NYT update on the Joan Rivers case

[Temeraire]

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http://www.nytimes.com/2016/05/13/nyregion/settlement-reached-in-joan-rivers-malpractice-case.html

I guess a little more information on the Joan Rivers case came out?

Dr. Bankulla looked around for Dr. Korovin to punch a hole in Ms. Rivers’s throat — an emergency cricothyrotomy, which Dr. Korovin should have been trained to do — but Dr. Korovin had already left the clinic, according to Dr. Bankulla’s notes.

Despite the obvious problem of not having any sux available, shouldn't the anesthesiologist (Dr. Bankulla) have been trained to do some kind of emergency surgical airway? I'm only an MS4 so I'm short on the details of residency training, but isn't residency supposed to teach you how to handle these types of horrific can't-ventilate-can't-intubate scenarios?

If not... yikes. 😱

 

[Ezekiel2517]

http://www.nytimes.com/2016/05/13/nyregion/settlement-reached-in-joan-rivers-malpractice-case.html

I guess a little more information on the Joan Rivers case came out?



Despite the obvious problem of not having any sux available, shouldn't the anesthesiologist (Dr. Bankulla) have been trained to do some kind of emergency surgical airway? I'm only an MS4 so I'm short on the details of residency training, but isn't residency supposed to teach you how to handle these types of horrific can't-ventilate-can't-intubate scenarios?

If not... yikes. 😱

You can learn about something or watch it done all you want. Everything changes when you actually have to do it yourself, especially under pressure. The vast majority of residents and even attendings will never perform a surgical airway. They never get the opportunity to.

 

[urge]

http://www.nytimes.com/2016/05/13/nyregion/settlement-reached-in-joan-rivers-malpractice-case.html

I guess a little more information on the Joan Rivers case came out?



Despite the obvious problem of not having any sux available, shouldn't the anesthesiologist (Dr. Bankulla) have been trained to do some kind of emergency surgical airway? I'm only an MS4 so I'm short on the details of residency training, but isn't residency supposed to teach you how to handle these types of horrific can't-ventilate-can't-intubate scenarios?

If not... yikes. 😱

Emergency surgical airways are not taught at most, if not all, anesthesia programs in the US.

 

[jthedestroyr]

Day 1 of residency, first call while on a surgery rotation, paged for a surgical airway. Call my upper level, "Call ENT now." So yeah, it goes to the ENT surgeons not us. It appears that a lot of the GS people don't want to do it either.

 

[Temeraire]

What about needle crichs then? http://aam.ucsf.edu/article/percutaneous-cricothyrotomy

(It does note at the bottom of the page how difficult it is to get real-life practice though...)

 

[urge]

Like Temeraire, I'm also an MS4. During the interview trail last fall, I had a chair of anesthesia present a similar case scenario to me. "You're the chief resident on call middle of the night, You can't get a hold of the attending, Can't intubate, can't ventilate, What do you do?"
Next question was "crike or trach? why?"
I too was under the impression that an anesthesiologist should be able to crike if the situation deems it necessary.

There are all sorts of stupid questions on the interview trail. I got asked whether I would try to take down an airplane hijacker if I had a clear a shot.

Does that mean they will give you some kind of tactical Navy SEAL training? No.

 

[Chloroform4Life]

Even if you have never done one before, in an emergency cant ventilate cant intubate situation where you've tried all the noninvasive tools on your belt, you should do a surgical airway if noone else is immediately available to do one. The worse that can happen is you cant get it and the patient dies. They will for sure die if you dont try. My guess is that this anesthesiologist was hesitant to cut her neck because of her celebrity status.

Im curious as to why this happened after the ENT surgeon left the clinic. Shouldn't the patient be fully awake at this point? For outpatient surgeries where I work, the surgeon always talk with the patient prior to discharge to share their findings.

 

[Mman]

Even if you have never done one before, in an emergency cant ventilate cant intubate situation where you've tried all the noninvasive tools on your belt, you should do a surgical airway if noone else is immediately available to do one. The worse that can happen is you cant get it and the patient dies. They will for sure die if you dont try. My guess is that this anesthesiologist was hesitant to cut her neck because of her celebrity status.

A 14 or 16g angiocath aimed in the midline somewhere below the hyoid can probably keep the patient alive. Screw a 10 cc syringe on to the angio cath and pull out the plunger. Stuff an ETT into the empty 10 cc syringe, hook up to your circuit, and squeeze in every last bit of O2 you can get.

As you said, what's the worst that happens? Pt is already going to die when you get to that point if you don't get it.

 

[Ezekiel2517]

A 14 or 16g angiocath aimed in the midline somewhere below the hyoid can probably keep the patient alive. Screw a 10 cc syringe on to the angio cath and pull out the plunger. Stuff an ETT into the empty 10 cc syringe, hook up to your circuit, and squeeze in every last bit of O2 you can get.

As you said, what's the worst that happens? Pt is already going to die when you get to that point if you don't get it.

Had to use this technique first year out of training. Was able to maintain the sat while getting the surgical airway kit and ramming in a 6.0 ett. It won't work for long but can buy you precious time.

 

[Chloroform4Life]

A 14 or 16g angiocath aimed in the midline somewhere below the hyoid can probably keep the patient alive. Screw a 10 cc syringe on to the angio cath and pull out the plunger. Stuff an ETT into the empty 10 cc syringe, hook up to your circuit, and squeeze in every last bit of O2 you can get.

As you said, what's the worst that happens? Pt is already going to die when you get to that point if you don't get it.

Also works with a 3cc syringe. The adaptor piece from a 7.0 ett that connects to the anesthesia circuit fits perfectly into a 3 cc syringe without plunger. This technique is particularly useful for pediayric cant intubate cant ventilate scenarios.

 

[IlDestriero]

I've done it (surgical cricothyrotomy) 3 times on trauma patients missing much of their faces. It's not rocket science. I would have cut Joan, she should have as well. I practiced twice. Once in some trauma class on a pig for a needle cricoid, which I did during residency for fiberoptic intubations with trans tracheal blocks, and once in a difficult airway course where we all got pig tracheas to simulate.
By the time you're going down that path, the patient is near death and is about to be unresuscitatable. You can't kill someone who's dead already, all you can do is save them, and NOBODY is coming to save your ass. So keep that thought out of your head. I have a couple friends/partners that look at malpractice claims, and it's crazy how long some people will let people be profoundly hypoxic. Go down the airway algorithm, and don't waste any time from step to step. Nut up, save the patient, and be a hero. Don't dick around try 50 different things, 10 DLs, wait for ENT, etc. if they're not immediately available, only to successfully revive the brain dead patient.
I hope none of us face this, but if you do, it's on YOU to act.
Joan could probably still be hosting on E and joking about her hoarse voice from her stupid Doctor (who cut her neck and saved her life).



All you really need is a 10 blade, your pinky finger, and an ETT.
--
Il Destriero

 

[rakotomazoto]

As supposed experts in airway management, we really should all be at least willing to attempt a cricothyrotomy or at the very least, a needle crich. Feeling comfortable with these procedures could have made a huge difference, but instead everyone was wringing their hands while JR died in front of their eyes. It is hard to imagine how mentally and emotionally damaging that would be, for me I might just give up practice and go be a ski instructor, loans be damned. Applicants should ask about this at every program on the interview trail. We have a senior-level course that includes simulation and cadavers to at least get some sort of hands-on experience with this sort of thing, although I am not sure that this would be enough alone for me to feel competent to act in the moment. It is easy to look at the case in hindsight and identify what went wrong and what we would have done differently, but in the moment I wonder if I would have reacted similarly. I have no condemnation for anyone who was there that day, only sympathy for anyone involved in such a terrible tragedy.

So far, the two times I have seen an airway situation that escalated this far we were already in the ENT room so it was only a minor emergency, equipment and an experienced attending and senior/junior ENT residents were already there and ready to go. The patient can deteriorate so quickly and unless you are ready to act immediately once you recognize the situation, that patient is dead and maybe your career is, too. To me, chest tube placement is another potentially life-saving skill that I would feel very uncomfortable doing by myself at this point in my training. Seems like one of those things that anyone who wants to call themselves a physician should at least be capable of doing in an emergency.

 

[Ezekiel2517]

I've done it (surgical cricothyrotomy) 3 times on trauma patients missing much of their faces. It's not rocket science.

Nothing in our specialty is rocket science. But I've seen plenty of EM attendings and even trauma surgeons have significant difficulty with it and a few times f*ck up horribly. I can place chest tubes and do bedside perc trachs and I'm sure plenty of people think these procedures are a piece of cake, but I can tell you they are most definitely not. The reason the surgeon makes it look so easy is cuz he's done a thousand of em. If you're fresh out of training or even been practicing a while but have no experience doing a surgical airway, I hope luck is on your side. It's very unlikely the pt will be an asa 1/2, 65kg 10% body fat, perfect anatomy with no comorbidities, who doesn't even bleed when you start cutting.

 

[Chloroform4Life]

During residency, I was involved in an angioedema case in the ED where the anesthesia attending could not get the airway and patient became impossible to ventilate. Pt was morbidly obese with no clear neck anatomy. Trauma surgeon was there and he cut the neck. He took 5 minutes and initially made the incision in the thyroid cartilage above the vocal cord and couldn't ventilate through that hole. He tried again distally and got it after some struggle. Pt lived. ENT fixed his neck. Outcome was good.

An ENT surgeon during my residency always said " don't worry about f****** up the neck, I can fix that, but I can't fix a dead patient"

 

[IlDestriero]

The more complicated the neck, the less time to make the decision to cut if you want a positive outcome. I kid you not, people are waiting >10 minutes in these lawsuits, one was over 20. Why bother at that point. They're only alive at that point because of high dose epi and CPR, the hypoxic injury and brain cell death started a long time ago.


--
Il Destriero

 

[vector2]

If you can slide an angiocath off into a big fatty mcgoo's IJ using ultrasound, you can probably do the same with their trachea.

And you don't even need an ET tube, machine, or other less common adapters to get O2 going. Hook up angiocath to IV extension tubing, put a three way stopcock on extension, rip the mask off a simple mask and place the tubing stump onto the stopcock, hook tubing to O2 tank, wall O2, or machine O2 outlet.

 

[digitox]

.

 

[deansrv72]

Had to use this technique first year out of training. Was able to maintain the sat while getting the surgical airway kit and ramming in a 6.0 ett. It won't work for long but can buy you precious time.

It will work longer with jet ventilation. Otherwise, even at 15lpm, oxygenation is all that is really occurring, through such a catheter.


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