Unfortunately, this particular patient didn't have any kind of medic alert bracelet on and we had to find out from his wife on scene that he had throat cancer but no idea what KIND of throat cancer. Also, unfortunately (for us and this patient), we did not, at the time, have trach's on board. This particular incident prompted us getting a few. Although since then we have not had an incident that would require a trach so I'm not sure if our full time paid paramedics would be able to successfully use it. Once we actually got to the hospital (workin' him the whole way) the ED staff only worked him for another 10 minutes or so before they called it. Two ED staff (I assume doctors, but could have been a resp. tech) also failed in their intubations before they trached him.
When I hear throat or esophogeal CA, I hope for the best but prepare for the worst.
I will first see if they are at all manageable by BLS methods like the BVM, oral or nasal airway. That is before I before I start with intubation. I will palpate for obvious masses and look for tongue movement or deformities. Checking jaw mobility is another factor. If the patient has had previous surgeries or radiation therapy is also helpful to know.
I will also have, in the ED, the smallest ETT but still adequate in length, even if it is uncuffed available, if I visualize even the slightest opening in the glottic region. This would be a last attempt in prep for a cric or percutaneous trach. The ETT will facilitate a small bronchoscope (pedi size) to pass for a visual as the trach is done in the hospital. Prior to all this, my preference would still be a BLS airway if at all possible, if there is slim chance of ETT placement, until a surgical opening is made. I've seen some of these tumors bleed like a cranked out water faucet.
Most tumors are supraglottic or right at the glottic area. Rarely are they subglottic. Thus, a trach incision will usually miss them. The tongue may also be involved. (sidenote: a tongue can be reconstructed from the lattissimus dorsi muscle)
This website has excellent links to give you a visual as to what prevents one from passing an ETT or even using the BVM.
http://www.lib.uiowa.edu/hardin/md/throatcancer.html
My disclaimer: Always talk to your medical director about any interesting or difficult cases to seek out his/her advice.
I have seen throat cancer at various stages of resection and treatment. I always get a thorough report from the surgeon and anestesiologist to prevent surprises. The creative methods it may take to ventilate a person never cease to amaze me. As I continue to mention in my posts, there are over 300 different airway devices and I still run across some that aren't on my list. RT is definitely a fascinating field and was a great career choice for me to broaden my education/knowledge from my Paramedic education/training. It made me respect the "skill" of intubation as both a science and an art.
