# From headlines: Metal water bottle extrication



## mycrofft (Jan 10, 2013)

http://todaynews.today.com/_news/2013/01/09/16285657-rossen-reports-metal-water-bottles-can-endanger-kids?lite

OK, you are called to a kids' soccer pitch or baseball field. It's August, and little Timmy was trying to lick the yellow ooze sluggishly lying on the bottom of the bottle after he drank the rest of his Dragonaide or whatever, and now his tongue is stuck. Really stuck. Been on for half an hour now.

You think back to an article you read (above) in a layperson journal, which said cutting the bottle bottom off had no effect.

1. How would you suggest removing it? This can include basic tools and materials readily at hand on the fire pumper and medical vehicle, or someone can run across the street to Coast to Coast and bring back in their hands.
2. What medical ramifications can you foresee? Are there medical measures to help this?












Another very very similar article:http://www.nydailynews.com/life-sty...-water-bottles-kill-doctors-article-1.1236701


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## EMT B (Jan 10, 2013)

lube. lots and lots of lube. does ALS have any anti inflamitories?


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## abckidsmom (Jan 10, 2013)

The capacity of the tongue to swell just astonishes me.  

I would transport with ice applied.  I have found that cutting metal with parts stuck in it just adds anxiety and time to the situation, and lidocaine helps so much in so many of these situations.


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## EpiEMS (Jan 10, 2013)

If I'm the only unit and I'm BLS? Don't agitate the child (any more than he or she is already agitated), keep him/her as comfortable as possible (mom and/or dad will be riding in back on this one), and expedite transport. Try applying ice, but I doubt it'll help *that* much. No touching until the ER, where they can gain airway control and do pain management.
Not much can really be done at the BLS level, far as I can see, unless I'm misunderstanding the problem.


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## abckidsmom (Jan 10, 2013)

On almost every single call involving a child, if the parents or adult caretakers are acting appropriately they get to ride in the back. It is rarely in your best interest or the best interest of the patient to separate a kid from his mom if she is controllable.


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## EpiEMS (Jan 10, 2013)

abckidsmom said:


> On almost every single call involving a child, if the parents or adult caretakers are acting appropriately they get to ride in the back. It is rarely in your best interest or the best interest of the patient to separate a kid from his mom if she is controllable.



Yup, never have had a parent/adult caretaker/guardian etc. be problematic. But I can certainly imagine how they could be!

Do you ever let the parent hold the child to keep the child relaxed? I've yet to try that, but I'm curious if it helps.


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## mycrofft (Jan 10, 2013)

I was thinking about ways to introduce positive pressure into the bottle either around the tongue or through an opening in the bottle away from the tongue.
Cooling the aluminum could cause the trapped air to contract, increasing the vacuum and maybe freezing the tongue (aluminum is an EXCELLENT heat conductor).  Heating could raise pressure but might cause swelling and possibly burn through conduction.

Maybe lube, slide the plastic cath off the longest and largest bore IV into the neck of the bottle and try applying fluid pressure into the bottle past the tongue with a *large* syringe? (Have to be large, couldn't do more than one push unless you had a one way valve in series. Fluid better than air because it would not compress and would act as a piston?).
Yeah, agree, sit em up, calm them (little xanax?), hold it so it didn't further aggravate the tongue, get to hospital because of chance for accidental injury if cutting was resorted to. (Dremel with cutoff wheel and constant water drip for cooling?).


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## CodeBru1984 (Jan 10, 2013)

I'm curious to see if there would be any airway management issues that would need to be immediately addressed on the BLS level/ALS levels resulting from the tongue being stuck in the bottle? 

Aside from that, there wouldn't be much at the BLS level I could do other than keeping the patient as calm and comfortable as possible, possibly throwing them on some oxygen via nasal cannula at 2-4/LPM and then transport to the nearest appropriate facility that is equipped to handle this type of emergency.


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## phideux (Jan 11, 2013)

The only thing I can come up with is tin snips to split it up far enough to get a ring cutter to the mouth of the bottle.


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## mycrofft (Jan 11, 2013)

CodeBru1984 said:


> I'm curious to see if there would be any airway management issues that would need to be immediately addressed on the BLS level/ALS levels resulting from the tongue being stuck in the bottle?
> 
> Aside from that, there wouldn't be much at the BLS level I could do other than keeping the patient as calm and comfortable as possible, possibly throwing them on some oxygen via nasal cannula at 2-4/LPM and then transport to the nearest appropriate facility that is equipped to handle this type of emergency.



That's if they start to experience anoxia as exhibited by etc etc right? Otherwise there is no clinical indication.

Try a nasal cannula with 4 lpm some time.  Once you get it, you may wonder about how "comforting" that dry smelly stuff actually is.


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## mycrofft (Jan 11, 2013)

phideux said:


> The only thing I can come up with is tin snips to split it up far enough to get a ring cutter to the mouth of the bottle.



Go try that. Used bottles are about 50 cents at Goodwill in a variety of colors.


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## lightsandsirens5 (Jan 11, 2013)

You ever tried to cut stainless steel with anything? Much less with tin snips. Tough stuff.

That being said, it can be done. Just not easily.

I'd try to squeeze a bunch of lido jelly all over everything. Use a syringe and IV Cath to try and get some inside. (Asking with that, I like the hydraulic pressure idea, I just don't think I'd give it a go in the field. I suppose it depends.)


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## CodeBru1984 (Jan 11, 2013)

mycrofft said:


> That's if they start to experience anoxia as exhibited by etc etc right? Otherwise there is no clinical indication.
> 
> Try a nasal cannula with 4 lpm some time.  Once you get it, you may wonder about how "comforting" that dry smelly stuff actually is.



That is correct.


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## mycrofft (Jan 11, 2013)

CodeBru1984 said:


> That is correct.



For the win!


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## phideux (Jan 13, 2013)

lightsandsirens5 said:


> You ever tried to cut stainless steel with anything? Much less with tin snips. Tough stuff.
> 
> That being said, it can be done. Just not easily.
> 
> I'd try to squeeze a bunch of lido jelly all over everything. Use a syringe and IV Cath to try and get some inside. (Asking with that, I like the hydraulic pressure idea, I just don't think I'd give it a go in the field. I suppose it depends.)



Are they Stainless?? I was thinking Aluminum and easy to cut.


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## EMT B (Jan 13, 2013)

hydraulic spreaders.


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## lightsandsirens5 (Jan 13, 2013)

EMT B said:


> hydraulic spreaders.



Or a hydraulic ram.... h34r:



phideux said:


> Are they Stainless?? I was thinking Aluminum and easy to cut.



There may be aluminum ones. I have several and they are all stainless steel. But like I said, there may very well be aluminum ones.


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## nightside (Jan 13, 2013)

*just an idea*

Drew out an idea using 14fr suction cath, bp cuff bulb and tubing, a double male christmas tree tubing adapter and lots of lube. Fit the suction tubing with lube between tongue and bottle opening, attach bp cuff bulb and tubing to suction cath with double christmas tree tubing adapter, close stopcock on bulb and pump away. This assmes the bottle is not already cut or punctured. You can release pressure if you need to also.

Of course you could always just transport to the ed and let them remove it but we are ems and could save the day! Think of how impressed the ed nurses will be when you tell them how you did it! Lol, jk. It would be fun to try with something other than an attached human tongue to see if it works.


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## EMT B (Jan 14, 2013)

lightsandsirens5 said:


> Or a hydraulic ram.... h34r:



i was serious. id call an engine company and get the spreaders and spread the bottle while we gradually move deeper and deeper in the bottle until it gets wide enough that we can pull it out.


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## shfd739 (Jan 14, 2013)

EMT B said:


> i was serious. id call an engine company and get the spreaders and spread the bottle while we gradually move deeper and deeper in the bottle until it gets wide enough that we can pull it out.



I've never seen spreader tips small enough to fit in the bottom of one of these bottles. I'm also against the idea of putting a hydraulic tool that close to a patients face. Too much that can happen. 

Destroying the sides of one of these bottles isn't too hard. It's the rolled/thick opening lip/flange that will be the challenge; And that's where the tongue is stuck. 

For me I'm doing supportive care, maybe nasal O2 if it becomes indicated and a nice, easy ride to the hospital. The trauma center can figure this out and they have a bigger bag of tricks to work out of.

I see the bigger problem for me is convincing some of our local FDs that I will not let them attempt to save the day on this one. Contrary to what they think, this is over their heads.


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## Veneficus (Jan 14, 2013)

soap and water.


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## mycrofft (Jan 14, 2013)

Try cutting or ripping one of those bottles, go buy a used one for 50c and do it. Sobering, especially if you watch what happens to the lumen of the part where the tongue is trapped. Maybe the O.R. is the best way to do this if a lube doesn't work.
I know having the kid screaming isn't going to help.


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## Tigger (Jan 14, 2013)

EMT B said:


> i was serious. id call an engine company and get the spreaders and spread the bottle while we gradually move deeper and deeper in the bottle until it gets wide enough that we can pull it out.



There is no way I would consider using hydraulic spreaders that close to someone's face, even if it was possible to get them into the bottle.


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## EMT B (Jan 14, 2013)

well youd have to cut the bottom off first


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## Tigger (Jan 14, 2013)

EMT B said:


> well youd have to cut the bottom off first


Even with the top off, getting a pair of mini spreaders would be a task and a half. Hydraulic tools are not really designed for this sort of precision work. 

Even this would struggle.


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## EMT B (Jan 14, 2013)

any sort of spreading tool that would work then?


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## Rialaigh (Jan 14, 2013)

I looked up the thermal coefficient and realized that cooling down an aluminum water bottle that size from lets say 70 degrees to ~25-30 degrees is only going to negatively affect the size of the bottle by 3-4 one thousands of an inch I believe. 

I think based on that I would probably 
1. Have the child lay supine on a stretcher
2. lidocaine everything reachable from the outside
3. cut a hole in the end of the bottle big enough to lidocaine everything on the inside (and to fit ice cubes inside the hole). 
4. fill the bottle (through the hole with the patient supine and the bottle being supported by someone) with ice. as the ice melts continue to re-top off.

 I think with this approach there is minimum discomfort and good chances you can reduce the swelling in a matter of 10-15 minutes enough that the seal breaks and the worst part is the kid gets a face full of ice and water. give him a slap on the back and tell him he did good.


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## mycrofft (Jan 15, 2013)

Tigger said:


> Even with the top off, getting a pair of mini spreaders would be a task and a half. Hydraulic tools are not really designed for this sort of precision work.
> 
> Even this would struggle.



Aw, that's CUTE!


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## mycrofft (Jan 15, 2013)

Rialaigh said:


> I looked up the thermal coefficient and realized that cooling down an aluminum water bottle that size from lets say 70 degrees to ~25-30 degrees is only going to negatively affect the size of the bottle by 3-4 one thousands of an inch I believe.
> 
> I think based on that I would probably
> 1. Have the child lay supine on a stretcher
> ...



1. Would the bottle freeze to the kid? 
   a. Add salt to ice, or dry ice?   

2. How about iced saline IV and refrigerated oxygen to induce therapeutic hypothermia and make the tissues shrink?*


Just kidding!

*Hey, it would make MY tissues shrink!h34r:


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