# Cricothyrotomy revisited



## ExpatMedic0 (Nov 15, 2013)

I read a recent article in EMS world which can be found here http://www.emsworld.com/news/11233937/ind-medic-credited-for-save-with-surgical-cricothyrotomy

What I found interesting was that, "...Of the 3 million AMR runs over the last two years in America, there have been only 38 successful cricothyrotomies"(emsworld.com).

What has your experience been with this procedure? 

Do you feel we get enough continuing education and Psychomotor practice to stay current on it?

Do you think its underutilized due to provider comfort level/lack of training, or that the correct number being done should probably be around 38/3 million?


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## chaz90 (Nov 15, 2013)

Well, they are supposed to be low frequency high yield procedures. Having said that, I would wager a guess they are under utilized in the US as a whole. I think there is a reluctance to go to something seen as that extreme, but there is a time and place for it. In this case, I find it interesting that the medic who performed the procedure had already done one earlier this year. Based off of the 38/3 million statistic you mentioned (and frankly, I don't know any others), the vast majority of medics could reasonably expect to get through a career of full time 911 without ever pulling out the cric kit. I don't have any information of course, but these statistics would lead me to believe that this particular medic has a much lower threshold to cut than most. The individual provider's comfort and personal attitude make a huge difference in willingness to take that step. We all need to know when the line is crossed and the scalpel (or QuikTrach kit) needs to be used, but I can confidently say that I have met paramedics who would never be comfortable pulling the trigger. 

Continuing training to keep up with this skill does need to be emphasized. Every expiring kit should be opened and used for education, and anatomy labs/skill practice should be held at least once a year to keep up some level of familiarity. Even a veteran medic is going to feel somewhat amped up when he realizes a cric is going to be necessary, and that isn't the time to pull out unfamiliar equipment or look for unfamiliar landmarks. I know that's why many services have gone to the QuikTrach. I've seen and played with the PerTrach, and that's painfully complicated to use as infrequently as we do. There's some argument to use a simple scalpel, spreader, and cut down ETT as well.


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## jwk (Nov 15, 2013)

ExpatMedic0 said:


> I read a recent article in EMS world which can be found here http://www.emsworld.com/news/11233937/ind-medic-credited-for-save-with-surgical-cricothyrotomy
> 
> What I found interesting was that, "...Of the 3 million AMR runs over the last two years in America, there have been only 38 successful cricothyrotomies"(emsworld.com).
> 
> ...


For the proper indications, clearly it should be done.  There are a number of cric sets on the market, some simple, some more complicated, but all allow a surgical airway to be placed fairly easily.  The hardest thing to do would be to pull the trigger because, no way around it, it's a really big deal.  It is easily the most invasive thing done by paramedics (or anyone dealing with airway management for that matter) and you can train on it all the time, but until you actually have to do it.....  I was in EMS for five years, and I do the airway management workshops for my anesthesia department - and have done more than 30,000 general anesthetics where every patient requires airway management and I've done exactly ZERO crics in my career spanning almost 40 years.  I've seen exactly one cric in all that time, done on the nursing floor at the hospital on a patient who lost their airway due to post-op bleeding from their neck surgery.  

Interesting that AMR gives their stats as "38 successful cricothyrotomies".  I wonder how many were attempted and what the problems were with those that were unsuccessful?  Bleeding?  Inability to place?  Improper placement?

I won't second guess the paramedic in question, because I wasn't there.  The article doesn't indicate if other airway management techniques were tried and were unsuccessful.  Crics are rare, as they should be and a cric as a PRIMARY method of airway management should be an exceedingly rare event, and of course one of those indications would be airway trauma.  My main concern is that they are used inappropriately as a backup to failed intubation.  Failed intubation should not mean failed airway management.  The progression should not be BVM - attempt ETT - cric.  If you use the ASA Difficult Airway Algorithm, a surgical airway is at the absolute bottom of the list.


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## Carlos Danger (Nov 15, 2013)

jwk said:


> If you use the ASA Difficult Airway Algorithm, a surgical airway is at the absolute bottom of the list.



It is at the bottom of the list for the ASA, but the ACOS used to (it may have changed; I haven't taken ATLS in years) say "3 failed attempts at ETI --> cut the neck. No foolin' around with sissy LMAs and such for us." I think that is still the approach at Shock Trauma. 

And unfortunately, some interpret it being at the bottom of the algorithm as meaning you should wait a long time, trying other things over and over, before you finally make the leap. 

I can see how one person might have to do 2 crics. Obviously it's statistically unlikely, but maybe he works in an area where he sees a disproportionate amount of severe trauma and is also for some reason less squeamish about it. Maybe he had some prior training (military) where they really drilled into his head not to hesitate doing it. 

I had a scene call once where I needed to do a cric but due to a combination of pre-existing abnormalities and severe neck and facial trauma, I could not locate the landmarks, and ended up doing a "blind / modified retrograde" instead (long story). Anyway I remember it was a fairly easy decision to make once I realized I would not be able to secure an airway otherwise. I think the hard part is reaching that point where you can see clearly that it needs to be done.


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## Christopher (Nov 15, 2013)

jwk said:


> My main concern is that they are used inappropriately as a backup to failed intubation.  Failed intubation should not mean failed airway management.  The progression should not be BVM - attempt ETT - cric.  If you use the ASA Difficult Airway Algorithm, a surgical airway is at the absolute bottom of the list.



I think if we had some generalized strategy for airway management, with the appropriate precautions taken for plans A, B, C (etc), then we'd not necessarily have this issue.

At the last local trauma conference, I heard our service area (7 county trauma catchment) sees 1-3 crics per year in the field and another 1-3 in the ED's trauma bay. They mentioned that none of the field crics were for a failed airway that wasn't a predictable failed airway (i.e. massive facial trauma).

Could they have adopted other strategies to optimally manage the airway? Probably.

I don't think we spend the appropriate time, training, or resources on ensuring we follow an adequate plan for airway/ventilation management.

I'm enjoying the Vortex approach which is becoming a popular (AU/NZ) means of simplifying the ASA algorithm into an "all comers" approach. Then combine this with a checklist to maximize their chance of following all the right steps.


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## Christopher (Nov 15, 2013)

chaz90 said:


> I know that's why many services have gone to the QuikTrach. I've seen and played with the PerTrach, and that's painfully complicated to use as infrequently as we do. There's some argument to use a simple scalpel, spreader, and cut down ETT as well.



I was very unhappy with the QuikTrach and PerTrach in cadaver labs. Lots of posterior tracheal wall damage. Local providers who have used them also did not like them. We've gone to the scapel/bougie technique (had a pig lab the other day) to greatly simplify our approach. At the same time GVL's have been added to the trucks at one service. No data yet on if this changes anything.


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## mycrofft (Nov 15, 2013)

Historically (back to the vaults for this one) they taught crics to first aiders! This (like _ad hoc_ tourniquets) resulted in many botched _ad hoc_ attempts resulting in severe bleeding (choice of onto the floor, into the airway, and into haematomas), thyroid injury, and most of all, failure. Having no resuscitation means once it was open, you needed a breathing victim to win, and that meant a very fast decision.  This poisoned the use of this potentially very useful, if relatively rare, tool.

Or ought it be more frequently used when/since oral airway passage seems to be so fricking hard?


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## EMT B (Nov 15, 2013)

one of the medics I work with said that both times he has needed a cric, he used a needle cric as a landmark to assist with the surgical procedure.


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## Tigger (Nov 15, 2013)

While doing some research on another topic I came across this from the New Hampshire state treatment guidelines:



> In summary: cricothyrotomy is a potentially dangerous procedure which does not save lives in New Hampshire.  It draws resources away from other airway management skills which are more likely to be effective.  The Board believes that the airway management skills of New Hampshire providers are excellent and that the record shows successful airway management is accomplished on a daily basis, even in the toughest cases, using the available non-cricothyrotomy airway modalities.



Thoughts?

The whole document with rationale is here.


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## DesertMedic66 (Nov 15, 2013)

In the last 2 years in my county we only had one patient that a cric was used on. Because of that our medical director decided to pull the skill from our scope. We are in the process of getting a new medical director so we will see if things change.


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## Handsome Robb (Nov 15, 2013)

As a service we usually have one crich a year. We run about 65-70k a year. I don't think we've ever done a needle crich, only surgical. We make our own crich kits. Scalpel, trach hook, trousseau dilator and a 6.0 ETT. I cut my ETTs down to just above the pilot line when I'm getting ready to do the procedure then pop the BVM adapter off and wipe the male part that goes into the ETT with alcohol so it sticks.

I've never done a live one. We rep it a lot though. Every time I'm in education I make a point of doing it at least once but unless you take the initiative we do annual skills once a year and review it as a mandatory training.


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## TheLocalMedic (Nov 15, 2013)

We only have needle crics available to us here.  The kits used to include a scalpel, but the story goes that a medic made an oops a number of years ago that got them taken out of the kits…  Never used one, never seen it used, and haven't even heard stories of them being used in this area.


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## Carlos Danger (Nov 15, 2013)

Tigger said:


> While doing some research on another topic I came across this from the New Hampshire state treatment guidelines:
> 
> 
> 
> ...



"Even surgical residents have a hard time maintaining cric skills"? That is honestly one of the stupidest things I have ever heard. 

Sounds like these board members had their minds made up about wanting to get rid of the skill, and looked for justification for it.

I sure hope none of them are ever one of those couple people a year who need it performed. 

When it needs to be done, there is no substitute.


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## triemal04 (Nov 15, 2013)

I suppose the argument for not allowing a cricothyrotomy could be made depending on the conditions that people where allowed to intubate under, and depending on the type of backups they had. 

It would be a piss-poor argument and not hold up under any real scrutiny, but I suppose I can see how someone might make a horrible decision and decide to make that argument.  

If all those people are allowed to do is intubate without ANY type of pharmacological assistance (no paralytics, no sedation, no procedural sedation) and have easy access to multiple backup airways (King, LMA, igel, etc) and in fact generally use those as their primary airway, then I suppose I can understand where that stance comes from.  I mean, at that point they will almost always be intubating people who are already dead.

Doesn't make it any less wrong though.


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## Handsome Robb (Nov 15, 2013)

Does anyone carry a jet insufflator to use with their needle crich? We don't, I tried to bag through one the other day, talk about temporizing measure. We have some ER docs that advocate us doing a needle first to get a bit of oxygenation before cutting but I just don't see how there is much of any oxygenation through one of those things. I know it's purely that, oxygenation not ventilation but is the difference in FiO2 really enough to buy you any sort of measurable extra time?


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## Christopher (Nov 15, 2013)

Robb said:


> Does anyone carry a jet insufflator to use with their needle crich? We don't, I tried to bag through one the other day, talk about temporizing measure. We have some ER docs that advocate us doing a needle first to get a bit of oxygenation before cutting but I just don't see how there is much of any oxygenation through one of those things. I know it's purely that, oxygenation not ventilation but is the difference in FiO2 really enough to buy you any sort of measurable extra time?



Minh Le Cong (of the RFDS, writes PHARM) advocates using a simple O2 tubing, holding it to the hub for inspiration and removing it for exhalation.


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## mycrofft (Nov 16, 2013)

Any surgical procedure with significant risk which is not actually practiced is potentially lethal.
If the saves per year are under ten (and no notation is made as to whether or how many iatrogenic crico-deaths occur), and the ancillary equip is not otherwise useful, then it makes sense not to do it.

The  FIRST thing we all learn is what NOT to do. It doesn't stop at the first thing by any chance.


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## Carlos Danger (Nov 16, 2013)

mycrofft said:


> Any surgical procedure with significant risk which is not actually practiced is potentially lethal.
> If the saves per year are under ten (and no notation is made as to whether or how many iatrogenic crico-deaths occur), and the ancillary equip is not otherwise useful, then not makes sense not to do it.
> 
> The  FIRST thing we all learn is what NOT to do. It doesn't stop at the first thing by any chance.



If cricothyrotomy can actually be shown to cause more harm than benefit, than I would agree. But I don't think that has been shown.

I would go so far as to making the argument that perhaps the main reason more aren't done is because they are under-utilized. I can't tell you how many times I've seen folks high-fiving each other because "we got the tube", but they leave out the fact that it took many attempts over an extended period of time, and a cric may have been a better option than that 8th intubation attempt.


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## mycrofft (Nov 16, 2013)

Halothane said:


> 1. If cricothyrotomy can actually be shown to cause more harm than benefit, than I would agree. But I don't think that has been shown.
> 
> I would go so far as to making the argument that perhaps the main reason more aren't done is because they are under-utilized. I can't tell you how many times I've seen folks high-fiving each other because "we got the tube", but they leave out the fact that it took many attempts over an extended period of time, and a cric may have been a better option than that 8th intubation attempt.  2.



1. Agreed. The issue I have is that it is demonstrable that if a procedure is not taught refreshed and *practiced* it becomes stale, no matter how competent you feel.

2. Yeah, "It's Miller Time" but the patient has an appointment in autopsy first.


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## triemal04 (Nov 16, 2013)

mycrofft said:


> Any surgical procedure with significant risk which is not actually practiced is potentially lethal.
> If the saves per year are under ten (and no notation is made as to whether or how many iatrogenic crico-deaths occur), and the ancillary equip is not otherwise useful, then it makes sense not to do it.
> 
> The  FIRST thing we all learn is what NOT to do. It doesn't stop at the first thing by any chance.


Risk vs reward.  

Yes, any procedure needs to be practiced to maintain a minimum level of competancy, but, if a crich is only being used when appropriate, ie you are unable to use an advanced airway of some kind, and unable to manually ventilate the patient, then this is not as applicable.

When you have to crich someone, if you don't, they are in effect dead.  The body may still technically be alive for a bit, but at that point the patient is not ventilating themself, and the provider is also unable to do so.

Simply because this is a rarely utilized skill does not make it any less important to have.


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## mycrofft (Nov 16, 2013)

If it is not practiced enough, ancillary equip is not carried, and the risk potential is high, the procedure stands a better chance of ending n iatrogenic death.

Mandate refreshers and equipment*, then enforce it and it starts to make some real sense, and might be used more often too.

*How about mandatory ER time (mandatory for practitioner and for ER's receiving state or federal funds) to keep certification beyond basic EMT level?


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## triemal04 (Nov 16, 2013)

mycrofft said:


> If it is not practiced enough, ancillary equip is not carried, and the risk potential is high, the procedure stands a better chance of ending n iatrogenic death.
> 
> Mandate refreshers and equipment*, then enforce it and it starts to make some real sense, and might be used more often too.
> 
> *How about mandatory ER time (mandatory for practitioner and for ER's receiving state or federal funds) to keep certification beyond basic EMT level?


Certainly.  If someone is going to use any skill they need to maintain a minimum competency level, and the risk associated with that skill will increase or decrease somewhat depending on the level.  

If you want to talk time in hospital to maintain an EMS cert we can, but it's going to be a very different conversation.

But again, to remove this specific skill because it is rarely done is a terrible idea.  When a crich is really needed (and I doubt any provider is going to do it unless it really, really, really is needed due to the stigma attached to it) it's not farfetched to say that the patient is dead and doesn't know it until the crich is done.

It is a neccasary tool to have.


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## Craig Alan Evans (Nov 16, 2013)

We use surgical kits with scalpel, dilator, hook, and tube. As a system we do about one a year. We train very often with deer trachs simulating blood flowing as we perform the procedure so the training is pretty realistic. We make sure every medic can do the procedure from cut to ventilation in under 30sec. Most do it under 15 seconds. The training is all muscle memory and I think the skill can be maintained very well with training such as this. Our assistant OMD is very hard core about our training and expects us to be able to do this procedure mindlessly and rapidly. He states, "when you have to do one of these you need it five minutes ago so you better be fast and efficient." I timed him at slightly less than 10 seconds from cut to ventilation. We have recently started training with introducing a bougie and then introducing the tube, skipping the hook step, but that has not been performed in the field yet. It's a valuable tool and when you need it there is no substitute. 

I just attended the annual Virginia EMS Symposium and saw a lecture on difficult airway management from a Buffalo NY Doc and he preached that the skill was too difficult to maintain and that it was too dangerous, fraught with complications, and should not be performed in the field. He recommended needle cric kits. 

When I asked him how he preferred to do the procedure he said, "I prefer a surgical cric, but that's me." He then went on to say he has only performed one in his many years of experience. 

My experience with needle kits is they have more steps and working parts to remember than a simple cut, cut, hook, dilate, tube. When we had kits years ago keeping up the skill was very difficult and we never used one in the field, probably due to the confidence of the provider. Once our Asst OMD entered the picture and brought us up to speed we started performing about one a year without issue and all very appropriate. 

I have performed one in the field, and since my job is to train other paramedics I don't plan on doing another until everyone on the call with me has performed one as well. With this being said I have been on two other surgical airway incidents in the mentor function and they went flawlessly and very rapidly. It's all about training. If you can't see the procedure in your mind and work through the steps rapidly and clearly then it's time to practice. 

That's my take.


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## Handsome Robb (Nov 16, 2013)

I will argue that a failed crich resulting in a death, unless that crich was in appropriately performed (read: not indicated) then you *cannot* call the death of the patient iatrogenic. 

It's been said multiple times, a crich is a last ditch effort, these patients are on the brink of death to begin with. How could you reasonably call the death of a patient requiring a crich iatrogenic?


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## mycrofft (Nov 16, 2013)

Robb said:


> I will argue that a failed crich resulting in a death, unless that crich was in appropriately performed (read: not indicated) then you *cannot* call the death of the patient iatrogenic.
> 
> It's been said multiple times, a crich is a last ditch effort, these patients are on the brink of death to begin with. How could you reasonably call the death of a patient requiring a crich iatrogenic?



Even if you are working on a pt on their last three pulses, if you kill them between pulses number 2 and 3, it's iatrogenic if it caused death. (Technically, even if you do it right and it caused death, it is iatrogenic). With Crikey-thyrotomy, that could conceivably include lacerating a major neck vessel or transfixing through the trachea and esophagus and into the anterior spine.

We call that "seizing defeat from the teeth of defeat". 

BUT, if crics get treated as something besides a last ditch hopeless Hail Mary, they would be done sooner, with proper pt anesthesia, and be more effective.


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## triemal04 (Nov 16, 2013)

mycrofft said:


> Even if you are working on a pt on their last three pulses, if you kill them between pulses number 2 and 3, it's iatrogenic if it was done incorrectly and caused death.
> 
> We call that "seizing defeat from the teeth of defeat".


That would really depend on exactly what actually killed the patient, and to some extent, semantics.

If an improperly performed crich was the the DIRECT cause of death (say the provider decided to perform a very long, very deep horizontal incision and cut the jugulars and carotids) that is one thing.

If the patient is dying, and then does die due to a lack of an airway, it's harder to say that the crich, even if improperly done, was the cause of death.  They were already going to be dead.  They already lacked an airway.  At that point an improperly done crich may have failed to resolve the problem, but it didn't cause it.

Like I said, semantics, and I have no doubt that, depending on those involved and who those people later talked, the provider still might face some problems.


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## jwk (Nov 16, 2013)

Craig Alan Evans said:


> We use surgical kits with scalpel, dilator, hook, and tube. As a system we do about one a year. We train very often with deer trachs simulating blood flowing as we perform the procedure so the training is pretty realistic. We make sure every medic can do the procedure from cut to ventilation in under 30sec. Most do it under 15 seconds. The training is all muscle memory and I think the skill can be maintained very well with training such as this. Our assistant OMD is very hard core about our training and expects us to be able to do this procedure mindlessly and rapidly.



No offense but there is no such thing as a mindless procedure.  You can think quickly as you're doing a procedure, but if you do it mindlessly, that's when mistakes are made, especially with a procedure like this.


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## Rialaigh (Nov 17, 2013)

Halothane said:


> *If cricothyrotomy can actually be shown to cause more harm than benefit, than I would agree. But I don't think that has been shown.
> *
> I would go so far as to making the argument that perhaps the main reason more aren't done is because they are under-utilized. I can't tell you how many times I've seen folks high-fiving each other because "we got the tube", but they leave out the fact that it took many attempts over an extended period of time, and a cric may have been a better option than that 8th intubation attempt.





I tend to go the other way in thinking. If a cricothyrotomy has been shown to provide more good than harm then lets consider doing it. But I don't think that has been shown either. 


Frankly this skill is done so rarely, good neuro intact outcomes are so rare when preformed as are completely botched attempts. Because of how rare all of this is to me it really doesn't matter whether we do it or not. We could spend this training time and time discussing or researching this on much more efficient and beneficial training and education. 


My issue isn't the skill in and of its-self. It's how high the opportunity cost of properly training and educating on this skill is verse the actual benefit achieved.


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## ExpatMedic0 (Nov 17, 2013)

It is the hail Mary of airway plays, that is for sure. However, I can't help but notice (speaking from only my own experience), we do not get enough practical training on this. It is a rare skill, but if push comes to shove, during a 20 year career, it seems like a large portion of medics could be faced with the decision to preform it or not, even if only once or twice in a career. I think (strictly speculation) that the skill may be under performed due to provider level comfort secondary to lack of annual hands on training.


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## Carlos Danger (Nov 17, 2013)

Rialaigh said:


> I tend to go the other way in thinking. If a cricothyrotomy has been shown to provide more good than harm then lets consider doing it. But I don't think that has been shown either.



Well, "if the benefits outweigh the risks, it should be in the protocols. If they don't, it should not" holds true for any procedure. And while I certainly agree that the intervention needs to prove itself and not the other way around, we are talking about something that has already been in the protocols for eons many places, not about adding something new that hasn't yet been fully proven.

I don't think anyone is arguing that a cricothyrotomy can't be a life-saving procedure in some cases, anyway. It's not like other very invasive procedures (chest tubes, pericardiocentesis) that have fallen out of favor because they have alternatives.....in a true CI/CV scenario, there simply are no alternatives.

In the example that I used earlier in this thread, my patient would absolutely have died on scene if I had not been trained in retrograde intubation. That's the only time I've used a surgical technique, but I've had several co-workers who have had to.

I just don't think the fact that it is very rarely needed is by itself justification to throw it out, and I don't think it is as difficult to maintain the skills as some claim, either.



ExpatMedic0 said:


> I think (strictly speculation) that the skill may be under performed due to provider level comfort secondary to lack of annual hands on training.



I have the same speculation, and in fact I think used properly, it probably shouldn't be quite as rare as it is....


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## Rialaigh (Nov 17, 2013)

Halothane said:


> Well, "if the benefits outweigh the risks, it should be in the protocols. If they don't, it should not" holds true for any procedure. And while I certainly agree that the intervention needs to prove itself and not the other way around, we are talking about something that has already been in the protocols for eons many places, not about adding something new that hasn't yet been fully proven.
> 
> I don't think anyone is arguing that a cricothyrotomy can't be a life-saving procedure in some cases, anyway. It's not like other very invasive procedures (chest tubes, pericardiocentesis) that have fallen out of favor because they have alternatives.....in a true CI/CV scenario, there simply are no alternatives.
> 
> ...




I agree it can be life saving. I guess my point was how much education and how little training is offered on this by most EMS agencies. Most agencies do not have access to labs that have this skill at all and realistic training is about near impossible to get most places. 

If it took 20 hours a year to keep yourself competent on crics and we had that option to spend those 20 hours on early recognition and management of the sepsis patient (including the possibility of field antibiotics, etc) I would take sepsis training every time. Per 100,000 calls or however you want to measure it volume wise cric's are a very very low benefit skill. They benefit that one patient a lot but the number of patients benefited is microscopic. If given a choice on how to use that time for providers I think there are many more areas where we could see benefits that are ten fold or a hundred fold what we see for cric's in a year.


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## mycrofft (Nov 17, 2013)

"That would really depend on exactly what actually killed the patient, and to some extent, semantics".

You just made every insurance company and will-drawing lawyer in America hiccough. :wacko:

Even if the pt is dying, if what you do is the proximal cause of death, you did it. Doesn't matter if I botched a crike, or Smith Klein  gave a chemotherapeutic experimental to a dying cancer patient with six months to live and it ate away her liver.

I'm sure if the practitioner is trained and practiced and it is a reasonable thing to do it is taken into account. By everyone except the patient's family's lawyer.


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## mycrofft (Nov 17, 2013)

Sidetrack:

By the argument being offered here that the measure's need is rare* but it ought to be still taught and used, then why do people want to absolutely stop using spine boards and KEDs?

 *(and maybe it ought not to be if it were done better?)


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## Craig Alan Evans (Nov 17, 2013)

jwk said:


> No offense but there is no such thing as a mindless procedure.  You can think quickly as you're doing a procedure, but if you do it mindlessly, that's when mistakes are made, especially with a procedure like this.



Sounds like semantics, but let's play this out. In my opinion all of the brainpower is spent in the decision to perform the procedure or not. Once you pull the trigger the process of doing it really is very simple. In these situations you do not have the luxury of thinking your way through it. You have to very quickly and deftly establish an airway. He who hesitates is lost. The only way to do that is with practice. Does a musician THINK about where his fingers are going when he plays the piano or the guitar? No, it all muscle memory and once you locate the landmarks it's a matter of two cuts a bougie and a tube, done. I'm not trying to downplay the seriousness of the event, but I think paramedics can be trained to a very high competency in the skills we perform. The whole procedure just isn't that complicated. There are only a couple of physical barriers to overcome to place a tube in the trachea and if you don't know the anatomy of the area you are cutting into enough to do it mindlessly then you shouldn't be doing it.


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## Carlos Danger (Nov 17, 2013)

Rialaigh said:


> I agree it can be life saving. I guess my point was how much education and how little training is offered on this by most EMS agencies. Most agencies do not have access to labs that have this skill at all and realistic training is about near impossible to get most places.
> 
> If it took 20 hours a year to keep yourself competent on crics and we had that option to spend those 20 hours on early recognition and management of the sepsis patient (including the possibility of field antibiotics, etc) I would take sepsis training every time. Per 100,000 calls or however you want to measure it volume wise cric's are a very very low benefit skill. They benefit that one patient a lot but the number of patients benefited is microscopic.mIf given a choice on how to use that time for providers I think there are many more areas where we could see benefits that are ten fold or a hundred fold what we see for cric's in a year.



That is interesting, but if we are going to take the approach that we'll focus heavily on things that we see often and completely discard things that are rare, then our protocol books and training programs will look awfully different than they do now. If we are really going to go by what the evidence shows makes a difference, we'd probably get rid of all advanced airway management, for instance. Why spend time practicing something that statistically benefits very few people?

20 hours is an awful lot, IMO, to spend annually on any one topic, but if anything deserves that type of time it is airway management. I think things like sepsis and most other topics should be reviewed between transports or even on one's own time, and invasive skills should be practiced 3-4 times per year in skills labs. Plenty of time to practice this skill. You can take a small group of 10 paramedics, and in 60 minutes you can review the airway protocol, review the relevant anatomy, talk about a couple scenarios, and each do 2 or 3 crics on the manikin.


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## mycrofft (Nov 17, 2013)

Craig Alan Evans said:


> Sounds like semantics, but let's play this out. In my opinion all of the brainpower is spent in the decision to perform the procedure or not. Once you pull the trigger the process of doing it really is very simple. In these situations you do not have the luxury of thinking your way through it. You have to very quickly and deftly establish an airway. He who hesitates is lost. The only way to do that is with practice. Does a musician THINK about where his fingers are going when he plays the piano or the guitar? No, it all muscle memory and once you locate the landmarks it's a matter of two cuts a bougie and a tube, done. I'm not trying to downplay the seriousness of the event, but I think paramedics can be trained to a very high competency in the skills we perform. The whole procedure just isn't that complicated. There are only a couple of physical barriers to overcome to place a tube in the trachea and if you don't know the anatomy of the area you are cutting into enough to do it mindlessly then you shouldn't be doing it.



Money shot.
AND by not treating it as a last resort poor redheaded step cousin maybe it can be done better?


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## jwk (Nov 17, 2013)

Craig Alan Evans said:


> Sounds like semantics, but let's play this out. In my opinion all of the brainpower is spent in the decision to perform the procedure or not. Once you pull the trigger the process of doing it really is very simple. In these situations you do not have the luxury of thinking your way through it. You have to very quickly and deftly establish an airway. He who hesitates is lost. The only way to do that is with practice. Does a musician THINK about where his fingers are going when he plays the piano or the guitar? No, it all muscle memory and once you locate the landmarks it's a matter of two cuts a bougie and a tube, done. I'm not trying to downplay the seriousness of the event, but I think paramedics can be trained to a very high competency in the skills we perform. The whole procedure just isn't that complicated. There are only a couple of physical barriers to overcome to place a tube in the trachea and if you don't know the anatomy of the area you are cutting into enough to do it mindlessly then you shouldn't be doing it.


I'm not arguing that it shouldn't be done.  There are certainly valid indications for it.  However, I disagree with the "muscle memory" concept - I don't think this is analogous to playing a musical instrument at all.  You do indeed have to think about where you cut - you use your fingers to identify the landmarks, but that doesn't mean you're not thinking about it.  The cricoid membrane is easily identifiable, but besides that, you're also making sure you're in, and staying in, the midline, making an incision that is deep enough but not too deep, etc.  I just don't think that's mindless nor is it automatic.  Whether it takes someone 10 seconds or 20 is a negligible difference - it's not a contest - it just has to be done right the first time.  

Of course different experiences play a role as well.  We have Melker cric kits (a big catheter variation) on our airway carts - those may not be the best for field providers because there are several parts which you have to know how to put together and use.  However, everyone in my group is intimately familiar with a modified Seldinger technique of catheter placement, and although I've not done a cricothyrotomy, I've done many cricoid sticks for other reasons.  Combining those two makes a cric a relatively easy procedure - except you actually have to DO IT.  I have no doubt that as many times as I've practiced it and taught it, the first time I actually have to do it I will take a deep breath and pucker up a little.


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## triemal04 (Nov 18, 2013)

mycrofft said:


> "That would really depend on exactly what actually killed the patient, and to some extent, semantics".
> 
> You just made every insurance company and will-drawing lawyer in America hiccough. :wacko:
> 
> ...


One more time, and very slowly.

There is a difference between CAUSING a death, and FAILING TO PREVENT a death.

If a patient does not have a patent airway, for instance due to severe trauma, and is unable to ventilate themself, they are going to die.  The CAUSE of death would be the lack of ventilation.  If attempts at placing an advanced airway fail, a BVM is ineffective, and a crich is ineffective, those did not CAUSE the death, they FAILED TO PREVENT IT.

This does not mean that there is no accountability, or that FAILING TO PREVENT a death means that everything was done right, it just means that the CAUSE of death was not the procedure.

If you refuse to understand that then it's the end of the conversation.


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## Handsome Robb (Nov 18, 2013)

I'm glad someone understood what I was trying to say...


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## Rialaigh (Nov 18, 2013)

Halothane said:


> That is interesting, but if we are going to take the approach that we'll focus heavily on things that we see often and completely discard things that are rare, then our protocol books and training programs will look awfully different than they do now. *If we are really going to go by what the evidence shows makes a difference, we'd probably get rid of all advanced airway management, for instance. Why spend time practicing something that statistically benefits very few people?*
> 
> 20 hours is an awful lot, IMO, to spend annually on any one topic, but if anything deserves that type of time it is airway management. I think things like sepsis and most other topics should be reviewed between transports or even on one's own time, and invasive skills should be practiced 3-4 times per year in skills labs. Plenty of time to practice this skill. You can take a small group of 10 paramedics, and in 60 minutes you can review the airway protocol, review the relevant anatomy, talk about a couple scenarios, and each do 2 or 3 crics on the manikin.



Shouldn't we be going by what evidence shows makes a difference. Isn't that what we are striving for, better evidence based treatments. Statistically in the studies that have been done there is 0 difference in hospital discharge outcome between those ventilated with a king airway and those who are tubed prehospitally. Some studies argue the tube actually causes worse outcomes...but we continue to tube person after person after person....

Plenty of arguments for tubing someone...plenty of sound scientific reasons....and 0 evidence to back up any of it. 


The reason I am not a fan of crics is because of how many other topics are out there that we could be training for using real evidence based practice to make a noticable difference in hospital stay and outcomes. If we were already doing everything else really well (The basics) then I would be all for doing advanced airway management better, but right now we don't even do the basics well, and the basics make a much larger difference in length of hospital stay and overall outcome.


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## mycrofft (Nov 18, 2013)

triemal04 said:


> One more time, and very slowly.
> 
> There is a difference between CAUSING a death, and FAILING TO PREVENT a death.YES. Or we'd all be murderers many times over.
> 
> ...



Ah, the conversation continues. Not to worry. Part and parcel of EMTLIFE. 

 I understand you. They key is whether the procedure _caused_ the death. 

Not that it was ineffective, I entirely agree. As in it was too late or it was ineffective. It can still be the right thing to do, but it just didn't or couldn't work. _A futile but not lethal attempt of the right thing *is no*t an iatrogenic death_. 

 But if I have a pt asphyxiating and thrashing and my 10 blade slips and severs a jugular, it is an accidental iatrogenic death. Iatrogenic doesn't mean it was the wrong thing to do, it just means that what was done _in a particular instance_ was the proximal cause of expiration. Not my fault, it was the pt's last chance, I did everything right, but the pt sunfished on me and the blade went kiddywankers. Medical examiner will write in cause of death is exsanguination but will also note pt was moribund due to airway embarrassment.

Part and parcel of the old concepts of "until you've killed someone you aren't a real surgeon" and "playing for points" (continuing care despite it being futile). 

Robb's initial response was "unless it is improperly performed it is not iatrogenic" or words to that immediate effect, and that is dead on (I mean, correct). 

Good, bad, wrong, right, if it is what crossed the "finished" line first, it's the cause of death. In fact you _*could*_ do something lethal (say, jumping up and down on the pt'/s chest after a drowning) but if the pt died first then it was not iatrogenic. Just really embarrassing.

Not intended to make anyone upset, it is splitting hairs, unless/until the trends start firming up. (Like laypersons misusing tourniquets led to TK's being banned from laypersons training for so many years). If you start seeing clusters or a creeping rising tide of such, then something needs a closer look.

Thanks for your patience and I hope this doesn't negatively affect your enjoyment of the website.

[There is one silver lining to this paradigm. If you do everything right, or you at least do everything possible that you could, and somehow it seemingly results in the pt expiring (or doesn't, might need an autopsy to tell) then you need to take it easier on yourself than some people will be wont to do].


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## triemal04 (Nov 18, 2013)

Just...no.


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## mycrofft (Nov 19, 2013)

Okay. I respect that.


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## Handsome Robb (Nov 19, 2013)

Ok ya if tweedle dee paramedic knicks a major vessel and they die of blood loss then fine, call it iatrogenic if you want to. Outside of that or a failed crich that wasn't indicated that results in a death I see no way for you to call these deaths iatrogenic.

You're very difficult to understand.


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## mycrofft (Nov 25, 2013)

No matter how close to the patient's inevitable expiration the act is performed, if an act performed in the course of medical care is the *proximal cause* of expiration, it is _iatrogenic_. 

Iatrogenic=harmful or non-curative results of medical treatment. Many things are iatrogenic and harmless (upset stomach from antibiotics, simple scars from surgery). It describes the point of origin, it is not in and of itself a value judgement (although in the case of a death there is some 'splaining to do). 

Therefore even if the cric is the patient's last chance to live, if the attempt to perform it creates a lethal wound, no matter how necessary the attempt was, then the death, no matter how inevitable, is iatrogenic; the pt died of exsanguination when he was originally dying of asphyxiation.

Hence my phrase, "Snatching defeat from the jaws of defeat".


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## ExpatMedic0 (Nov 25, 2013)

I have only done them on human cadavers and pigs, however... if you do it properly I think the possibility of hitting a major vessel is low, unless your like freaking Freddy Krueger or Edward Scissor hands up in there.


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## mycrofft (Nov 25, 2013)

*Choice of instruments*


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