Crics in the field

[trauma1534]

I am curious as to how many medics out there have actually ever done a cric in the field. I know it is one of those paths less traveled with airway, but who has done one? I saw a patient RSI'ed, or attempted to be RSI'ed, the medic could not get him tubed. He inserted the combi and still no rise and fall. This was a nightmare. He refused to cric because he said it would cause more harm than good. How is that? We needed an airway... never got it because the big brave "mightymedics" on the truck who was going to be all big and bad and RSI couldn't tube after the drugs. Get this... the patient had a good airway before the RSI, they were RSI'ing because he was very combative. The man wound up coding, with no airway.... he died! We bagged all the way to the hospital with no rise and fall of the chest. What an idiot or a couple idiots might I add! Any thoughts?

 

[Guardian]

that sucks

 

[BloodNGlory02]

Doing a cric isnt going to make the chest rise and fall if a combitube isnt doing it either. Did you try to confirm tube placement in a different way? Did you have gastric sounds? distention?

 

[Ridryder911]

I unfortunately have performed probably 15 or more, but, it was 12 years after I had entered the field, then performed two within a week, and never had to again or another 3 years... so yes, when they need it i do it. No big deal.. just like RSI is no big deal either.. they are all procedures.

Your call needs to be reviewed by TQI, if what you are saying is true. A Paramedic should be prepared to crich if they are going to RSI... period. That is one of the steps... If one cannot intubate, then alternative airway (king, LMA, PTL , etc..) hell, even BLS with a BVM and airway if you are able to get air in if the RSI fails. Crich if one can not get air into patient whatever measures it takes... These are the standard steps. Before cutting, one needs to value the risks of it. It appears, that there was an obstruction... and does sound like an airway from hell.

Now, before we start bashing medics .. Why was the patient combative? Was this a trauma or head injury patient?


R/r 911

 

[akflightmedic]

You are correct.

A cric is a last ditch effort and many medics will go their whole career without ever having done one, either due to the system/state not allowing it or the opportunity not presenting itself.

I myself have been in EMS since 1994 and I have done three crics. Two of them I knew was futile but it was my last ditch effort to say I had done everything possible for the patient. The third one actually saved the man's life and he was discharged without any defecits a short while later.

Crics just are not needed all that often in most typical environments, we have too many other tools at our disposal these days. However, if you are in a situation that warrants it, do not hesitate but be completely prepared before starting.

I am sad to hear about the case you presented because that was most unfortunate. I know of a service that went through the same situation, they ended up settling with the victim's family plus RSI was removed from their guidelines. How many patients will this effect in the future now that because of that one screw up by one medic, none of then no longer have the option to RSI.

There are other alternatives to dealing with combativeness besides RSI. One of my old ground sevrices used to carry Haldol (Vitamin H)..lol. It was most useful and sure beat the hell out of RSI'ing someone for no reason other than to gain compliance.

I would like more deatils about the incident, because it sounds as if there was a huge failure in the system overall. First, too many medics do not adequately prepare for accessing an airway. They think they push a few drugs and tube and easy as pie, all done. There is much thought process that should be done prior to an intuation especially an RSi situation. Prior to pushing any drugs, the airway should be assessed for difficulty. One tool is using the Mallampati scale, somethig which many medics will say "huh, the what?" Using this scale will predict how difficult the attempt will be. You also need to have backup plans already thought through and the equipment ready for use should it be needed. Scrambling through the cabinets after the fact does th patient no good.

Second, there are techniques to employ while intubating. You can let your partner pick the patient up by the arms, so the head hangs back, you can drop their head off the end of the stretcher, you can semi Fowler them and stand over them ( which is a great technique), you can use the two man intubation method. Not only should you try different positioning, you also use the BURP method. Too many people just merely apply the Sellicks manuever which is ok but all should know the BURP. Using this method usually shifts the cords into direct view. Very simply, its backwards, upwards, right pressure.

Finally, the last failure was the drugs pushed. When RSI'ing someone, we use a short acting and long acting paralytic. The reasoning is this: if you are unable to ventialte the patient after pushing the short acting drug, or you are unable to tube him..guess what?? It wears off within a minute or two!! No loss of life needed due to failure to intubate what was previously a concious patent airway patient. You do not push the long acting drugs until you are positive you have an adequate secured airway..period!

I am also surprised that a combitube was unable to ventilate the patient. Were there extenuating circumstances you have not divulged yet? Such as massive trauma, etc. Did the medic try to ventilate the other tube since one of them wasnt working? Just curious, as I was not there and I can only go on what you provide. This is a good learning scenario for all, unfortunately it cost someone their life.

 

[Fedmedic]

Been there, done that.

 

[DT4EMS]

None for me. I look at is as being lucky I guess. I have only had a couple of people in my 16 years in EMS I couldn't intubate..........but that was prior to RSI and they were not in need of a Cric.

I have also "heard" of the nightmares that follow a Cric............. from admin. One of the best medics (and smartest) almost lost his job over a Cric. The Cric went well, and when we was getting ready to secure the tube, he asked a person to hold it for just a second......... well.......... that person lost control and down it went.

THe medic never tried to hide it. He documented everything and reported it to his supervisor. They picked the call apart and said the patient "could have been" bagged instead.

The only mistake the medic made was failing to secure the tube. If that would have happened without a hitch..........nothing would have been said about the call.

Now......... street medics should't have to "routinely" Cric people if they are something is wrong.............like their intubation skills. If you are a flight medic it may be a different story. FLight medics are like the SWAT of EMS. When people are in trouble they call EMS, when EMS are in trouble they call flight medics.

 

[FFEMT1764]

Where I work we dont have RSI or needle Cric, and we prolly never will do the cric thing. RSI may come in the next year or so...our MD is really strict on this because of issues in the past with poor QA and providers doing whatever they wanted. The state here says we only have to have LMA to back up RSI, so I likely will never do a cric unless I get the idea in my head to fly some day.

 

[VentMedic]

Bad outcome on this cric.

http://www.news-leader.com/apps/pbcs.dll/article?AID=/20070427/BREAKING01/70427031

 

[Ridryder911]

Very confusing report. That he was terminated for unrelated event earlier this month.. (sure ). The child was taken to an ER then died enroute from hypoxia while enroute from one hospital to another. The airway was never secured in the original ER ?..

R/r 911

 

[VentMedic]

The hospital part muddies the waters... This will be of most interest for legal eagles. Who is what percentage responsible which contributing factors?

http://www.ky3.com/news/3212631.html

 

[Ridryder911]

All I can say is, that I am glad I was not on that call.... Both as a medic and receiving end.

R/r 911

 

[DT4EMS]

We are following this one pretty close

http://www.ky3.com/news/3212631.html

I heard some "rumors" on the call. Someone said something about having to "hold" the patient down while the procedure was performed. I do NOT know that to be fact.

There is no winner in this tragedy. Many lives are affected for sure. My prayers are with the families of all affected EMS and pateint.

 

[Emtgirl21]

I guess something can go tragicly wrong in any agency or on any call, but Cox and St John's are both awsome companies. Just said to hear something like this happening so close to home.

 

[Anomalous]

It doesn't help things when the reporter says, "after several attempts to establish an airway — including a failed procedure in which Busker attempted to cut a hole in Chad's trachea." I wouldn't exactly describe it as cutting a hole in it.

 

[Ridryder911]

It doesn't help things when the reporter says, "after several attempts to establish an airway — including a failed procedure in which Busker attempted to cut a hole in Chad's trachea." I wouldn't exactly describe it as cutting a hole in it.

Well, as bad as it is worded, it is actually either puncturing a hole or cutting a hole in through the cricoid membrane-trachea. If a surgical opening was attempted then yes a 180 degree opening should had been performed.

R/r 911