Thank you for another outstanding talk. What a perfect distillation of the concepts you’ve been teaching that have saved so many lives. Unfortunately, the vast majority of physicians outside the FOAMed community seem to believe that every patient deserves a trial of PEA arrest prior to cricothyrotomy. We know better, and must still do the right thing regardless of the emails that follow.

Scott, you are incapable of doing a ‘cast and not teaching me something. As I scanned the show notes before listening, I thought to myself: HOP killers, difficult airways, crics: now HERE’s a ‘cast in my wheelhouse. And then I listened, and I learned. I’ve never done inline waveform capnography when doing bag mask ventilation. For some reason, I’ve had a mental block whereby I’ve always reserved the inline capnography for post-placement of either ETT, SGA, or cric. But as you rightly point out, when doing BMV, it’s tough to tell by just feel and watching chest rise how successful you are at ventilating. Thank you for that tip.

NONE of us will ever get enough physical practice at doing crics. We can and must endeavor to get as much physical practice as possible in the sim lab and the cadaver lab, but it’s never enough to completely remove the fear that makes people start crics too late. The one thing that can do that is disciplined MENTAL practice (visualization) on a daily basis. It’s gotta be part of a pre-shift ritual.

Great case that gave me flashbacks to my most recent cric.

A couple comments,

1. Fortunately, not all hospitals look at a surgical airway as a Sentinel Event. In fact at my facilities I have never been criticized for my airway choices or performance. Even my most recent “cric”. Which turned out to be a supraglottic or sublingual airway, which was necessitated by comlete calcification of the cartilaginous and membranous structures of the neck.

2. Not all EMS medical directors consider a surgical airway a failure. Howeve, many medical directors are familiar with the “hero” mentality of some ems providers that affect the decision to perform a surgical airway. When 1 in 100 provides account for >80% of your surgical airways, well, you have to question the decisin making.

3. As was pointed out earlier, we will never get enough experience with surgical airways. This is especially true of HEMs providers. Most HEMs providers manage <15 airways a year which is barely adequate for "normal" airway management, much less the difficult airway.

Thanks for the awesome 'cast. See you at SMACC

Mike

Wow… great podcast!

I can’t agree with you more.. it’s a dying skillset that scares the heck out of most providers. The only way to be ready is learning from situations like you described, mental preparedness, and hands on practice whether that be simulation or by cadaver. The latter is hard to obtain for the average provider.

While I’m genuinely heartbroken that I probably won’t be able to attend SMACC; however, I was able to attend CCTMC this past year and participated in the anatomy lab, in which Bill Hinckley (who’s comment I saw above) lectured on Cricothyrotomy. Forgive me if I misquote you Dr Hinckley, but “we all have the best simulator available between our ears.” Whether or not your intent was to create that same mental practice/imagery, you did a masterful job! You could do a whole series on medical imagery education! I felt like I was there experiencing it first hand… Keep it coming!

RE: 141 (airway at Janus General w/ 45 y/o male w/ sarcoid).

Extremely nicely done.

I was sorta on the fence about re-upping for CME membership until I heard this one. Got on it today.

Jim Carroll, CRNA
Wisconsin