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Thu Jan 11 15:45:03 GMT 2007

Well said.

Dr.K.R.Rajesh, MS,DipNB,FRCS,FRCS(Orth)
Consultant Upper Limb Surgeon
Division of Upper Limb , Arthroscopy & Joint Replacement Surgery.
Cosmopolitan Hospital
Trivandrum,Kerala,India.

Mobile-9447191205

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Guy Jackson
Sent: 11 January 2007 14:50
To: Trauma &amp; Critical Care mailing list
Subject: Re: "emergency cricothyrotomy"

Lance,

The first thing your M&M should do is establish the basics. Was there a
Standard Operating Procedure, and was the 'heli-doc' following it? If not,
you should review his education, and why he was let out alone; i.e. he was
inadequately supported. What resources were available to train and certify
him? Were they adequate? If he was following it, you need to question the
SOP. It seems to me that most who have responded so far feel that it was a
little soon to be moving to a surgical style airway (I agree). Were there
airway adjuncts such as a bougie and LMA available, and why was 'heli-doc'
not trained to use them before moving to a cric?

You see, at every stage it is the system and not the elements enacting it
that needs to be reviewed. No egos need be bruised, and the lessons learned
for the system will ensure a better system is in place next time. That is
the patient you are really doing the M&M for.

Now let me play devil's advocate for a moment in order to prepare you for a
debate that may arise, and is usually undecidable. You describe a patient
with 'no neurological function' below a mid cervical level, but with
'abdominal parasthesia'. I assume that this means that there was no motor
function, but sensation was at least partially functional. This implies
incomplete cord injury, which may recover to a degree. How hard did you pull
for that grade 1 intubation? Did this move the spine around the fracture
site, and did this compromise the cord? There is no evidence either way,
both in individual cases and in the literature, but it remains a concern.
Should the system teach both you and 'heli-doc' to use a bougie when you can
just visualise the back of the larynx, leaving you able to say that you used
minimum force? This, along with manual in line stabilisation, is what I
encourage my trainees to do in resus. In theatre I do fiberoptics for this
reason (usually asleep), as I can leave the collar on and guarantee no
c-spine movement. I may be neurotic (my neurosurgeon thinks so) but I feel
safe with this. That is a product of my training, and a testament to my
trainers. The same applies to both you and 'heli-doc'.

At the end of the day we are all products of our training and the system we
operate. Thus your M&M should focus on these, and leave your egos out of it.

Guy Jackson
Anaesthetist
London, UK.

----- Original Message -----
From: "Jean-Pierre Arsenault" <jparseno at yahoo.com>
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Sent: Wednesday, January 10, 2007 1:50 AM
Subject: Re: "emergency cricothyrotomy"

This comes to repeat an old surgical saying: if it ain't broken, don't fix
it!  The patients saturation was appropriate and a missed intubation is one
of the few iatrogenic injuries who can kill a patient on the spot, and the
indication shouldn't be taken lightly... especially when you're in the field
with no backup of "anesthetic gizmos" which were all mentioned.

Maybe a "scoop and run" approach would have been more appropriate?  But then
again, I personnally have no experience in helicopter evac...maybe if I did
the thought of having to instrument the airway of the patient during
transport would have pushed me to intubate (or try to!).

JP

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