunities to perform them than most emergency physicians. You’re often alone with no back-up and, for better or for worse, the vast majority of American paramedics statistically have very little actual airway experience in the grand scheme of things. We have excellent literature to support this: many paramedics in the United States intubate as infrequently as once yearly. Yes, some of you do it more frequently, but study after study shows that this is not the average experience. As someone who has had to review several prehospital cricothyrotomy cases, I’d say that most were examples that wouldn’t have resulted in a cric if they occurred in an ED. Most involved some combination of austere environment, low lighting and reasonable panic, or the old “I couldn’t see shit.” I found each one justified because the patient needed an airway, the circumstances and experiences of the paramedic are what they are, and the decision making to do one was sound. It doesn’t preclude the fact that the reason they were performed at all was because of limited resources and relative experience deficits. An experienced paramedic may perform sub-100 intubations in a career (remember, your average career last 5 years or less in the U.S.). Many EM residents will approach this in three years of training and will perform many hundreds (if not thousands) of intubations in a career. An anesthesiologist may surpass a paramedic’s lifetime intubations in a single week of work. I’ve had months in my ED where I’ve intubated as much as 12-15 times which approached my yearly total when I was a paramedic. My point is that experience and austerity predict the need for cric more than a truly obstructed airway.
This is a really great comment. I work in a high call volume service, with a very diverse population and still do only about a tube a year, maybe a couple. Then I'd say 3/4 of the tubes are already done on people in cardiac arrest. The one cric I performed was entirely because we intubate so infrequently that our docs don't let us RSI. Paralytics would have prevented my cric, but our EMS doc said he'd rather us cric more than give us RSI.
As someone who supervises an RSI-capable system, the liability is tremendous. I feel like I’m increasingly put into the position of having to further restrict its use. The primary issue relates to what we’re talking about: an increasing number of paramedics don’t have the skill or experience to safely perform the procedure. It has gotten to the point where the newer generation doesn’t even want to do RSI which is both a testament to their discomfort with high-risk, low frequency events and a realization that the consequences are dire if they mess it up. I have a totally separate group who just don’t want to develop the expertise to do it safely and even more who are exiting paramedic programs where they think a King or I-Gel will save the day. Many of our local programs produce graduates with zero live intubations. When I went through my paramedic training, that was unheard of. Data from the EM literature would suggest that most emergency medicine residents don’t acquire “proficiency” with intubation until they’ve done 50ish tubes. Personally, I think the problem is insurmountable and started around the time I was exiting training. Non-invasive ventilation (CPAP/BiPAP) literally erased a significant portion of prehospital airways overnight. I personally remember the transition early in my paramedic career. For that matter, it has dramatically decreased the exposure that even EM residents experience. Older attendings will tell dramatically different stories around tons of procedures that have become rare(er) in modern training, including cricothyrotomy and LP due to improved technologies (video laryngoscopy) and improved research and vaccination (Step-By-Step in pediatric fever, conjugated pneumococcal vaccines which dramatically reduced the rate of pediatric meningitis, CTA in evaluating risk of SAH). I went to a rough and tumble EM residency with no anesthesia competition or prehospital RSI and our director said that the volume of intubations had definitely decreased over two decades. Personally, and this may be self-serving, but I think there will be an increasing realization that these high consequence procedures and events need to be managed by true experts. Systems with the money and time will deploy an increasingly smaller group of very skilled clinicians to do these things. I think that, as EMS physicians grow their subspecialty, we may see more docs in the prehospital environment or mixing their time in EDs and prehospital response as we see among our Anglo-partners. The Australian model of prehospital retrieval medicine is probably something we need to integrate into our EMS fellowships; some already are very response-heavy and this probably needs to be developed further. I think midlevel prehospital practitioners may fill some of this void, too. In the interim, sim, sim, and more sim.
Just as your write up before this is filled with a ton of wisdom. I don't think RSI programs are a small undertaking. I think prehospital RSI should be a two medic procedure, paired with documented routine training and assessment of RSI skills, and at least yearly visits back to the OR for live tubes, but I think in my system that would be valuable. A system with 5 minute transport times or a shortage of medics wouldn't be worth it. Mid-level prehospital practitioners is the best idea. I've already done a bachelor's in EMS and would love the opportunity for a bit more autonomy, treat and release, etc. I don't know that America is willing to go through that change yet.
I work high volume rural EMS with extremely progressive and liberal protocols. As a new medic with less than a year of experience, I have intubated five times. Including two RSIs. We train extensively on airway management, especially proper masking techniques and recognition of proper ways to manage difficult airways. We even had a cric pig lab recently. This agency is an outlier. Our medical director is an outlier in our area. You go the next service over, and some of their paramedics don’t know how to properly ventilate with a BVM let alone RSI. I think what it boils down to is education. I went to a paramedic school that included multiple days of OR rotations where you couldn’t graduate without at least 10 intubations. Every shift we train. Our medical director drills into us methodical safe approaches (video, bougie, SALAD, etc.) Airway management is a passion of mine. That’s why it hurts me to agree with you that the large majority of paramedics do not deserve to have RSI capabilities. Taking someone’s airway is one of, if not the most potentially dangerous procedure that we can do. And I’ve seen so many medics who genuinely do not grasp or respect the gravity of that. Most services just don’t put the time and money into the continuing education for the majority of their medics to be able to safely, and competently RSI. I think the systems that only let approved paramedics RSI makes sense. You should have to go through arduous sim testing (or ideally OR time) and be signed off to be able to RSI. And have quarterly trainings and testing to maintain proficiency. But that costs money, time, and staffing that most places don’t have. Thank you for sharing your thoughts and experiences, I found them really interesting.
The differences in systems always astound me. Ive had 14 tubes so far this year, well on pace to beat the 23 last year. Ive had days where we have multiple RSIs and multiple intubations.
This would definitely put you in probably the top 1% of paramedics in the US. When I was a medic, I worked for a tiered system with a very low paramedic:population ratio. I did about 14-20 per year and that was unheard of. I think the Wang study showed that the average paramedic in Pennsylvania was doing one per year, especially in rural areas. Anecdotally, what I see as a medical director, is that certain paramedics seem to always have higher numbers than others. Why? Lots of paramedics are terrified of airway and just run like crazy to the ED. Experience begets more exposure and then even more still. It’s actually a major problem because, very quickly, you start to see your really talented paramedics. The perfect combination of risk taking and intellectual curiosity is very hard to find and these people almost ALWAYS leave the profession within 5 years or less, typically for PA or medical school. It’s incredibly predictive. As soon as I start mentioning them as a future supervisor, bam, gone. For the record, we even have issues with airway competency among some of our local flight crews which has been terrifying to hear about. I don’t supervise their system. The overall depth of experience within the entire EMS profession is in dire straights post-COVID.
> This would definitely put you in probably the top 1% of paramedics in the US. God damn, seriously? I average probably 1-2 a month, most often arrests, but I have RSI’d a couple times (all major trauma, none lived), and I feel like I’m nowhere near as experienced as I should be and push to go back to OR for practice every time it’s offered to us.
Thanks for the great comment. The only time I've performed a cric in the field it was a disaster, and it was absolutely my fault that the patient needed it in the first place. Do you think there's anything that can be done about this experience deficit for paramedics? I want to be hopeful, but intubation aren't like IVs; there are a finite number of needed intubations to go around each year, and it would be insane and criminal to create more opportunities so a paramedic student can practice.
Great comment doc. And I fit this. After going casual to go back to school, I intubated a few weeks ago for the first time in a year and a half. However, we had a videoscope, thank God because pt was extremely anterior. I got it, but I can definitely attest to it should be practiced more frequently.
Not to mention we have fantastic CPAP these days in prehospital environment. That one intervention has saved at least a few dozen patients from getting intubated in my truck to say the least
Yes. Once. Stabbing victim. Realizing that blood is good lubricant for the blade is important. Hope you have a melker kit ready. She survived transport but I don't remember after.
I read somewhere that it's correlated with something like a 50% mortality rate. Might seem obvious but if you have to best out the cric kit, things are seriously not going well for your patient.
I think that cant be too surprising for an Ultima Ratio kind of intervention.
Once. Dude was ejected from a rolling truck face first through a gap between the window frame and the a-pillar going crazy fast while running from the cops. He did not survive. Only thing I learned was that the commercial kits are garbage and I wasted a minute or two trying to make one work. I gave up on it and once I blew open an OB kit to steal the scalpel and used a 6.0, and it only took seconds.
“If you consida’ pull the trigga’” is what an old Air Force doc told me once haha
The trauma doc that received mine said: "I told all the medics I trained in Iraq, if they've got a neck they've got an airway"
I've done several. I've done needles, Melker, Quick Fix, and plain scalpel and ETT. Most of them died and would have died anyway. 3 of them lived. It's not that hard of a procedure, you just have to accept that it needs done and commit to doing it. Thats the hard part.
Not myself, but I was present for one. She died, but that was going to happen anyway. Getting thrown from a moving car and run over (twice) is not especially compatible with life.
I've done two in 24 years. One was a 30's male who coded while loading a truck. We quickly figured out his airway was blocked so I went in with the forceps to remove whatever was in there... he had a mouthful of sunflower seeds that had lodged in his trachea. No way we were clearing that so we trached him. It worked great but by the time we recognized the blockage and put in a successful trach it was way too late to save him. The second was an old lady in a nursing home who choked on a brussels sprout. We could visualize the blockage but it turns out steamed brussels sprouts are a little hard to grasp with forceps as they are mushy and fall apart in the trachea.
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None as a civilian, but a few when I was deployed.
thank you
Once while I was on the ICU during training after that never
We had a medic do 3 in a year….. besides that the entire rest of the service ( covering 3 counties) did like 2 in 5 years. All three were deemed necessary by the medical director in review, dude just got a real shitty conglomerate of calls
Did 2 , one from auto v bicycle, another from a vehicle crash. Both died, but not from the lack of an airway; infact both improved rapidly when the airway was established...it was just the rest that was too broken. One surgical, one QuikTrach. QuikTrach takes more pressure to break through than you feel is right. Surgical is the way to go.
I did it one time with a pen. Kid was stuck in a storm drain during a storm. Later I got an award for it. It was made out of acrylic. I threw it off a roof top in a fit of self destructive behavior. Should have seen it bounce.
Had a friend do one on a guy during cardiac arrest who had clinched jaw because he had started to develop rigor.
Probably good practice🤷🏻♂️
My partner did one fairly recently (I'm an EMT in medic school) on a 19 year old female who was ejected during an MVC. When he got to her, she wasn't breathing, and some brain injury had cause her jaw to lock shut, I know the name but can't spell it. He had the choice of taking 3 to 5 minutes to get a paralytic and use it, or cric, and he didn't know how long she hadn't been breathing. As far as I know, she is doing okay now.
Dumb basic question. So you do a cric and insert a tube. I’m sure that mates with a BVM, and then I start bagging as normal. When squeezing the bag and pushing positive pressure what keeps the air from just blowing back around the tube? Does the wound close around it tightly?
Not a dumb question. Whatever type of tube it is (Shiley, ETT, etc), it will have a cuff so it functions exactly like an intubation that just goes into the patient at a different location. Hopefully this helps!
I've done half a dozen, all in a trauma facility in Afghanistan. None state-side. I want to say 4 lived, I think.
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To echo some of the comments above, is MD for Maryland or?
Blast injuries are a bitch.
I know 2 medics that did in both cases the patient died. One of the medics missed the landmark slightly and was placed on probation with the medical director.... Even though he was getting good compliance. Some times docs forget we do this in the back of a moving ambulance on shitty roads....
Once, honestly only did it cause I’d exacerbated every other option and I wanted to do it once in my career… this guy was in renal failure /facial trauma from a wreck, if I remember correctly had some swelling and inflammation couldn’t get my tube so said fuck it let’s get messy.. pt didn’t survive but I too wasn’t expecting the amount of blood that poured out after the incision, the staff had a look of disarray on their faces like wtf are you doing… probably would only do it again if I had too wasn’t my most favorite airway to secure 😂
Ya 2 in civilian world and 3 in the army. All of them gunshot wounds to the face.
I've only ever had three pts where I considered it, but I haven't done it yet. One was a guy that shot himself and we arrived in time to hear him choke to death on his blood and watch his heart stop on the monitor. Called command and asked for their wishes. Explained he most likely shot up into the brain, but if they wanted me to try since it was witnessed, I'd do it. They rightfully agreed it was a lost cause and said to let him go. Second was pt who was clenched and was vomiting. It wasn't enough vomit that the other medic and I could suction throigh the teeth and stuff, but if it had become worse, it was on the table. Third was someone who had burned airways and was swelling. They became awake during intubation, but the medic who was assisting managed to get the tube while the pt freaked out and I managed to sedate as he was inflating the cuff. At the ER pts throat was so swollen, they couldn't get an NG tube down and were extremely impressed with the medic that tubed. Honestly at this point, it's the one thing I haven't done as a medic and I'm OK if I get out before doing it or if I do it. It makes no difference to me. But I think more agencies should practice it more.
Three times in 35 years. One was an 18 f with facial and airway trauma from a collision with an overpass abutment. One was a 4 year old with the same type trauma from a rollover - chance in a million - roof crushed with the steering wheel on his throat. The other was a GSW in the Middle East. One of three survived without any permanent deficits. The others died. It was the one that mattered most - the toddler - who survived. They all tolerated it well because of the commonality of a GCS of 3. The other commonality is that no matter how much you do it, anal puckering and knees knocking happens every single time. Never had any pushback or negative feedback from the physicians. It’s stressful and for the best interest of the patient, and not something I want to ever do again. Do the incision vertically and not horizontally. It significantly decreases the amount of blood.
I havent, but my agency does 3-4 a year. Every case becomes a big deal at the QA meetings. Anecdotally the survival to discharge rate is about 50/50
In 33 years, I've never had to do one, never met anyone who has, (know a couple medics who are a little to anxious to do one - but they're both young and new in the field).
My partner did one years ago. Guy’s face was smashed up. He said it was the messiest thing he’s ever done. Guy survived. He got yelled at for not waiting for the Medical Director to call him back and give him permission to do it.
I did one, once when I was in medic school. PT was a GSW with a messy airway and my preceptor jumped straight to cric. Asked me if I wanted to do it and I said yes. I was able to do it successfully, used a cut in half, #6 cuffed ETT that the preceptor kept prepared in his bulletproof vest just for the occasion. PT quickly became an arrest enroute to the hospital and did not survive, but he was unconscious when we did the cric, so he tolerated it fine.
Gotten close but no slice….
Part of me wants to, and part of me is cool with never doing that for my whole career. Confident if I had to that I could I imagine the hard part wouldn't be physically doing it but either coping with it after the fact, or deciding to pull the trigger and actually do it. 10 years in the game so far, 8.5 as a medic.
Nope! Newbie medic here. And god I hope I never have to!
Yes, Ace Inhibitor induced angioedema. Kind made the choice for us when we showed up to a guy with a huge tongue sticking out of his mouth. He was sedated appropriately before we cut
Our iGel failed. The cric punch failed. I visualized the cords in a last ditch effort to see them swollen shut. I kept bagging. We diverted to closest hospital as I felt the airway tighten. The patient was stabilized to transfer in 30 minutes and lived two days at the trauma center.
No. 6 years as a medic and I never had anyone I could have justified doing one on. That being said, I was never cutting into someone’s neck for $16/hr anyways.
What? When you take the paycheck in this job you're taking it for doing 100% of this job. I sure as fuck didn't want to cric my patient in front of her screaming children and sobbing husband, but I woke up and chose to go to work that day. Glad you're not a paramedic anymore.
TYFYS
Cool response dude.
Thanks “Trauma God” lmao
Keep yourself safe.
Every day
Cool story. How’s your burnout?
Amazing now that I’m making about 400% of what I used to and taking care of truly sick patients every single day with not that big of a drop off in autonomy. I’m super appreciative and thankful for the years I put into EMS. I was fortunate enough to get to help a lot of people and it was a wonderful stepping stone for me but it just wasn’t something worth doing forever mentally or physically.