Failed Airway

[Groove]

Mainly an educational case for the medical students and residents but I thought the rest of you might also be interested.

So, I'm wrapping up my charts on a Fri evening early swing shift and planning on sneaking out a bit early when the overnight doc arrives in 15 mins when the charge nurse comes up going "They need you in the ICU! Something about a failed airway!" I inwardly groan because I rarely get called up there by our ACNPs (who are actually very good) unless it's a total sh** storm. At my hospital, the NPs staff the ICU completely by themselves at night while the attendings sleep at home and the pulmonary group runs multiple ICUs in town and have established this practice. Although I have a lot of problems with this practice pattern, again... the ACNPs up there are actually very good and I've trained a few of them personally and would vouch for them. Regardless...here's the case:

Supermorbid obese guy in his late 40s with no neck, small mouth, copious head/neck blubber in ARDS and septic shock on a rotoprone bed with lost ETT undergoing active compressions/ACLS & being bagged with little air exchange. When they called me I had grabbed an LMA, cric kit, glidescope and fiberoptic intubating stylet. For starters, I really don't know anything about these rotoprone beds. This guy was strapped down and his neck almost completely immobilized with his head in this vice like contraption and nobody could seem to tell me how to get his head/neck free from the top of the bed. I was told RT had lost his airway during one of those spinning maneuvers and they had been coding him for the past 20 mins with multiple attempts by the ACNP. He had a billion lines coming out and had apparently been on deep sedation w/paralysis prior to this event (propofol/vec?). Anesthesia had just showed up (CRNA) and deferred everything to me. She didn't seem too excited to step up to the plate and there was no anesthesia MD in house. Glidescope went in with much difficulty revealing a huge tongue with grade 4 view at an extreme hyper acute angle no doubt d/t the lack of neck mobility and body position. Copious bloody secretions and supraglottic edema. I tried to get the rigid ETT stylet into the glottic inlet and couldn't muscle it into place. There was no way. I then tried a bougie with no luck either. I then tried a fiberoptic intubating stylet (with video laryngoscope in place) after bending it at an extreme angle and although it came into the VL field of view, could not get anywhere near the glottis with it. I then ripped open the cric kit and slashed a vertical incision over the neck and cut down through the subcutaneous tissues over the trachea. Blood was quickly pooling at this point and prior to the incision I couldn't feel any trachea and having done a few of these I knew as soon as I made the incision through fat and platysma, normally I can sink my fingers in there and feel tracheal anatomy pretty well and I didn't want to dissect down any further not really knowing where I was at and accidentally hit jugular or carotid, etc.. So, I used my fingers to verify anatomical positioning, got my bearings, dissected a little more and then made a horizontal stab through the cricothyroid membrane, finger dilated it and, with my finger in place, passed a cuffed melker cannula with inner dilator in place (so I could feel it easily along my finger which was plugging the tracheotomy), connected the ambubag and had BS and positive chest rise. (ROSC) 4x4s were used to tamponade and stuff the incisional site around the neck to obtain hemostasis. Then I used an ambu slim bronch to verify position and eval for any tracheobronchial bleeding (none). I then recommended that they call ENT and GS to take to the OR and get better hemostasis and convert to trach. ENT was apparently not available (partial call at our hospital) and GS said they would do it Monday (wtf?).

In hindsight, if there had been some way to quickly get this guy free from the bed and ramp his shoulders and back, I think I could have achieved a much better body position for intubation conditions but this guy was literally shackled down in that damn space age bed and nobody seemed to be able to tell me how to free him up.

Another option would have been to go immediately to fiberoptic nasotracheal intubation after my first look with the glidescope realizing that endotracheal intubation was going to be almost impossible. We didn't have a bronch in the room though and I calculated that it would be time prohibitive given the circumstances. However I did notice later on that when I needed it for tracheal verification, they seemed to find it and set it up pretty fast.

As for the cric, normally I would stick a bougie through the cric and pass a shiley or the melker over the bougie but I didn't have one nearby. Anytime I have to do one of these (rare), I always intend to use the percutaneous kit but in the heat of the moment when seconds count, I always doubt that I can successfully percutaneously cric them as quickly as I can surgically, so I always end up with a slash and stab which is how I was trained and I find it very difficult to overcome training in order to try something that you are less familiar with during those critical moments.

Thoughts? Would anybody have approached it differently?

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[GeneralVeers]

Sounds bad, but I probably just would have called it........

 

[Groove]

Sounds bad, but I probably just would have called it........

LOL, you're probably right.

Ironically, I checked the progress notes this morning and they've made him a DNR and are putting him on hospice. He apparently had multi system organ failure and I guess last night was the final straw.

 

[GeneralVeers]

LOL, you're probably right.

Ironically, I checked the progress notes this morning and they've made him a DNR and are putting him on hospice. He apparently had multi system organ failure and I guess last night was the final straw.

It would certainly be a cool teaching procedure, but as far as benefit to the patient it probably would have none. This is a morbidly obese guy with organ failure, and anoxic brain injury for 20 minutes. Best case if he wasn't made DNR would be be to live out his final days as a trached vegetable in a LTAC with frequent ambulance trips to the ED for sepsis, and mucous plugs.

 

[gro2001]

Mainly an educational case for the medical students and residents but I thought the rest of you might also be interested.

So, I'm wrapping up my charts on a Fri evening early swing shift and planning on sneaking out a bit early when the overnight doc arrives in 15 mins when the charge nurse comes up going "They need you in the ICU! Something about a failed airway!" I inwardly groan because I rarely get called up there by our ACNPs (who are actually very good) unless it's a total sh** storm. At my hospital, the NPs staff the ICU completely by themselves at night while the attendings sleep at home and the pulmonary group runs multiple ICUs in town and have established this practice. Although I have a lot of problems with this practice pattern, again... the ACNPs up there are actually very good and I've trained a few of them personally and would vouch for them. Regardless...here's the case:

Supermorbid obese guy in his late 40s with no neck, small mouth, copious head/neck blubber in ARDS and septic shock on a rotoprone bed with lost ETT undergoing active compressions/ACLS & being bagged with little air exchange. When they called me I had grabbed our cric kit, glidescope and fiberoptic intubating stylet. For starters, I really don't know anything about these rotoprone beds. This guy was strapped down and his neck almost completely immobilized with his head in this vice like contraption and nobody could seem to tell me how to get his head/neck free from the top of the bed. I was told RT had lost his airway during one of those spinning maneuvers and they had been coding him for the past 20 mins with multiple attempts by the ACNP. He had a billion lines coming out and had apparently been on deep sedation w/paralysis prior to this event (propofol/vec?). Anesthesia had just showed up (CRNA) and deferred everything to me. She didn't seem too excited to step up to the plate and there was no anesthesia MD in house. Glidescope went in with much difficulty revealing a huge tongue with grade 4 view at an extreme hyper acute angle no doubt d/t the lack of neck mobility and body position. Copious bloody secretions and supraglottic edema. I tried to get the rigid ETT stylet into the glottic inlet and couldn't muscle it into place. There was no way. I then tried a bougie with no luck either. I then tried a fiberoptic intubating stylet (with video laryngoscope in place) after bending it at an extreme angle and although it came into the VL field of view, could not get anywhere near the glottis with it. I then ripped open the cric kit and slashed a vertical incision over the neck and cut down through the subcutaneous tissues over the trachea. Blood was quickly pooling at this point and prior to the incision I couldn't feel any trachea and having done a few of these I knew as soon as I made the incision through fat and platysma, normally I can sink my fingers in there and feel tracheal anatomy pretty well and I didn't want to dissect down any further not really knowing where I was at and accidentally hit jugular or carotid, etc.. So, I used my fingers to verify anatomical positioning, got my bearings, dissected a little more and then made a horizontal stab through the cricothyroid membrane, finger dilated it and with my finger in place passed a cuffed melker cannula through and inflated, connected the ambubag and had BS and positive chest rise. (ROSC) 4x4s were used to tamponade and stuff the incisional site around the neck to obtain hemostasis. Then I used an ambu slim bronch to verify position and eval for any tracheobronchial bleeding (none). I then recommended that they call ENT and GS to take to the OR and get better hemostasis and convert to trach. ENT was apparently not available (partial call at our hospital) and GS said they would do it Monday (wtf?).

In hindsight, if there had been some way to quickly get this guy free from the bed and ramp his shoulders and back, I think I could have achieved a much better body position for intubation conditions but this guy was literally shackled down in that damn space age bed and nobody seemed to be able to tell me how to free him up.

Another option would have been to go immediately to fiberoptic nasotracheal intubation after my first look with the glidescope realizing that endotracheal intubation was going to be almost impossible. We didn't have a bronch in the room though and I calculated that it would be time prohibitive given the circumstances. However I did notice later on that when I needed it for tracheal verification, they seemed to find it and set it up pretty fast.

As for the cric, normally I would stick a bougie through the cric and pass a shiley or the melker over the bougie but I didn't have one nearby. Anytime I have to do one of these (rare), I always intend to use the percutaneous kit but in the heat of the moment when seconds count, I always doubt that I can successfully percutaneously cric them as quickly as I can surgically, so I always end up with a slash and stab which is how I was trained and I find it very difficult to overcome training in order to try something that you are less familiar with during those critical moments.

Thoughts? Would anybody have approached it differently?

Interesting case, thanks for sharing.

My first step would have probably been to shove some sort of supraglotic device down there first (ideally an i-gel, but I'd happily take an LMA or a King) to turn it from a can't intubate/can't ventilate scenario to a just can't intubate one.

If that worked, then I'd probably just bag through that while figuring out how to get him unhooked from the pronation bed straps. If nobody was able to articulate how to do that the answer would probably involve my trauma shears.

If the supraglotic device didn't work, I'd proceed pretty much like you did.

 

[Groove]

Interesting case, thanks for sharing.

My first step would have probably been to shove some sort of supraglotic device down there first (ideally an i-gel, but I'd happily take an LMA or a King) to turn it from a can't intubate/can't ventilate scenario to a just can't intubate one.

If that worked, then I'd probably just bag through that while figuring out how to get him unhooked from the pronation bed straps. If nobody was able to articulate how to do that the answer would probably involve my trauma shears.

If the supraglotic device didn't work, I'd proceed pretty much like you did.

Good thoughts. I had also brought an LMA 4 (we don't have i-gels which would have been preferable in this case since they are so much smaller) and given the extreme position of his head/neck and small mouth with difficulty even getting a laryngoscope blade in there, I didn't think I could actually get the LMA in his mouth. It might have been worth just trying it. Perhaps asking to see if they had a smaller one or even a King laryngeal tube. If not, perhaps choosing to attempt the LMA in place of the fiberoptic intubating stylet after VL had failed with rigid stylet and bougie prior to making decision to cric.

 

[southerndoc]

Great job. I think I would've passed it off to the oncoming doc. Just kidding... or am I?

I've done only 1 cric. I'm sure I'll be just as nervous the next time as I was the last time.

 

[Groove]

Another idea would have been to have someone two hand and strong arm my VL blade (which would only give a quasi decent view with significant force) and hold it, while a second operator passed either a nasotracheal or orotracheal bronch and then tried to maneuver it into place for FOI.

 

[miacomet]

Not a failed airway, because you got an airway. Congratulate yourself!

 

[bravotwozero]

Nice job Groove. That’s a hair raising moment right there....

That being said, your scenario reminds me of all the times I busted my a$$ in the ED to resuscitate a dying patient, only to be made DNR next day or sometimes even a few hours later. It’s appalling how bad the process and coordination is for DNR end of life or hospice.

I especially love it when a patient is a full code, but on hospice. Wtf?

 

[TooMuchResearch]

Sounds like you did a great job. Very difficult from this position to guess about what you should or should not have done instead. I'm not sure an LMA would have helped you much with **** for lungs, though I suppose you could still run the vent with high pressures and see what happens while you move on to flexible bronch (nice that it was actually available - those single use Ambu scopes are pretty nice...if my staff can find the monitor for them) or cric.

 

[cyanide12345678]

I personally would have stuck a supraglottic in, ran things for another one or two rounds and called it.

Good job on the airway though. That is one scary airway.

 

[bravotwozero]

*cue Alanis Morissette ‘ironic’*

It’s an emergency criiic
5 hours before DNR,
Who would have thought?
It figures...

 

[TooMuchResearch]

I wasn't necessarily under the impression OP was running the code but called for airway management?

I personally would have stuck a supraglottic in, ran things for another one or two rounds and called it.

Good job on the airway though. That is one scary airway.

 

[deleted109597]

I wasn't necessarily under the impression OP was running the code but called for airway management?

Except, he's the doc in the scenario. The ACNP doesn't get to run the show once you're there.

 

[thegenius]

Mainly an educational case for the medical students and residents but I thought the rest of you might also be interested.

So, I'm wrapping up my charts on a Fri evening early swing shift and planning on sneaking out a bit early when the overnight doc arrives in 15 mins when the charge nurse comes up going "They need you in the ICU! Something about a failed airway!" I inwardly groan because I rarely get called up there by our ACNPs (who are actually very good) unless it's a total sh** storm. At my hospital, the NPs staff the ICU completely by themselves at night while the attendings sleep at home and the pulmonary group runs multiple ICUs in town and have established this practice. Although I have a lot of problems with this practice pattern, again... the ACNPs up there are actually very good and I've trained a few of them personally and would vouch for them. Regardless...here's the case:

Supermorbid obese guy in his late 40s with no neck, small mouth, copious head/neck blubber in ARDS and septic shock on a rotoprone bed with lost ETT undergoing active compressions/ACLS & being bagged with little air exchange. When they called me I had grabbed an LMA, cric kit, glidescope and fiberoptic intubating stylet. For starters, I really don't know anything about these rotoprone beds. This guy was strapped down and his neck almost completely immobilized with his head in this vice like contraption and nobody could seem to tell me how to get his head/neck free from the top of the bed. I was told RT had lost his airway during one of those spinning maneuvers and they had been coding him for the past 20 mins with multiple attempts by the ACNP. He had a billion lines coming out and had apparently been on deep sedation w/paralysis prior to this event (propofol/vec?). Anesthesia had just showed up (CRNA) and deferred everything to me. She didn't seem too excited to step up to the plate and there was no anesthesia MD in house. Glidescope went in with much difficulty revealing a huge tongue with grade 4 view at an extreme hyper acute angle no doubt d/t the lack of neck mobility and body position. Copious bloody secretions and supraglottic edema. I tried to get the rigid ETT stylet into the glottic inlet and couldn't muscle it into place. There was no way. I then tried a bougie with no luck either. I then tried a fiberoptic intubating stylet (with video laryngoscope in place) after bending it at an extreme angle and although it came into the VL field of view, could not get anywhere near the glottis with it. I then ripped open the cric kit and slashed a vertical incision over the neck and cut down through the subcutaneous tissues over the trachea. Blood was quickly pooling at this point and prior to the incision I couldn't feel any trachea and having done a few of these I knew as soon as I made the incision through fat and platysma, normally I can sink my fingers in there and feel tracheal anatomy pretty well and I didn't want to dissect down any further not really knowing where I was at and accidentally hit jugular or carotid, etc.. So, I used my fingers to verify anatomical positioning, got my bearings, dissected a little more and then made a horizontal stab through the cricothyroid membrane, finger dilated it and, with my finger in place, passed a cuffed melker cannula with inner dilator in place (so I could feel it easily along my finger which Rotoprone bedwas plugging the tracheotomy), connected the ambubag and had BS and positive chest rise. (ROSC) 4x4s were used to tamponade and stuff the incisional site around the neck to obtain hemostasis. Then I used an ambu slim bronch to verify position and eval for any tracheobronchial bleeding (none). I then recommended that they call ENT and GS to take to the OR and get better hemostasis and convert to trach. ENT was apparently not available (partial call at our hospital) and GS said they would do it Monday (wtf?).

In hindsight, if there had been some way to quickly get this guy free from the bed and ramp his shoulders and back, I think I could have achieved a much better body position for intubation conditions but this guy was literally shackled down in that damn space age bed and nobody seemed to be able to tell me how to free him up.

Another option would have been to go immediately to fiberoptic nasotracheal intubation after my first look with the glidescope realizing that endotracheal intubation was going to be almost impossible. We didn't have a bronch in the room though and I calculated that it would be time prohibitive given the circumstances. However I did notice later on that when I needed it for tracheal verification, they seemed to find it and set it up pretty fast.

As for the cric, normally I would stick a bougie through the cric and pass a shiley or the melker over the bougie but I didn't have one nearby. Anytime I have to do one of these (rare), I always intend to use the percutaneous kit but in the heat of the moment when seconds count, I always doubt that I can successfully percutaneously cric them as quickly as I can surgically, so I always end up with a slash and stab which is how I was trained and I find it very difficult to overcome training in order to try something that you are less familiar with during those critical moments.

Thoughts? Would anybody have approached it differently?

Umm...well I've never done nor seen a cric in my life.

You did everything I would have thought of if not more. I commend you.

And....he was in one of these things?

If so that is a terrible nightmare!

 

[thegenius]

There is that metal ring just cephalad to the patient's head that gets in the way of everything. However invented this bed obviously has not intubated in the past.

 

[Groove]

Umm...well I've never done nor seen a cric in my life.

You did everything I would have thought of if not more. I commend you.

And....he was in one of these things?

If so that is a terrible nightmare!

That’s the one. F’ing nightmare is right. They should require the pt to be trached prior to even getting in the damn thing!

 

[Cryc_to_the_point]

What level of ****storm would i start if I had opted to cut those straps holding the head?

 

[deleted109597]

Umm...well I've never done nor seen a cric in my life.

Wait, what? It's required by the RRC. Even in simulation.
Sure, it's a rare procedure, but it's one of those SHTF things that when you need to do it, you need to do it.

 

[TooMuchResearch]

I practice it in my head from time to time so at least the mental skill remains.

Wait, what? It's required by the RRC. Even in simulation.
Sure, it's a rare procedure, but it's one of those SHTF things that when you need to do it, you need to do it.

 

[thegenius]

Wait, what? It's required by the RRC. Even in simulation.
Sure, it's a rare procedure, but it's one of those SHTF things that when you need to do it, you need to do it.

What are you trying to say? Are you purposely trying to antagonize me?

you need to do it?

What are you getting at?

 

[thegenius]

That’s the one. F’ing nightmare is right. They should require the pt to be trached prior to even getting in the damn thing!

I would strongly consider writing to hospital management that a core group of people (RN's, CRNA's or whomever) who are supposed know how that thing works know how to operate that monstrosity. Almost like they need to be credentialed to use it.

 

[gro2001]

What level of ****storm would i start if I had opted to cut those straps holding the head?

I think in the scenario described by Groove, likely no **** storm at all. You're literally trying to save the patient's life, time is of the essence, and the people around you don't have a way to do it more expeditiously. Even if someone in admin raised a question about it, I'd probably respond with an email asking what they would like done the next time this situation comes up. No way anyone is putting in writing anything that would imply they are valuing the equipment over a patient's life.

 

[TooMuchResearch]

Sure they would, but they'd probably back off, at least this time, and then wait for some other reason to remove you from the medical staff

I think in the scenario described by Groove, likely no **** storm at all. You're literally trying to save the patient's life, time is of the essence, and the people around you don't have a way to do it more expeditiously. Even if someone in admin raised a question about it, I'd probably respond with an email asking what they would like done the next time this situation comes up. No way anyone is putting in writing anything that would imply they are valuing the equipment over a patient's life.

 

[BoardingDoc]

What are you trying to say? Are you purposely trying to antagonize me?

you need to do it?

What are you getting at?

What he's getting at: You make it sound like you don't know how to do a cric, which is a required part of training in order to become a BC EM doc. If this is true, that's obviously a problem. If what you meant to say was that you have only done crics in sim (which I assume to be the case) then that's fine.

 

[deleted547339]

That’s one of the several reasons we don’t use the rotoprone beds anymore. Also, our patients are too fat.

Good job veers.

Also, for those that they they’d drop an LMA/igel- that’s probably not the answer. Good chance it won’t seat 2/2 redundant tissue, but, more importantly, the amount of airway pressure this guy will need to oxygenate given his ards and body habitus wouldn’t be likely deliverable through a Supra-glottic.

 

[deleted859535]

First of all, strong f'in work. For all the residents reading this - one day, something like this will happen to you, some horrendous airway in your ED at 0100 in the morning or something. You may or may not be single coverage. Plan for it before you get there. It's part of why our specialty exists.

Second of all - I would've done the same. The one thought I had was that we're fortunate to have these flex bronch setups where I would've given that a shot to maneuver into airway and advance the ETT over it. Can't get it = I cut. Carefully. Cringed reading that description.

What are you trying to say? Are you purposely trying to antagonize me?

you need to do it?

What are you getting at?

Unsure what the issue is. @Dr.McNinja is correct in saying that a cric is an RRC-required procedure in the United States. And when you need to do a cric, it's because you need to do a cric right now.

 

[AlmostAnMD]

retrograde?

 

[Groove]

That’s one of the several reasons we don’t use the rotoprone beds anymore. Also, our patients are too fat.

Good job veers.

Also, for those that they they’d drop an LMA/igel- that’s probably not the answer. Good chance it won’t seat 2/2 redundant tissue, but, more importantly, the amount of airway pressure this guy will need to oxygenate given his ards and body habitus wouldn’t be likely deliverable through a Supra-glottic.

Prob right. I asked one of the NPs who works up there about the pt yesterday and he said the guy had been on a PEEP of 20, so LMA def would have been a no go.

As for the discussions about cric experience, I'll be honest... I've never considered doing a few crics to be a badge of honor. I almost always hyper analyze the case afterwards and try to figure out what went wrong that led to what I consider to be the ultimate failed airway scenario. I like to think there is almost always a way to avoid surgical cric, but will admit that sometimes it's needed and hey...that's why we were trained to do it in residency. However, you have to admit...most of us would be a little wary of someone's airway experience if they started bragging about doing 20 crics! I'd be thinking "Damn, can this guy not intubate?"

I read a study one time that claimed > 95% success rates for first time surgical cricothyrotomy even among people with no prior real world experience. The hardest part is just making the decision to cut...after that, everyone knows the anatomy. It's not rocket science. The only tip I can think to give would be that in live pt's, especially here in the South, it's difficult for me to feel any trachea at all but once you cut through fat and platysma and really sink your fingers in there, you can feel all the landmarks much more easily.

 

[Groove]

retrograde?

Good thought but this guy's neck was whale blubber and even if you could have percutaneously found his trachea and passed a wire, I doubt it would have passed through at such an acute angle. Take your chin and put it on your chest....that's how this guy's head and neck was positioned in that metal deathtrap of a bed.

 

[TooMuchResearch]

On a failed airway code? I'm not even sure retrograde intubation is a tool I want to keep in the mental box anymore.

retrograde?

 

[Groove]

I never want to see one of those beds again, I hope the case made our ICU docs decide to start using something else. It reminded me of Arnold from that scene in Total Recall.

 

[TooMuchResearch]

In 30 seconds you'll be dead and I'll blow this place up and be home in time for Corn Flakes.

I never want to see one of those beds again, I hope the case made our ICU docs decide to start using something else. It reminded me of Arnold from that scene in Total Recall.

View attachment 280922

 

[BoardingDoc]

In 30 seconds you'll be dead and I'll blow this place up and be home in time for Corn Flakes.

Well, I guess I know what I'm watching tonight. Maybe a double header with Robocop.

 

[deleted109597]

What are you trying to say? Are you purposely trying to antagonize me?

you need to do it?

What are you getting at?

No?
I'm saying if the patient needs a cric, they need a cric. It's not elective, it's not something you can set up and do in an urgent manner. It needs to be done right then, in a very short period of time.

And the rest is because you have to do 3 to graduate residency. Sim counts.

 

[thegenius]

What did I ever write to suggest that the OP should have waited to do the cric? I wrote nothing like that. The response reflecting my comment was non sequitur, but written in a way to imply what I wrote was wrong. I found it very irritating, unprofessional, and antagonizing.

I did graduate from an accredited, and generally well acclaimed ER residency and yes I’ve done sim crics. Everybody who has graduated from an accredited US ER residency has done real or sim crics. It’s a given unless it is known that people who respond to this forum are not ER docs.

Al I wrote was I haven’t done one and commended the OP for his efforts. Then I read “you can’t wait to do it and when SHTF you have to do it now”.

Well no s$^t Sherlock.

 

[deleted109597]

I merely quoted that you said you'd never seen one in your life.
You seem to be taking the second part of my quote out of context and acting as if I was directing it at you. My apologies if you feel that way, it's not.

 

[TooMuchResearch]

Well, I guess I know what I'm watching tonight. Maybe a double header with Robocop.

You're welcome. My scribe the other day was only familiar with the remakes of those.

 

[GeneralVeers]

You're welcome. My scribe the other day was only familiar with the remakes of those.

Scribes are usually millenials. They are unaware of the existence of any media or pop culture before they were born.

During downtime one of my favorite activities is to quiz the 20-something scribes on common historical or pop culture events. Questions like: "Who did we fight in WWII" usually elicit hysterically ignorant and funny answers.

 

[bigtuna]

That metal halo at the head of the bed opens up so you can do procedures from the head of the bed. And all of the pieces around the head are easily removed.

 

[dchristismi]

Mad props.

I like the Melchor kits, although last time I used one I forgot that the last dilator stays on the trach, bent the wire and had to start over.
Mentally running through the motions helps a lot.

But still, mad props.

(FWIW, and the real reason I am responding... when my hospice patients aren't DNR, it's not that I haven't tried. There are almost always extenuating circumstances, and/or the patient is really young, or they're quite new to hospice. I currently have a 23 yo on my service who is slowly getting to that point, but still freaks out when I bring it up. But... he's 23. He'll get there, hopefully before his cancer gets him. But it's not for me not trying.)

Also, FWIW, MODS in a rota-prone is a recipe for disaster. It's probably the only option save an oscillator (do they even still use those?) or ECMO, but still, they are airway nightmares.

 

[jw3600]

I merely quoted that you said you'd never seen one in your life.
You seem to be taking the second part of my quote out of context and acting as if I was directing it at you. My apologies if you feel that way, it's not.

I feel like it was pretty obvious he meant on a patient. And he was not counting sim.

 

[deleted547339]

Prob right. I asked one of the NPs who works up there about the pt yesterday and he said the guy had been on a PEEP of 20, so LMA def would have been a no go.

As for the discussions about cric experience, I'll be honest... I've never considered doing a few crics to be a badge of honor. I almost always hyper analyze the case afterwards and try to figure out what went wrong that led to what I consider to be the ultimate failed airway scenario. I like to think there is almost always a way to avoid surgical cric, but will admit that sometimes it's needed and hey...that's why we were trained to do it in residency. However, you have to admit...most of us would be a little wary of someone's airway experience if they started bragging about doing 20 crics! I'd be thinking "Damn, can this guy not intubate?"

I read a study one time that claimed > 95% success rates for first time surgical cricothyrotomy even among people with no prior real world experience. The hardest part is just making the decision to cut...after that, everyone knows the anatomy. It's not rocket science. The only tip I can think to give would be that in live pt's, especially here in the South, it's difficult for me to feel any trachea at all but once you cut through fat and platysma and really sink your fingers in there, you can feel all the landmarks much more easily.

Sorry, don’t know why I thought veers was the OP, good job groove.

 

[deleted547339]

retrograde?

Stop.

 

[TooMuchResearch]

Veers was the one who said he would have just called it.

Sorry, don’t know why I thought veers was the OP, good job groove.

 

[deleted109597]

I like the Melchor kits, although last time I used one I forgot that the last dilator stays on the trach, bent the wire and had to start over.
Mentally running through the motions helps a lot.

Not a fan of Melkers. Data says they're nowhere near as good, easy, or fast as scalpel finger bougie.
And they cause a lot more injuries.

 

[GeneralVeers]

Veers was the one who said he would have just called it.

I took it as a compliment of my impeccable judgement

 

[migm]

I have the same thoughts about the perc kit. I do the surgical one (mostly sims, one real) and wonder, wtf this is a lot of blood. I shoulda done the perc - but training overrides in that scenario. Is packing the best way to handle the venous bleeding that occurs?

 

[bravotwozero]

would cautery be available as an option?