# First Surgical Cric



## Epi-do (Mar 22, 2010)

So, I had a horribly F-ed up run recently - self-inflicted gunshot wound to the face.  We couldn't suction enough to be able to see anything for an oral intubation.  Believe me, we tried.  There was also NO ventilating this patient without a tube.  There was nothing left to place the BVM on.

We had no radial, carotid, or apical pulses, but he was still taking agonal respirations.  I contacted medical control letting them know what we had, including a detailed description of the injury.  Luck of the draw was that the doc on the other end wanted us to go ahead and begin resuscitative efforts, we loaded the pt up and headed off to the trauma center.

After coming to the realization that we just weren't going to get the tube on this guy, I pulled out the cric kit, and promptly attempted to hand it off to the other medic that was with me.  I really wasn't looking forward to having to do it.  The other medic said that it was ok, and he would work on getting the lines in and pushing drugs, so there I was with the kit laid out on the cabinet-top next to me, quickly looking over the copy of the protocol that was included in the kit.

I was so sick to my stomach and thought for sure I was going to puke the entire time I was doing it.  The other medic and the EMT in the back with me both commented at the hospital about how calm I appeared while performing the procedure, but I can assure you I was totally panicking on the inside.  I do have to say, I was surprised at how _easy_ it was to actually do.  I can also say I am in no hurry to repeat it anytime soon.

Needless to say, he was called almost immediately once we arrived at the ER.  One of the local medical directors was working and after everything was done he came and talked to me.  He complimented me on the cric, saying that it looked perfect.  He also said he was going to pass along to my medical director what a good job I had done with the run.  He told me that had he been the one to get my radio report while onscene, he would have allowed me to call it since the injury was incompatible with life, but luck of the draw had it that I got one of the other docs.  

All in all, given the set of circumstances I was handed, the run went pretty well.  I have that first cric behind me, something that most medics never have to do, and managed to keep it together until on the way back to station from the ER.  I think every single crew that came in after us stopped and told me what a great job I had done while I was working on the paperwork.  It's awesome to get compliments from your peers & the medical director after such a difficult run, but at the same time....well, I would have been happy to go several years before ever having to make that call.  Even my partner commented to me about how I have gotten some of the most messed up runs he has ever been on in the last year and a half, since I got my medic cert.


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## Veneficus (Mar 22, 2010)

super job,

welcome to the black cloud club


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## mycrofft (Mar 22, 2010)

*Good on you. Sometimes you have to play for points 'cause there's no winning.*

I had a 12 y/o do an offset .357 to the right superior parietal and out the top in 1981 and it has bothered me subconsciously for a long time. Airway went west the moment we turned him supine but we all knew it would happen and he expired in the ambulance.

Your patient's disaster may save another's life in the future because you know what to do and that you can do it.


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## EMSLaw (Mar 22, 2010)

Veneficus said:


> super job,
> 
> welcome to the black cloud club



All the best people are members. 

Sounds like a good job.  Next time, you'll do a trach with your penknife and the barrel of a bic pen.


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## firetender (Mar 22, 2010)

That call had your name on it. Get used to it. 

Someone else maybe wouldn't have done so well, but it doesn't matter because regardless, you have another little item in your bag of tricks. This one goes in the "tried it and it works" slot; much more preferable than the one labelled, "The durn thing is supposed to work; I ain't gonna rest 'til I get it right!"

BTW, if there was a chance, you gave it to him.


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## usafmedic45 (Mar 23, 2010)

> Luck of the draw was that the doc on the other end wanted us to go ahead and begin resuscitative efforts, we loaded the pt up and headed off to the trauma center.



Yeah, no sense in wasting a potentially good set of donor organs.  Something good should come out of bad situations like this whenever possible. 



> After coming to the realization that we just weren't going to get the tube on this guy, I pulled out the cric kit, and promptly attempted to hand it off to the other medic that was with me.



Why even bother trying to tube them?  If the face is actually gone or mangled to the point you can tell what is what, then a surgical airway should be a first step.  It's plausible deniability that you didn't try to do a visualized airway.



> I really wasn't looking forward to having to do it.



Why?  As Pete Rosen likes to say the hardest part of doing a cric is picking up the scalpel.



> I was so sick to my stomach and thought for sure I was going to puke the entire time I was doing it.



Not sure I understand the uneasiness.  It's a technically simpler procedure than intubation especially in circumstances such as what you're describing. 



> Needless to say, he was called almost immediately once we arrived at the ER.



Well, it was good practice for the next time when you will hopefully have a viable patient. 



> The other medic and the EMT in the back with me both commented at the hospital about how calm I appeared while performing the procedure, but I can assure you I was totally panicking on the inside.



One of my friends growing up (I used to hang out at the VFW as a kid....weird, I know) was a company commander on Omaha Beach.  He told me once that "Bravery is simply the ability to hide your fear well enough to do your job and not let anyone else realize you're ****ing yourself".  He wasn't going to BS a ten year old. 



> I do have to say, I was surprised at how easy it was to actually do.



Seriously, it's easier to do than it is to properly ventilate someone with a BVM while holding good mask seal with the other hand.  I've always argued that surgical airways are easier than most IVs we do and can not honestly fathom why so many people (docs, medics, RTs, etc) have such an aversion to them even in situations to which they are ideally suited.



> It's awesome to get compliments from your peers & the medical director after such a difficult run, but at the same time....well, I would have been happy to go several years before ever having to make that call.



Very true.  I prefer my calls like I dislike my people: simple and stupid. Give me something I can do something to fix and send the patient on their way.  Of course at the same time, I've been accused of having ice water in my veins when it comes to calls like you've described....regardless, nice work on a difficult case.  As someone said, if this patient had any chance, you provided it by doing that surgical airway.


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## mycrofft (Mar 23, 2010)

*USAF, good to read you! Comments:*

Facial injuries have long been recognized to cause folks to lose it. Same reason the monster in horror movies has a deformed face, or peolple lose it about clowns. One of our officers was shot; when I heard he was shot in the face, it shocked people to hear me say "good", because if airway is patent facial injuries often do not involve vital structures. (Not always, but often). I've seen new EMT's get green over a broken nose when they can work on an angulated tibia no trouble.

People screw up crikes (especially with the Tom Mix penknife and a Parker ball point pen barrel) by slipping or otherwise hitting the thyroid. Bloody, can require super duper suctioning, plus you may have just given this pt a shot of thyroid hormones. 

I like your approach, if the face is established as unapproachable, move down and don't waste time.


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## usafmedic45 (Mar 23, 2010)

> People screw up crikes (especially with the Tom Mix penknife and a Parker ball point pen barrel) by slipping or otherwise hitting the thyroid. Bloody, can require super duper suctioning, plus you may have just given this pt a shot of thyroid hormones.



Oh, I've seen a surgical resident hit a carotid during a badly botched one, but if you paid attention during training and remember to make a VERTICAL incision (the resident made a horizontal incision) there are few ways to bungle a cric that is going to significantly worsen the patient's condition.  The other one that come to mind is subcutaneous placement of the airway, which should be pretty obvious when the patient's neck looks like that of a randy bullfrog after you bag them a few times.  This is the one reason that I remind the audience for the difficult airway presentations I give at conferences (EMS, RT and otherwise) that you should _always_ verify the placement of a surgical airway the same as you do a standard oral intubation.  That means at least two or three clinical findings (chest rise, breath sounds, etc) as well as use of a CO2 detector.


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## usafmedic45 (Mar 23, 2010)

> Facial injuries have long been recognized to cause folks to lose it.



Point taken.  Eye injuries make me squeamish, although not as bad as they used to.  I'd take someone with their face blown off or shredded than an impaled object through the eye.   

Ditto for childbirth.  I've only managed a 25% success rate of not vomiting after delivering a baby.


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## Epi-do (Mar 23, 2010)

usafmedic45 said:


> Yeah, no sense in wasting a potentially good set of donor organs.  Something good should come out of bad situations like this whenever possible.



Actually, that was the exact reasoning of the doc on the other end of the radio.   




usafmedic45 said:


> It's plausible deniability that you didn't try to do a visualized airway.





usafmedic45 said:


> Why?  As Pete Rosen likes to say the hardest part of doing a cric is picking up the scalpel.



I would have to agree with both of these statements.  It was something I _really_ didn't want to do.  Even after deciding that it was the only alternative left for the airway, it wasn't a matter of _wanting_ to do it, but rather, realizing it _had_ to be done.



usafmedic45 said:


> Not sure I understand the uneasiness.  It's a technically simpler procedure than intubation especially in circumstances such as what you're describing.



Maybe it was the whole idea that his face was gone, maybe it was the fact that I have only been a medic for roughly 18 months and had just gotten another crap run.  A large part of it was the thought of taking the scalpel and cutting into his neck - something about it really bothered me.

Thanks for all of the kind words, everyone!


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## NomadicMedic (Mar 24, 2010)

I'm in medic school, just heading into our final quarter...

A classmate was thrust into the situation of having to preform a cric just before the midterm break. 

She feels awful about it, but knows it was the only thing to do. She's still bothered about it, but at least she was able to just move right to it after realizing that oral intubation wasn't possible.

I'll admit, she has bigger balls than I do.  I'm sure if the situation came to it, I could do it... but man... that's a big decision. 

Call me a wimp or whatever, but I honestly hope that I never have to do it.


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## usafmedic45 (Mar 24, 2010)

> She's still bothered about it, but at least she was able to just move right to it after realizing that oral intubation wasn't possible.



Like I said, I just don't understand why medics who are not bothered by far more invasive procedures (central lines, needle decompressions, etc) are bothered so much by surgical airways.  Personally I cringe more having to watch someone take out their contacts than having to do a surgical airway...but as I've said, there's that ice water issue again. LOL



> Maybe it was the whole idea that his face was gone, maybe it was the fact that I have only been a medic for roughly 18 months and had just gotten another crap run.



Very true.  I feel your pain on that one...my very first shift as an ALS provider straight out of class (working with a EMT-B partner) I had three codes and a bad MVA.  However, I really do enjoy procedures...even though I dislike the circumstances that necessitate them, I really like invasive procedures. 



> A large part of it was the thought of taking the scalpel and cutting into his neck - something about it really bothered me.



Probably because it goes against everything we're taught about knives....still given the alternative (patient definitely dies if you don't vs. probably will if you do) I can't see the hang-up persisting, but that is just me.  I'm pretty odd like that. 



> Actually, that was the exact reasoning of the doc on the other end of the radio.



Great minds think alike.



> Call me a wimp or whatever, but I honestly hope that I never have to do it.



It doesn't make you a wimp and if anyone says so, please tell them to come talk to me.  Anyone who hopes they have to do one probably should question their motivation for being in EMS.  Remember, the "really exciting" case for us is someone else's "very bad" (and potentially, last) day.  I'd be perfectly happy never doing another cric so long as I practice, but at the same time, I won't hesitate if the situation presents itself.


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## mycrofft (Mar 25, 2010)

*I wonder what it's like to undergo one?*

I have trouble enough as it is, I can imagine breathing through a little airway like that.
Whatever happened to the deal with a big bore (BIG) "needle" (almost a trochar), high pressure O2 and a bypass to use as a crich ventilator?


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## usafmedic45 (Mar 25, 2010)

> I have trouble enough as it is, I can imagine breathing through a little airway like that.


It's not that small of a tube (speaking about surgical cric, not needle cric obviously).  I mean in a standard adult you can use a 4.0-5.0 ETT tube.  Most people without long standing pulmonary disease or a major restrictive process can pull adequate volumes through it.  That aside, if they are getting their neck cut, they are probably also going to get ventilated with a BVM.  I can not recall a case where the person was allowed to breath completely on their own after being cric'ed without any assistance.



> Whatever happened to the deal with a big bore (BIG) "needle" (almost a trochar), high pressure O2 and a bypass to use as a crich ventilator?



I believe what you are speaking of is simply a modified version of a needle cric called transtracheal jet ventilation, which is a misnomer since it is not intended to _ventilate_ the patient per se.  It's a stop gap measure to _oxygenate_ the patient until you can get a more definitive airway in place.  Some services still carry it and it has it's place as a way to buy a little time.  Most of the setups I have seen use a 10, 12 or 14 gauge angiocath and not anything approaching a "trocar".


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## mycrofft (Mar 25, 2010)

*Thanks you're right, I'd never even seen one much less done it.*

THanks!


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## mikie (Mar 25, 2010)

mycrofft said:


> I have trouble enough as it is, I can imagine breathing through a little airway like that.
> Whatever happened to the deal with a big bore (BIG) "needle" (almost a trochar), high pressure O2 and a bypass to use as a crich ventilator?



You do bring up a good point.  I am not very educated in Needle Cric's.  How is such a small needle (12GA isn't it?) going to provide adequate diameter for ventilation? 

I just see it like placing a garden nozzle on the end of a 2" charged fire line.


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## Shishkabob (Mar 25, 2010)

mikie said:


> You do bring up a good point.  I am not very educated in Needle Cric's.  How is such a small needle (12GA isn't it?) going to provide adequate diameter for ventilation?




It's not.  It's meant as a stop-gap so you can haul butt to the hospital where a surgical airway can be performed.  You have about ~20 minutes with a needle cric of being able to get air in... if you don't get to the hospital in that time frame, you are going to have problems.



Piece of fun trivia... Biotel here in the Dallas area allows the drip chamber of a macro drip set to be used as the needle cric.  When cut, the chamber is a perfect fit for a BVM.


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## Veneficus (Mar 25, 2010)

Linuss said:


> It's not.  It's meant as a stop-gap so you can haul butt to the hospital where a surgical airway can be performed.  You have about ~20 minutes with a needle cric of being able to get air in... if you don't get to the hospital in that time frame, you are going to have problems.
> 
> 
> 
> Piece of fun trivia... Biotel here in the Dallas area allows the drip chamber of a macro drip set to be used as the needle cric.  When cut, the chamber is a perfect fit for a BVM.



Sounds to me like a modified pertrach. A much better alternative to a needle cric without jet.


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## reaper (Mar 25, 2010)

mikie said:


> You do bring up a good point.  I am not very educated in Needle Cric's.  How is such a small needle (12GA isn't it?) going to provide adequate diameter for ventilation?
> 
> *I just see it like placing a garden nozzle on the end of a 2" charged fire line*.



Look at your analogy. At least you are getting some water out!


If the pt is unable to move any air and you are not allowed to preform a cric, I would rather you use a needle cric. It is better then letting them die!


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## usafmedic45 (Mar 25, 2010)

> Biotel here in the Dallas area allows the drip chamber of a macro drip set to be used as the needle cric. When cut, the chamber is a perfect fit for a BVM.



...or you can hook a 3 cc syringe barrel to the angiocath and then take the BVM connector off of a 5.0 ETT.  It usually fits well.  The other option is to hook a syringe to it and stick the tip of the cuffed ETT into the barrel of the syringe and inflate the cuff. The first method works better but the second works pretty well in a pinch and you don't have to worry about cutting the drip chamber at an odd or uneven angle which can make connecting it to the BVM difficult.



> if you don't get to the hospital in that time frame, you are going to have problems.



Mostly from the astronomically high PCO2 that happens when you oxygenate but don't ventilate.  I've seen two prehospital jet ventilation cases come into the hospital and both had PCO2 in excess of 150.  One was 196 (as a reference normal is 35-45).


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## mycrofft (Mar 26, 2010)

*So the ideal setup would also include a suction component to evacuate used up air?*

Somebody patent this thread.

A book or article comparing efficacies of related prehospital and maybe a few hospital measures would be very very interesting. Airways, ventilation, IV access, IV instillation, spinal immobilization would be the biggees. Maybe Consumer Reports will do it?


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## usafmedic45 (Mar 27, 2010)

> So the ideal setup would also include a suction component to evacuate used up air?



Nah, it just wouldn't be effective enough.  Honestly, my theory is if you're going to try to do transtracheal jet ventilation, it really should be chased with a second angiocath through which you can pass the guidewire for a retrograde intubation but very few EMS agencies allow the practice.  \



> A book or article comparing efficacies of related prehospital and maybe a few hospital measures would be very very interesting. Airways, ventilation, IV access, IV instillation, spinal immobilization would be the biggees. Maybe Consumer Reports will do it?



You could start a thread and post the articles from Pubmed on the subject.  I would do it myself, but I don't have the time this weekend to do it.


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## mycrofft (Mar 27, 2010)

*I'll be busy visiting my one day old first granddaughter.*

Vent probably already has it written up and updated quarterly.


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## usafmedic45 (Mar 27, 2010)

mycrofft said:


> Vent probably already has it written up and updated quarterly.


True...she's all over crap like that.  God bless her for it too.  

BTW, congrats on the grand-critter.


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