Minh Discusses Three Examples of Airway Management gone Bad

 Three Cases of Airway Disaster

In this podcast short, Minh Le Cong discusses three airway disasters.

Case I

The first case Minh mentions is Just a Routine Operation: The Tragedy of Elaine Bromiley. Here is the incredible and saddening video:

The conclusions of the investigation and coroner’s report are chilling.
Case II

The second case Minh mentions is the Jankowski Case from Perth in 2001.

Full PDF Transcript is Here

This case really highlights how crucial quantitative ETCO2 is at every intubation. Further, needle cric failed 3 times before someone finally grabbed a scalpel.

Case III

The final case mentioned is the Rasmussen case; the best description of the case is at an medical indemnity site: Invivo.

 

Minh’s Acronyms:

Minh Le Cong

MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA,GEM, Dip AeroMedical Retrieval & Transport(Otago),Cert IV TAA Senior Lecturer ( Aeromedical retrieval), JCU School of Public health Tropical Medicine & Rehabilitation Sciences Medical Education Officer – Royal Flying Doctor Service, Queensland Section

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Comments

  1. Hi Scott. I was there at case III. Hence my mistrust of the needle- jet vent technique. Ultrasound might have been the only winning technique that day.
    The main points to take from case 3 is – history of airway problems us the best predictor. Do an awake technique if in doubt.
    For tricky cases ask yourself: what is plan A, B, c…. And am I the right guy for the job?
    Thanks guys
    Casey
    For tricky cases ask yourself

  2. Exceptional case studies Scott.

  3. Minh Le Cong says:

    thanks Scott for taking the time and effort to research and post these cases. You impress me for having gone away and looked into each case I cited.

    I deliberately mention those cases as to me they demonstrate a couple of salient points about emergency airway management.

    Firstly you must diagnose the problem early and clearly. Declaring the emergency loudly and giving it a name will galvanise you and your assistants into necessary action.

    Secondly the last two cases in Perth to me illustrate the non inferiority of the two techniques. IN the Jankowski case yes indeed needle cric failed and surgical cric succeeded. But in the Rasmussen case, surgical cric failed equally even at the hands of a specialist surgeon.

  4. Hi Minh, I was there in the Rassmussen case. The needle cric-jet vent resulted in massive surgical emphysema, which then made any surgical approach impossible.
    This demonstrates the non-benign nature of needle cric, you can make it worse with a needle!

    As for my”opinion” about the best approach – well, I think this falls into the category of “suck it and see”. Essentially, that is what my / our job is – we train, we garner experience and we make critical calls on a minute – minute basis. Ask me how I know when to change a vent mode, or certify a psych patient – I would have no answer. There are not clear algorithms in much of what we do, if there were we could be replaced by shaven monkeys! (see recent PE debate) we must be comfortable with some degree of uncertainty
    There are too many variables and imaginable scenarios to have a single “right way”, CICO remains a rare event. We should all have practiced these techniques and have a clue – so on the fateful day, we can proceed with some confidence – and trust our gut / gestalt / inner monkey….
    Casey

    • Minh Le cong says:

      Thanks Casey
      Humans are mostly risk averse creatures. If anything the recent PE debate and Wall Street market crash demonstrate that!
      There is little point in telling docs they gotta do it this way if they perceive the risk to be too great
      I have two cases I know of where surgical cric went wrong. One failure but eventual successful orotracheal intubation on reattempt using bougie and one death due to misplacement of surgical cric
      Does that mean I mistrust the scalpel bougie cric or standard surgical cric technique ? no….but I have to try to learn how to improve my chance of success.
      Same thing with needle cric.

  5. If only this post would force us to remember and trace the steps of Bougie cric at the back of our mind, this single post could save lives. And we owe our patients to have this locked up in our armamentarium, even if only theoretically, but ready when the time comes.

    This only shows how unfair to ask help from our anaesthesia colleagues on cases like this, they’re not trained to do this. And so, we should be.

    Amazing, graphic cases! Thanks!

  6. Matt Brown says:

    Another hot topic! Thanks again Scott.
    I feel more comfortable as a ‘knife-guy’ for two reasons. One is the simplicity of the equipment involved, and all reading this know that if there is going to be something missing or a ill-fitting connection, it happens when a patient crashes. Second, Oxygenation without ventilation in these already hugely acidic patients must cause some of them to go into PEA, even as we see the SpO2 rising. I guess it’s a hard thing to prove in what is a rare population, and I confess I haven’t looked for any cases of unexplained cardiac arrest following successful needle cric, but after placing the cannula, I would be just as desperate to get on and put in some real hollow plastic to start moving some air as I was in the first place.

    • i’m with you buddy

      • Minh Le Cong says:

        Thanks Scott and Matt
        I appreciate there is disbelief amongst yourselves as to the efficacy of the needle cric technique Heard and I describe. I also appreciate whatever I might offer as testimony to its efficacy that disbelief will remain amongst many until you are having to deal with the situation for yourselves and what you choose to do I totally agree at least prepare and train for it religiously.

        There is no reason why you could not perform both techniques in rapid succession, by placing a cannula quickly and provide apnoeic oxygenation and then handing that off to an assistant and then proceeding to do a more definitive surgical airway. If you train and drill this then little time extra will be added to the whole rescue procedure and additional safety will be added . Who would not want improved oxygenation prior to cutting the neck with a scalpel?

        I do not buy the arguement that scalpel techniques are simpler as you need less equipment. The needle cric uses : a needle cannula, oxygen tubing, oxygen supply and a syringe…thats my method modified from Heard’s as I have done it in real life

        The scalpel bougie requires : a scalpel, a bougie, an airway(ETT or trachie tube), BVM and/or oxygen supply.

        No difference in quantity of gear required for each technique.
        What is simpler to do you argue? Well I am sure we have all attempted multiple goes at inserting an arterial line or CVC or PIV with no thought given at all. It is somewhat a rite of passage for critical care training to stick lots of needles in all parts of the body repeatedly. Surgically you apply knife to skin less than needle to skin in crit care training. That’s just a fact of the life of an emergency doc.

        So it is illogical to conclude that you regard cutting the neck simpler to do than inserting a needle.

        Paradoxically despite the NAP4 report finding many failures of needle cric, the authors did not recommend removing the advice of needle cric from the difficult airway guidelines. You might ask yourself why that is the case?

  7. Matt Brown says:

    Minh, that’s a good point about the paeds, I hadn’t thought of that,
    I don’t really see it as a debate that anybody needs to win. A two-man team managing a critical patient in a pint-sized, pant-shaker chopper is a different ballgame to my academic hospital, where there are 5 guys and girls all gagging for the airway, safe in the knowledge that there are 4 back-ups should there be a hitch. Great podcast guys! I believe one learns best by forming opinions on a subject, making this a great forum for learning. Say hi to the newlywed Jase Peterken for me Minh!

  8. Minh Le Cong says:

    thanks Matt, I will pass on my regards to the newly wed Jason.
    Its coincidental but he had to tube a head injured 4 yo in a remote clinic a week before his wedding. Everything went fine but it is a reminder we should always regard all age groups in our thinking around emergency airway management and low resource settings
    I think Bruce Lee put it best when he taught “Your opponent decides your style of fighting..your technique must adapt to your opponent”
    How many of us would readily put knife to neck in the patient with impalpable neck anatomy and on therapeutic warfarin or dabigatran..even worse what if they had bled into their head from over anticoagulation and you failed to tube and were in a CICV/CICO situation?

    I am aware some would argue in that terrible scenario you have little to lose as the patient is going to die if you do not try. Yes thats true but I question how many of us would have the gumption to proceed in such a high risk setting. In reality as borne out by cases like the ones listed here, even highly experienced doctors , will not choose that high risk gamble and just keep trying to intubate or doing something else. We all think we would react differently but Martin Bromiley has some very wise words to caution us in his foreword to the NAP4 publication. I sometimes doubt even repeated training will change that human element. Paradoxically you could theorise that a robot programmed and equipped to perform surgical airway using real time USS guidance would do a better job as it would not hesitate or be deterred by blood, stress once activated.
    I agree I don’t think this is a debate that needs a clear winner. I applaud Scott and Cliff Reid for raising the issues of best practice in emergency airway management and trying to stimulate discussion and considered thought on the matter
    We do not have an accepted best practice standard in emergency airway training and it is left up to some organisations and individuals to push this agenda. The airway research literature is unfortunately predominated by attempts to demonstrate the efficacy of various new devices over older or other new devices. I am unconvinced any new device will ever achieve the HOly grail of emergency airway management. The debate will and should continue!

  9. Jason, RN says:

    Very compelling video, I plan to share it at an Airway class I am teaching this week with our Air Ambulance program. Airway training and practices vary so much from hospital to hospital, and EMS Program to EMS Program. I heard about an ER MD that told a flight nurse recently that Bougies are for wimps…two days later he couldnt intubate an obese lady? These discussions are wonderful and motivate myself and others to pursue excellence in our clinical practice. There really is no excuse for the first scenario, they were completely unprepared for failure, which in our field is unacceptable. Thank you.

    • the greatest warriors and tacticians in military history have always planned for failure. I don’t have much respect for a doc that would state, “bougies are for wimps.”

      • Minh Le cong says:

        Thanks Jason
        I agree with Scott. Thinking you are invulnerable from adverse events does not promote safety in clinical practice . Turning up to a gunfight with a knife (excuse the surgical airway pun) is a recipe for disaster

        I was doing my journal reading yesterday and came across this excellent anesthetic article that encapsulates the major points we have been debating. If you can access the complete article I would recommend it’s worth
        http://www.aaic.net.au/Document/?D=20101065

  10. Teresa Goodell says:

    I found the first video the most compelling lesson of these cases. I’ll remember it when teaching student nurses about the concept of “silence kills.” It’s a great example of that. Thanks.

    TTG, RN, CNS

  11. Hi there,
    I’ve just recently started reading this blog and downloading the related podcasts off iTunes. May I just say what an incredible resouce these materials are; the sterling work of Dr Weingart (and contributors) is deeply, deeply appreciated. I imagine that producing such high quality material must take a great deal of time and effort, for, in all likelihood, minimal remuneration in return. That this is so only heightens one’s respect and appreciation for all of you.

    As to this particular post, I’ve viewed the video concerning the unfortunate case of Elaine Bromiley and did a little reading online. I thought the following report (anonymised) of an independent inquiry, headed by Prof M. Harmer, President of the Association of Anaesthetists of Great Britain & Ireland, may be of interest:
    http://www.chfg.org/wp-content/uploads/ElaineBromileyAnonymousReport.pdf

  12. Jim, CRNA says:

    Thanks for the hard work you put into producing such quality podcasts. Know that you positively affect patient care on a global scale, far transcending your ED.

    • Tim Suharto says:

      Hey Scott,
      love your stuff. I think you are doing an excellent job getting rarely discussed issues out in a really accessible forum. As an Anaesthetic registrar in Sydney with a special interest in critical care and trauma these podcasts inspire those of us working at the cold-face to think more deeply and be more prepared. It’s someone’s mother, father, son and daughter and we should be at our best. So thanks.

      • Thanks so much, Tim!

      • Minh Le Cong says:

        May I echo Jim and Tim’s appreciation of the work you put into EMCrit , Scott?
        I do not know how many times readers have provided feedback on the practicality of your teaching to real world clinical practice but wanted to do so here.
        I learnt the concept of delayed sequence intubation from Scott and had the perfect opportunity to apply it to an actual critical patient on retrieval last Friday night.
        The lady was in pulmonary edema and going south despite NIPPV which she did not tolerate at all well. Anyway I used DSI to good effect and it goes to show the power of internet based learning and discussion forums and podcasts to real cases. I did not go to any conference, or hospital or do a 2day workshop to learn this. it was all through EMCrit . keep the faith, bro.

  13. Minh Le Cong says:

    Scott, I am not sure you are aware of this airway management case in 2006, after Elaine Bromiley’s . It’s worthy of review by all airway practitioners as it has important human factors elements.
    http://www.scotcourts.gov.uk/opinions/2010FAI15.html

    • Great additional case. Seems like equipment familiarity also played a role in addition to the human factors failures you mention.

  14. ColoradoanMD says:

    Truly wishing for more detail about the first case. What were the induction medications, and why did she not begin spontaneously breathing after 1 or 2 minutes. Did the anesthetists use neuromuscular blockade with the propofol shown in the ‘reconstruction’ video? Other than providing a message of, “Gee, you really need to be prepared and always thinking of worse-case scenerios,” what’s the value of this video? There is no relevant detail allowing me to evaluate my own practices.

    • I think the link immediately following the video (investigation/coroners report) has all of that info and the take-home messages. Let me know what you think.

    • Minh Le Cong says:

      I understand the desire for more detail in cases like this. It is our disbelief that elective surgery and anaesthesia can result in such tragedy that makes us want to search for answers. We would like to be able to trust that our own practices would not lead to such results

      I think this misses the point. If an air line pilot tried to keep landing at their primary destination airport and due to bad weather kept failing AND they kept trying to do that until they ran out of fuel and crashed killing multiple passengers WHAT WOULD BE THE LINE OF ENQUIRY?
      I think it would go along the line of why did the pilot not switch to their alternate landing point and change course?
      Not about what technical point/decision could have been made to improve the chance of successful landing at the primary destination.

      Three doctors in an elective surgery , one of them an ENT surgeon. The patient is unable to be adequately oxygenated and intubated for a long period of time(21 min I believe) and no surgical airway attempt is made. This is in an otherwise fit and healthy 37 yo woman with no acute emergency condition.
      Thats got nothing to do with technical skill. Thats got to do with how we behave in stressful failed situations we are not used to .

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