If you haven't already, you must watch the Cricothyrotomy Wee
If you want to have any idea what I am talking about…
Here is the comment that sparked this podcast
How to Plan Your Airway
- Take Account of the Whole Situation, both Immediate and Delayed Issues
- Pick the Plan the Fails Best
What is a Bad Option IMrHO?
- Anything through the nose without cutting the wires
What are the Good Options
- Cut the Jaw Wires, Prep for Cric, Perform Awake Fiberoptic Nasal Intubation, then sedate/analgese
- Cut the Jaw Wires, Prep for Cric, Perform RSI, then sedate/analgese
- Perform an Awake Cric
- Perform an Awake Trach
How to Cut Jaw Wires (Arch Bars/Wired Jaw)
There will be 2-5 wires connecting the lugs of the arch bars–you need to cut all of them and retrieve the wires. There may also be elastic that needs to be cut. Medical wire-cutters are best, diagonal cutters also work. In a pinch, any heavy scissors will get through these wires. Then grab them with hemostats and pull them out.
Not many articles in the literature on this topic, but here is one Jones RT et al.
I think it is essential to understand the hardware and how long it takes to cut the wires. So watch this wiring video and then this cutting the wires video.
Do Crics Need to Come Out Right Away?
Probably not
- American Journal of Otolaryngology 2000;121(3):195
- British Journal of Oral and Maxillofacial Surgery 2013;51:779
NAP4
In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises — NAP4 Study
Online Etiquette when Discussing Cases
- Just be nice
- Assume that there were factors you might not understand because you were not there
- Phrase as, “I think if I was in this situation, I would have…”
- If you are going to go nasty, make sure you have the knowledge base to comment (this last one does not pertain to the comment above)
Consent for Filming
- discussed in the podcast
Other Discussions of the Case (For Better or Worse)
Additional New Information
More on EMCrit
- Das SMACC Cric Station(Opens in a new browser tab)
- Cric Page
- Podcast 231 – How to Practice Cricothyroidotomy (Cric)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I’m not even vaguely qualified to comment on the airway issues (1st year medical student, though I was a medic in the military for ten years). A few questions: if you cut the wires, how much do you have to worry about some little piece of crap dropping back into the airway and making the situation with your “meta-stable” patient even worse? How much does your average ED doc even know about how to cut those wires without causing further problems? As far as informed consent, I would say it’s definitely a concern in this case. The question is not… Read more »
I trust that in good faith colleagues like Dr Weingart and Dr Strayer ( who filmed the video) would only post video material of patient care with written consent. I do not understand why this is being questioned or there is an assertion that this is unethical conduct. It is an open video post that has already been downloaded 200000 times and if there was any hint of trying to hide the video it clearly is gone. These doctors have nothing to gain by providing this learning material so openly except their reputations and so I accept it is done… Read more »
I am certainly not questioning Dr. Weingart’s intentions (to the extent one can judge character from listening to a podcast, he seems like an excellent human being). That said, there are some subtle, complicated, and important issues around whether or not this patient could give truly informed consent in this situation. My two cents: I think if Dr. Parekh or Dr. Strayer went back and spoke to this patient once he was no longer in extremis, not sedated, and definitely neurologically intact, and explained exactly what they were going to do with the video and why, and got the patient’s… Read more »
I think the issue was some thought the pt was consented prior to filming. I thought that was addressed in this podcast. The filming is for QA/QI. The consent to use publicly was after written consent when the pt was totally past their acute care phase.
Whoops, my bad- didn’t realize that you’d recorded another episode. Now that I’ve actually listened to it (::hangs head in shame::) I think the consent issues were handled just right, and the physicians in question did a nice job of balancing the patient privacy and confidentiality concerns with the obvious value of the video for education. This is still an interesting ethics case from a standpoint of how we balance those two issues, and I’d love to hear what people think about how that balance plays out in the FOAM world. Now that this kind of info is going to… Read more »
Jason the answer to your ? is very rarely do we ever have actual patients appear in the FOAM world. Even case descriptions are usually altered to make sure they are unidentifiable. My plan was to de-identify the video (which actually is not hard) even with the consent just as a matter of course. However, once Ram told me to publish the photo of him shaking the patient’s hand, that seemed unnecessary.
So what about the issue of broader distribution? Do you see a difference between FOAM and the more restricted world of medical journals? Note I’m not angling for any specific answer here- I haven’t formed an opinion about this and would genuinely like to hear what you think. Also, because I haven’t yet: thank you for posting this in the first place! It was very valuable to see this on a breathing patient rather than in a cadaver or goat lab.
A question to ask is, how would publishing on a podcast be any different than publishing in an open access journal? Dissemination pattern would be the same, if anything the open access might be easier to find via pubmed. See nejm Videos in Clinical Medicine for an example. These are also not behind a paywall.
Haters gonna hate!
Kudos for diplomacy and good education here, Scott.
With greater dissemination via FOAMEd come the trolls. I believe seeing is believing and this is why the video is so confronting to some. Personally I think the video is one of the greatest pieces of airway education in the last decade. it demystifies. “Knowledge dispels fear ” motto of Australian Parachute regiment training school.
I hope I would have the sense to perform an “elective” surgical cric in this patient. An unresponsive patient with multiple runs of V-tach with a jaw that is wired shut is, despite appearing “stable” is as critical as it gets. This patient is so sick that he was DEAD just a few minutes ago. Post-arrest patient are famously uncooperative, frequently combative, and often vomit. While many people really might “get away” with doing a nasal intubation, or trying to cut open his mouth, it would be pretty hard to defend a lost airway, filled with unsuctional vomit, while you… Read more »
I certainly appreciate the video for the valuable training tool it is. I am not a Doctor, but it is in my scope of practice as a Paramedic. Other than a cadaver, I have never attempted the procedure. Seeing it done live, by a higher level of care, will certainly stick in my head for that possible time in the future I may have to open up the cric kit on my unit. I did enjoy the vigorous conversation on the other thread, always good to hear the thought processes behind the Doctors I work under.
Nice work on the airways. Definitely faster than fighting with wires in unstable patient. Thx for great material. @rubbadoc
Thank you for the great, educational video, as well as the insightful comments Scott. I agree that prior to really doing *anything* to that airway, it would be prudent to cut the wires so that at least you could suction the patient should badness occur – regardless what approach you’re choosing. I hope it’s ok discussing the video here. A few points regarding awake fiberoptic nasal intubation. You brought up the time required for topicalization and the mandatory oral access to accomplish this. In my last institution, we would topicalize nasally using a 10% cocaine solution (0.5ml) and then inject… Read more »
Please understand that I am NOT a medical doctor. I am ‘just a’ Canadian Advanced Life Support paramedic. I take in CE opportunities such as what Doctor Weingart provides as well as opportunities such as those found on a couple of other valued sites provided by Doctors such as Doctor Amal Mattu and Doctor Mel Herbert. I value the many insights and even direct skills associated with my work in the field as many of these presentations are not only added information to anticipate what would be expected and what options are available for my patient’s, but also what information… Read more »
I don’t understand where the criticism of the decision making is coming from. Pertinent questions: 1. Does the patients clinical condition mandate an urgent definitive airway? Yes. 2. Is the oral route an option? No, not without implementing an unfamiliar step in the process, with equipment that is not readily available, which may or may not work. 3. Is the nasal route an option? No; without the ability to anteriorise the jaw/tongue, or control fluid in the airway, it is not a useful option. This leaves a surgical option, either via cricoid or tracheal route. In this instance, the expertise… Read more »
My only thought watching the original video was appreciation to those who performed and filmed it. I can’t say I’ve seen a video of a cricothyrotomy otherwise, and it’s a great learning resource. I in no way would have predicted the outcry this video prompted. It makes me wonder if there’s some innate psychological distaste people have for aggressive procedures such as cricothyrotomy. The guy is alive! They saved his life! I think there’s a strong parallel to IO placement. I’ve noticed that healthcare providers will attempt an IV or central line 20 times in a crashing or “metastable” patient… Read more »
Yes, yes, yes! This made me laugh out loud, as I feel it is incredibly accurate. I work in a single-coverage rural ED 2.5 hours from a large academic center and with traveling nursing and respiratory staff…which makes locating things quite interesting and no opinions or help in these situations until AFTER the patient is completely ready for long transport. This is how it totally would have gone down in my life.
Scott, Thanks for this podcast. I’m sure we all agree on many more points that we would disagree. I would like to own up to my comments. I was not able to review my posting, but now that you quote it I understand your concerns, and am not too proud to apologize. Sorry! My general rule is sleep on it before online interactions in particular, which I unfortunately bypassed, and am bypassing now for better or for worse…. I think i reacted as I did out of concerns about “presentation.” I will try to elucidate as best I can. I… Read more »
Dr. Weinstein, As a ABEM boarded ED physician I’d like to add that i fully agree with your comments. I see nothing rude or troll like about them (and they are certainly kinder than what I would have said had I gotten there first). While a cric is clearly indicated in a situation that involves irreversible upper airway distortion – be it massive angioedema or trauma – it is far from clear that it was the prudent next step in this situation. The critical word there is irreversible. I took care of this patient in residency (+ desaturating COPD –… Read more »
http://www.rcoa.ac.uk/system/files/CSQ-NAP4-Full.pdf
page 112, bottom left
I’ve listened to the emcrit podcast and other FOAM for a while now and one of the real positives is how constructive discussions and criticisms generally are. Sometimes a comment is made in a way that appears sniping or nit-picky just as in offline life. Occasionally the perpetrator is pulled up on their comment or tone. Rarely the perpetrator acknowledges this constructively and apologises. I don’t know you Dr Weinstein but I can’t help but respect that you aren’t too big to apologise. I trust that your integrity continues to repay you handsomely. With the benefit of reading your explanation… Read more »
Scott, Awesome video- a big thank you to the patient and those clinicians involved for making this available. I wanted to ask about the choice of scalpel for a cric. Obviously, whatever scalpel is closest at hand will work the best but if you had to choose- do you prefer a 10 or 11 blade? This came up on the Reddit thread and it’s an interesting detail to talk about. Some were saying you would get a more precise cut with an 11 blade but you may get more exposure with a 10 blade. However, some were saying that cutting… Read more »
I prefer 11, but it really doesn’t matter. Nor do I agree with the idea of a different gribe for both blades. The grip depends on where you are cutting. The difference is with the 10, you should be cutting with the blade’s belly and with the 11 it should be the tip of the blade .
Of all the ups And downs and arguments over airways…my exp from being all over the USA is that docs just can seem to agree on who intubates better, what procedure is right or wrong or done too soon or too late, or when to intubate for that matter. This case went well with no hickups and is of great educational value. The right choice is the one when looking back saves the patient. We make mistakes all the time and have luck shining down on us in the worst moments. At most facilities, the ED would have called surgery… Read more »
My comment is not on the case but on Scott’s approach to responding to the degrading commentary posted about the initial video. Thanks Scott for your uber professional approach. We, as a community, do such an outstanding job representing our specialty. Unless I just constantly miss the egotistical EM FOAM posts, I have to say that we are, as a group, very humble, very patient centered, very forgiving and very supportive of one another. I think that the EM based FOAM leads the pack–not only in FOAM itself, but also in how to represent your specialty publically. EM puts its… Read more »
Excellent discussion Great Outcome”and there was much rejoicing” “That which we do often we do well; that which we don’t do often we ought not do.” – Wayne B. Wheeler MD JD FACEP I can’t say I agree with Wayne and I believe our specialty has taken great leaps through simulation and broader discussion of rare and adverse events. I can say I have always been alarmed and usually have had breakfast in my hand or mouth when a colleague has asked me to “cut the neck” to a sum total of 5 times. Once I was in the car… Read more »
I agree that awake cricothyroidotomy was the best approach here. It is probably the approach I would have taken, any attempts at nasal access without ability to open the mouth for suction and to perform jaw thrust etc to aid tube passage seem far too risky with low chance of success. The issue of retrospective consent for filming has obviously been sorted here, but it very much depends on your institutions policy. I know that at my place it definitely would not be ok to film something on your personal camera/phone and then seek retrospective consent from the patient. All… Read more »
Hey Scott, I loved the cric video. I have trained for this, including cadaver training, but I have never done it live. I found it very helpful to see this video, particularly the effects of motion and bleeding on the procedure. Regarding criticisms & consent discussion: The patient had an optimal outcome, so what is the problem? Perhaps this is simplistic to cite “ends justifying the means”, but seriously! If I find myself critically ill, I want Weingart or another similarly-minded physician taking care of me. I don’t practice in the US, as such there are probably different practice patterns… Read more »
Great video. A good cric observation was needed in our world. I cant really think of another scenario where an elective cric would arise. Great job practicing Max Agg med.
Fabulous/fascinating video.
Perhaps lightweight, but I would have considered (and perhaps actually done) giving the patient some ketamine and maybe sedative before the procedure.
Re cutting the wires: In my experience, patients who have had their jaws wired for several days can loose quite a bit of mouth opening because the muscles of mastication tighten considerably. A few days can be required to regain normal mandibular excursion. So this patient could have been a very difficult oral intubation after the wires were cut. I think the decision to cric was laudable.
As a paramedic I found the cric video to be an incredible educational tool that I quickly showed to all my fellow coworkers. Outside of a cadaver lab I have never done a cric and resources like this are few and far between. Watching it in real time and on an actual patient was pure gold. I applaud Scott’s professionalism and also Dr. Weinstein’s professional response back regarding his original post.
Scott, Great video, and really good commentary. I am an EM physician in Detroit. I listened to your podcast, and I had a few questions: Regarding the preference of a cric over RSI, you mentioned that the cric enabled the ICU to maintain the patient without sedation, and thus avoid hypothermia, and facilitate serial neuro exams. But wouldn’t that be true for any post arrest patient with fluctuating conscious level? Maybe we should perform surgical airways on all of them? It’s a good thought process, but I think the rationale went beyond the wired jaw case, to any post arrest… Read more »
I’m an EM doc at a teaching hospital and prehospital medical director and I really appreciate the learning opportunity the original video combined with the back and forth discussion afterwards has provided. I’ve had conversations about this entire scenario with a wide variety of “airway managers” including anesthesiologists, EM docs, trauma surgeons, flight nurses, and firefighter/paramedics. They each have a different perspective and environment in which they practice. It’s been very thought provoking. There are two main take home points on this case – the first is the need to familiarize ourselves with dealing with jaws that are wired shut.… Read more »
Interesting and unusual case. Thanks for sharing. I am wondering if the introduction of the bougie would have been easier from a cephaled to caudal direction. In the video, I hear the concern about “resistance” and wonder if it is simply because of the orientation of the bougie. Regardless, thanks for having recorded the procedure in the acute situation. Great for after action review. Maybe we should chip in and get Scott (and John Hinds) a Go-Pro to strap to their heads! Where I work, rubber bands are used instead of wires. I guess it is a surgical preference/need. A… Read more »
I’m not being critical of doing the cricothyrotomy, but I think blind or fiberoptically guided nasotracheal intubation (without cutting the wires) was too quickly dismissed as an option at the top of this page. I think I would have prepped the neck, tried nasal intubation, and then done the cric if the nasal attempt failed.
Hey Scott. Great video. I think many will benefit from this “controversial’ video. Any thoughts on once the wires are cut how mobile the mandible would be? I can’t imagine this would be the definite solution, although I haven’t cut any wired jaws.
Brendan ( I’m an NP who works in emergency medicine) I think there has been a lot of constructive debate around this case. Ultimately, I think it’s really difficult to put yourself in the shoes of the physician “in the moment.” Who knows what one would have done, and I think it’s very easy to play “Monday Morning Quarterback.” Honestly, I think if you performed a cric, and can go back and see the patient (meaning they’re alive) then who cares. I’ll take all the nasty and derisive comments you can throw at me. One thing I’ve seen from not… Read more »
I thought Dr Weinstein’s original comments (I think they were his) were reasonable, blunt, but inoffensive. I don’t think labelling him a troll (and depicting this graphically with a banner) and a “Monday morning quarterback” is polite discourse. This is overly defensive, if not offensive in its own right. I was going to post comments along the same lines as Dr Weinstein (and having spoken to my colleagues, the same thoughts occurred to many of them) but didn’t because I anticipated an unpleasant response just like this. “If you are going to go nasty, make sure you have the knowledge… Read more »
Jo- The content of Dr. Weinstein’s comments were not at issue but I feel that some of his editorial phrases buried within his critique undermined the value of them and created the appearance of a troll. I don’t understand how statements like “good thing you were lucky” and “like a procedure created by EM docs” were helpful to establish his argument except to demean and devalue the other party. Dr. Weinstein’s posting most recently was entirely professional and with that in mind it appears that his initial comments reflected what happens when you post your first draft when you are… Read more »
Jo, clearly you object to a few things about this video and the case. Thats fine. Its your opinion. However I dont understand your objection in regard to ethical conduct here by the physicians involved. Essentially you are accusing them of unethical conduct. That in itself is unfair and ungrounded. If the physician’s employers and/or the family of patient or the patient himself wanted to sue /discipline over this recording, it would have been incredibly easy to do so by now and we would not have any video online to see. The consent process has been described in the podcast… Read more »
Scott I can’t agree more with you about this whole awake cric thing without hurting myself. I have an unrelated question I’ve wanted to ask you and this is as good a place as any. I have been a long time listener and have been puzzled when you mention which type of alcoholic beverage you are curently drinking on some of your podcasts. I am equally befuddled at the amount of drinking that goes on at ACEP and many other meetngs of Emergency Physicians. We all almost daily see disease, destruction and death as a direct or indirect result of… Read more »
To insinuate someone is a troll isn’t pleasant if that person felt that other learners may benefit for a counter view, provide alternatives and warn of dangers. Perfectly reasonable (although tone of original comment could have been slightly kinder and less accusatory, I guess). We can debate endlessly on who was first to cast the stone or first to be offended and reach no conclusion. Defence to offence is a natural instinct. And counter offence triggers a vicious cycle. I hope this will not be the case. This is a great learning platform which I hope we can preserve and… Read more »
This podcast makes me think of Time Bomb by Iration.
The Difficult Airway Society are revising their 2004 guidelines, currently in draft and the move is away from needle cric to surgical. This makes a lot of anaesthetists nervous, so having a training resource like this video I think is helpful regardless of the viewer stance on weather or not it was the right airway approach. It’s clearly far better starting a surgical cric with half decent sats rather than starting late after exhaustive other attempts at securing the airway have failed – you don’t need hypoxia as permission to do the right thing and get on to a surgical… Read more »
Hi Scott Thanks for your review of the professionalism required to make Social Media education fun and engaging for all. In Aussie Rules Football there is a common saying: “Play the ball, not the man.” Which basically means that you should focus your aggression on the subject (the ball) and try to win it, rather than attack / tackle the other players. We should spend more time discussing the topic less about the size, number or flavour of the other players. Online professionalism is no different to real time professionalism. You can be hard on the idea, but stay soft… Read more »
My name is Mike Capriola. I am an attending at a single MD coverage rural ED in North Carolina with an annual volume of about 37,000. I am a long time listener to your podcasts and an admirer of your show. I watched the cric show and felt it was an excellent learning experience. I also listened to the follow up show. I have had this nagging thought that this cric was unnecessary, but couldn’t figure out exactly why or how to articulate it, until now. In defense of the decision to cric the patient as opposed to cutting the… Read more »