In my humble opinion, there are two life saving procedures that as ED docs, we should be able to perform. As they are rare, i thought i’d share some of my thoughts on what it felt like being in a stressful situation and some common learning points. Both cases are based on moulages and simulation scenarios I have been involved in.
The two procedures I’m talking about are:
1) Surgical Airway
2) ED Thoracotomy
First the Surgical Airway:
The moulage: A patient with severe facial burns in a rural ED resus. Although he was fully conscious initially, it wouldn’t be a stressful moulage if his airway didn’t deteriorate rapidly and the nearest Major Trauma Centre is an hour away. It ended up being a difficult intubation eventually leading to a cannot intubate, cannot ventilate (CICV) situation. After the moulage debrief, I had written some personal learning points down.
A few months previously, i had given a talk on surgical airway. This was essentially an amalgamation of Scott Weingart’s SMACC talk and Andy Neill’s awesome anatomy talk. I would advise any EM doc (no matter what level of training) to read/listen to them. So as I had spent a while preparing the presentation by reading and listening to any and all podcasts/blogs about the surgical airway, I felt reasonably confident in doing one if I needed to……
My learning points are:
1) Preparation is key. In the words of Cmdr Hadfield: “Sweat the small stuff”. Know what and where your kit is. Do you know where the surgical airway kit is in your own resus? If you are privileged to work in a HEMS unit, moulage a failed airway and surgical airway drill with the para/dr at the beginning of the shift together. Both the paramedic and I had worked together a number of times previously and we both felt comfortable with not only how to do it but where we would position ourselves and what kit needed to be out and ready. I think most if not all of the docs have visualised doing a surgical airway and expected it to be a bloody procedure so not to worry about the bleeding but focus on getting a tube down. I think one of the most difficult aspects of dealing with patients with difficult airways is actually making the decision to do the surgical airway. If time, position the patient to try and maximise your first look. “The first look is your best look….”. The moulage patient had no Cspine concerns hence we put blankets under the shoulders etc. However I didn’t appreciate that this “patient” couldn’t lie flat due to the fixed flexion of his neck. This meant the trachea would have been posterior than normal.
2) Bigger is better: Use a 22 blade to make an incision and if there is a patient who’s CTM (Cricothyroid membrane) you can’t feel, make a vertical incision first. Make it a long one and stay in the midline. Then dissect down to the CTM. Use the “Stab and Rock”/ “Scalp finger bougie” technique or which ever method you are comfortable using thereafter. Keep something in the hole at all times. Size 10 bougie for a Size 6/6.5 ETT. Remember sharps management.
3) Importance of the intubating team relationship: The ODA/ODP is there to keep the doctor from becoming too task fixated during a difficult airway RSI (Rapid Sequence Induction). In Resus (particularly in the UK, where an anaesthetist will manage the airway, although this is slowly changing) it is the job of the ED Doc to prevent the anaesthetist from becoming task focused. “10 secs for 10 mins”: The ED I work in now has a RSI checklist. Surgical airway is mentioned on it as well as the Plan A & B. Running through it, will enable all those present to be on the same page. You may have an on call consultant to call upon for advice. If you have time, use them!. By talking through your approach to the RSI, they may give you some pearls of wisdom that you hadn’t thought of. During the moulage, I had made a call to “on call consultant” who said “Remember to give the patient some more ketamine before performing a surgical airway”. The clinicians need to believe in their ability to perform this procedure and instil confidence and calmness to others around us, even though we may be feeling stressed internally.
I have visualised performing this many times prior to actually doing it. What would I need? How would I do it? What would I say to those around me? etc…. . The learning points below have come out of many debriefs of moulages, actual cases and simulations sessions during my ED career.
Lets say the scenario given is: “You are the lead doc in resus. At 3pm the “red phone” rings, there is an adult male trauma call coming in 10mins of a penetrating chest injury who has a deteriorating conscious level”. As the patient is wheeled into Resus, he is now being ventilated with a BVM and hypotensive. Code Red activated.
How would you manage/ prepare yourselves and the trauma team in 10 mins. What kit would you get out ready? Would you call any other specialities down that are not usually part of the trauma team? Are you comfortable being able to lead this trauma. Lets say you are in a swanky MTC with lots of people including senior clinicians able to help you. In the simiulation scenario I was in, this is what happened next:
- Patient had an RSI. Whilst the anaesthetist was preparing for it, I remembered saying ( and the video playback confirmed it!) “Im going to do a thoracostomy on his left side as soon as the Rocuronium goes in and Dr X will do the Right…..”. The concept of doing thoracostomies simultaneously with intubation in a Peri-arrest patient was something new to me since working with HEMS, as was cross checking the site of the thoracostomies with Dr X. No blood/ air release.
- A bedside USS: large cardiac tamponade
- Resuscitative thoracotomy: 22 blade, Tough cut scissors, Gigli saw and inco pads. “Basic Kit but thorough training needed….”. Make your first cut deep enough so you are through to muscle. Before opening the chest, extend your thoracosotomy wounds posteriorly. This will allow the chest to open up like a “clamshell”, maximising your ability to identify anatomy. Use the Inco pads to lift the chest up. If the patient’s pericardium is very tense you may not be able to raise a “tent” with some Spencer Wells to make an incision. If this is the case, carefully make an incision with your scalpel trying to avoiding cutting the heart! Once the pericardium was open a large clot was released and there were 3 wounds. Then the cardiothoracic surgeons had arrived and sutured the wounds. You may need to clamp the internal mammary arteries if the resuscitation is successful, as they start to bleed. David Menzies did a nice post on his learning points from doing a thoracotomy-
4. Patient went to theatre.
5. Scenario ends in high fives as we are told he is discharged from hospital 2 weeks later. :o)
On the debrief one of the most important aspects to come out was that it can be useful to have multiple team leaders for the sick code red trauma patients. One will oversee everything and the others will have allocated smaller “teams” to manage, like the administration of blood products for example. I suppose you could liken it to a mini, mini, mini, mini (you get my drift) major incident where there silver and bronze command report to gold.Remember the role of being a team leader continues and is taken up by other senior clinicians as the patient goes to theatre and then onto the ICU.
The chance of survival from a ED thoracotomy is increased if a) the patient makes it to hospital and b) their heart never stopped beating c) it is a penetrating rather than a blunt injury.
There are multiple online blogs, papers and talks on how to do a thoracotomy, including this one from Trauma.org and this from Life in the Fast Lane. Read them, you never know when you may need to do it.
So my 3 Learning Points (although there are lots more) that are common to both cases:
1) The most difficult part is making the decision to do the procedure
2) “Sweat the small stuff…” Preparation is key. Be mentally prepared by visualising how you would do the procedure and go on the multiple courses available.
3) The role of being a good team leader and the importance of non-technical skills in managing sick patients. There are Trauma Team Leader courses, online posts on human factors, CRM (Crew Resource Management) and the role they play in managing sick patients.