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Tue Jan 9 14:15:13 GMT 2007

Thank-you

>>> gflores911 at gmail.com 1/9/2007 03:05 am >>>
Hi Lance,

Although another attempt at the same thing (intubation) proved to be
successful, a working definition of insanity is trying the same thing over
and over while expecting a different result each time. IMHO, another team
member may try one more time if the new attempt will be by the most
experienced team member. Maybe you had a better skill level, were in a "good
day" or any combination of the two of them. You said the epiglottis was
larger than usual. Could it have been getting swollen? Imagine not being
able to intubate and now not being able to ventilate while having trouble
with the cric!!!! Like Ron Gross said, I would've considered an LMA
(preferably an intubating LMA) before the cric without trying the oral ET
intubation.

Anybody can fail an airway and we will always fail an airway from time to
time (some sooner than others). If you are good at oral ETs, then my take
home message from your case is to strengthen your team's backup plan.
Everybody benefits from this (you, the doc, and the patient).

Gustavo E. Flores Bauer, MSIII EMT-P :.
www.EmergencyTeam.Net 
San Juan, Puerto Rico
Iberoamerican University School of Medicine
Santo Domingo, Dominican Republic

Cel: 829-770-0707
Fax: 809-686-6988
MSN Messenger: gustavoflores911
Skype: gflores911
E-Mail: gustavo at emergencyteam.net 

Ideas not coupled with action never become bigger 
than the brain cells they occupied.

     - Arnold H. Glasgow

"My karma ran over your dogma".

S:.F:.U:.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] 
On Behalf Of meredith mcbride
Sent: Monday, January 08, 2007 8:20 AM
To: Trauma &amp, Critical Care mailing list
Subject: Re: "emergency cricothyrotomy"

Before proceeding with surgical airway, it's reasonable for other team
members with airway expertise to attempt a secure airway after one person
has failed, especially in a patient with a reliable bagged airway.

LanceO Oosthuizen <LanceO at sedibeng.gov.za> wrote:
  Hi All

I am an ALS paramedic from SA just south of Johannesburg. Just recently I
received a call of a male patient 29 who came off a quad bike in a remote
area just out side the town where I live. The mechanism was that he veered
off the road and hit a wire fence and well cemented pole next to the road.
He was not wearing a helmet.

O/A I found the patient lying supine about 4 m from the point of impact. The
patients vitals were as follows:

GCS = 12/15
BP = 110/45
Pulse = 64 bpm no significant pathology on the ECG tracing
HGT = 5.4 mmol/l
SpO2 = 94% with 60 % re-breather.

H-T revealed that the patient has no neurological function from the
shoulders down, even to deep pain stimulation. there were areas of mottling
and the patient had parasthaesia over the left anterior abdominal area.
There were abrasions to the hands and the left flank. The patient had an
ethanol smell on the breath and bystanders mentioned that he had been
drinking.

My immediate action was to control c-spine manually and fully immobilize the
patient, insert bilateral large bore I.V. lines. We were about 100 km from
the nearest facility with a neurosurgeon. My reaction was to task the
medical helicopter to cas-evac the patient to the hospital.

When the Chopper arrived the attending Doctor assessed the patient and
elected to RSI the patient, due to the distance (20 min flight) and patient
was intoxicated. After administering etomidate and sux the Doctor then
proceeded the intubation, first attempt was unsuccessful the patient was
then pre-oxygenated to a sats of 99%. Second and third attempt was also
unsuccessful, but managing to pre-oxygenate the patient after each failed
attempt. He mentioned that the patient has a difficult air-way and was
difficult to visualize the cords.

After the third failed attempt the Doctor then elected for an "emergency
cric" on the patient. I requested one more attempt by my self and he refused
me to have an attempt, I made it known to him that I thought to go for an
cric was a bit of a harsh move now. None the less he still proceeded.
Several attempts were made at the cric, but with no success, I then stood in
and lost my temper a bit and told the Doctor to stand aside and that I would
take over now and attempt to intubate the patient orally. I managed to
intubate the patient on the first attempt visualizing the cords with ease. I
would score the patients air way a 2 for difficulty at the most as he did
have a rather large tongue and the epiglottis was also larger than usual.

I am just requesting the view of any one on this call, on the 24th January
2007 I will be attending a M&M on this matter.

Regards,

Lance
Critical Care Assistant Paramedic South Africa.

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