Friday, 19 September 2008

Can I get an airway!

Back in January I was on set of RRV shits and on this particular day I was asked if I could incorporate a special event as part of my shift. It was a horse racing event and they regularly need us to be on duty for the jockeys and spectators. After the event I would see out the remainder of my shift on the RRV. My crew mate for this event was a newly qualified Technician and hadn't covered this before. It's money for old rope really as most of the time nothing much happens and getting time and a half seems too good an opportunity to miss. After having our free fry up we headed over to the 4X4 and waited for the racing to start. 'Much happen here?' he said, 'Nah, a couple of fallers but nothing too serious, the jockeys are usually up and about by the time we get to em and they usually tell us to F*** off!'. A couple of races later we were in the other 4X4 when two horses collided, one of the jockeys was kicked in the head in the process and knocked unconscious. When we got the track there were two horses on the deck, both extremely distressed. The jockey was semi conscious. While we were attending to him the vet came over and started examining the horses. One had a broken neck and the other had a broken femur, the decision was made to put them down there and then. The jockey was now coming round, he heard what was happening and got up. Oh well there goes our C-spine control! There was no stopping him, he was sobbing his heart out at the prospect that his horse was now going to be destroyed. There was no other option. The jockey was lead to an awaiting field ambulance, under protest, to be examined at the medical room by one of the Dr's. He seemed relatively uninjured considering he had been booted in the head by a horse. Thank god for helmets!

The rest of the event was non eventful but my crew mate did say 'I thought nothing ever happens at these events!', 'Oh well it must be me!' I replied. I dropped him back at the station so he could go home. I, however had to remain on base to finish my shift.

The station was not the one I'm usually based at even though it is less than a mile from home. I know all the crews well as I used be Patient transport there.

I was sitting watching the TV and slowly getting bored, I had been there for 2 hours and hadn't got a call. A crew came in and after a bit of friendly banter the station alerters went off and out they went, it was a Cat A breathing difficulties. I sat twiddling my thumbs again. Next thing the red phone rang, 'Can you go and back up a crew with a cardiac arrest secondary to Anaphylaxis!' A job at last! Better get a wiggle on to this one. It was now dark and the job was about 5 minutes away, as I pulled in off the main road I could see the ambulance at the end of the cul de sac. The crew were working on the patient. The Paramedic had just put in an Intraosseous line into the patients leg, using the EZ-IO drill and the Technician was bagging the patient. I could see that patients face had swollen considerably. I grabbed my intubation roll and went straight over. 'Is your airway good?'I said. 'I think so' said the Tech. 'Let's have a look'. I could see that the patient's tongue was protruding out of his mouth, in fact it was nearly the size of my boot. It was rapidly swelling before us even though he was in cardiac arrest. The Tech doing CPR and the Paramedic was administering adrenaline at this point. I tried to bag the patient but felt lot's of resistance in the patients chest, due to the fact his lower airways were now so constricted. I inserted the laryngoscope and tried to sweep his tongue to the left in order for me to get a view of his vocal cords so I could insert a breathing tube (known as intubation), nothing! His tongue and airway had swollen so much I couldn't see a thing so I opted for a surgical airway. I got out the quicktrach (pictured above) and before opening it I located the landmark (the insertion site) on his neck. With it in my hand the other Paramedic also felt for the landmark, just before I inserted I had another feel for the landmark and to my amazement at least 3cm of fluid had accumulated within the tissues. I found the site again and inserted it into his neck. I connected the catheter mount and then the BVM and started ventilating, I had a quick listen to his chest to make sure air was going in both sides, it was. Now we had to move him. The vehicle had to be moved as well, problem was when it was being moved I was putting in a 16g IV into his hand and the vehicle was the only source of light, when the vehicle moved, the side light went out briefly but thankfully I managed to get the line in. I hooked up some fluids and ran it wide open. As the crew got the patient on a scoop stretcher, onto the vehicle trolley and then on board, I quickly cleaned up the scene. It was like a mini war zone. I locked up the 4X4 and found the wife, I helped her into the front of the cab. With the crew in the back still working on him I then drove them into hospital. The wife was numb and in obvious shock. She was silent on the way in. At hospital another crew opened the back doors and helped us unload. The anesthetist put some adrenaline down the surgical airway as there was now some resistance to ventilation, this seemed to work well. More IVs were sited and massive volumes of fluids were infused. The hospital staff worked on this guy for a good 45 minutes but decided it was no good. The patient was declared deceased. Even after the resuscitation was stopped the patient was still swelling up, I have never seen anything like it.
It was quite deflating, we tried our best but nothing worked. As it turned out the patient was on beta blockers which can block the effects of adrenaline. We carry a drug called glucagen which is one of our treatments for hypoglycemia, it could have been used as it has inatropic effects (basically raising blood pressure) and is an antidote for beta blocker poisoning. Unfortunately it's not in our guidelines for use in this situation. One of the Dr's mentioned it but it was too late. I may in the future use it for these sort of patients preferably before they go into cardiac arrest but will call the hospital to get the OK from one of the Dr's.
To top it all as we were leaving scene I hit a parked car, although I wasn't aware of this I did hear a bang as we were leaving but felt nothing. I thought it was one of the crew shutting one of the doors. It turned out that someone (probably me!) left one of the external side doors open and it hit a car. I only found out when I spoke to PTS member on base who said a guy had turned up at the station telling him what had happened. He was fine about it as he knew how serious the job was. I filled out the various insurance forms and as far as I know his car is now repaired.
Basically there are two types of surgical airway, needle cricothyroidotomy and surgical cricothyroidotomy. Paramedics are routinely trained in the needle version. This is where you insert a large bore cannula through the windpipe, connect O2 tubing and turn up the O2 full blast. There should also be a hole in the tube or a device with a hole (such as a three way tap). With the O2 turned up we then place a finger over the hole for one second and then release for four seconds. This is known as jet inslufation. This will buy you minutes as you can't effectively ventilate a patient, just oxygenate them. The patient then retains Carbon dioxide, they need a definitive airway.
The surgical version is usually performed with a scalpel and a shortened endotracheal tube is inserted, this protects the airway from vomit and blood etc. To complicate matters further, where I work we are fortunate to have surgical airway devices like the one pictured. This is sort of in between the two types of cricothyroidotomy. On the plus side, you can insert it quickly and once in situ you can ventilate someone. These devices are good when there is a complete upper airway obstruction. On the down side, you can't secure the airway and protect the lungs from vomit or blood.
But let it be said, this is an extremely rare procedure to have to carry out, perhaps once in your career rare. There are probably thousands of Dr's who have never performed this and some never will, it's that rare!
I assisted with one when I was a Technician, in fact I actually suggested it. After that job the paramedic said 'You and your bloody right ideas!'


Anonymous said...

typo "shits" haha. I love the blog well done and best of luck in your career

mac said...

Your not bloody wrong! I did a spell check, couldn't believe it! I think I've rectified it. Note to self, Must do better.