Surgical Cricothyrotomy Under Pressure

I have spent nearly fifteen years working in the emergency medical field. Most of which involved working at a busy rural county 911 ambulance service, but I also worked in such places as doctor's offices and emergency rooms. During that time, I worked my way up the ladder from just being a part time ambulance driver, to a seasoned Paramedic. As with all emergency medical workers, I have been on so many runs that it is hard to pick out which runs were harder than others; however, there are always a couple of runs that seem to stick out in my mind. One involved a three car accident with several fatalities and numerous seriously wounded. One of these patients became the recipient of my first "In the field" surgical cricothyrotomy. It was a very late summer night. Traffic on highway 231 in west central Indiana was very light, but three cars managed to find each other at the same time, on the same corner. Reports say that a southbound vehicle was across the center and drove into a northbound car. The third vehicle was heading north and never seen the accident coming and proceeded to drive into the first two vehicles. However the accident happened, it left a very big impression on many people for the rest of their lives.

My partner and I were on the first ambulance to arrive on the scene. It was a horrible sight to see. Barely able to make out that there were three cars amongst the tangled metal, we knew we were in for a long night. My partner and I split up in order to get a good assessment of injuries in a short amount of time. The first vehicle I came to was still occupied by three people. It was an elderly couple along with their 12 year old grandchild. They were on their way home from a late night at church.

The grandfather was the driver, and was obviously killed in the accident. His airbag had deployed, but even that was not enough to prevent the massive head injuries that he had sustained. The grandmother was alive, but in very critical condition. She was unconscious, but breathing. The child was awake and crying, but had received facial injuries that I suspect came from a mixture of flying glass, and hitting his head on the seat in front of him. I began to work on the grandmother while directing a fireman to hold manual c-spine on the child. I applied oxygen to the grandmother, and maintained her airway, while instructing other bystanders in setting up IV equipment for me and preparing a long back board to receive the patient on. After establishing two IV's on the patient and getting her moved to the backboard with c-spine in place, I sent her with other first responders to be put in the back of the ambulance. It was then that I proceeded to find my partner with her hands full at the second vehicle. It was also about this time that our second paramedic unit arrived. The paramedic was sent to the ambulances to treat and receive incoming patients that we sent to her.

The second vehicle was occupied by four people, and all were in critical condition. My partner had managed to put oxygen on two of them, and had placed three in c-collars. Of these patients, all had sustained serious head, neck, and back injuries, along with numerous lacerations and fractures. Although they were all conscious and awake, it was clear that they all were in dire need of medical help and treatment at a major trauma center as soon as possible. We summoned two helicopters with a 20 minute ETA to the scene. It was at this time that another responder reported to us that the two occupants of the third vehicle were killed in the accident. We began treating the four critical patients we had in vehicle two, and preparing them for transport by both helicopter, and our ambulances. After getting all four patients in c-spine, and starting an IV on each, we started sending them to the ambulances for further treatment and transportation.

I decided to make a quick check of the third vehicle, just to insure that the report I had received about the occupants was true. To my surprise, I found only one of the two occupants to be deceased. The other was unconscious and barely breathing. He had sustained massive head and facial damage, and his airway was filled with blood. It was obvious that this patient had serious skull injuries, as deformity and crepitus were just a few of the injuries noted. After getting assistance from fellow emergency medical technicians, I began to suction the patient’s airway and provide oxygen to him. After a few failed attempts at artificial airways like ETT and Combitubes, I decided the only way to provide this patient a patent airway was to perform a surgical cricothyrotomy on him.

I had spent years in EMS, and had only witnessed a surgical cricothyrotomy a couple of times. Somehow, I had always managed to dodge the bullet, so to speak. It just always seemed that I was never put into the position of being the one to do it. This time was different. This patient needed an airway, and I was the one that was going to have to provide it to him.

I started by preparing all of my supplies. A scalpel, dressings, tape, antiseptic, a 6.0 ETT, and a BVM were the supplies I would need. While my partner was providing whatever oxygen she could by way of BVM and OP airway, I was cleaning the area that I would make the cricothyrotomy. Once cleaned, I found the notch in the cricothyroid membrane and made my first incision. It was a vertical incision over the notch, and only through the first few layers of tissue, but stopping before cutting into the membrane. I then spread the tissue and made a horizontal incision between the rings of the cricothyroid membrane, and into the trachea. Keeping the incision small enough to maintain structure of the trachea, but large enough to pass an ETT into, I completed the needed incisions. I then held the incisions open with a small laryngoscope blade and passed the ETT into the opening. We then secured the tube with a dressing and a lot of tape, and began to suction blood out of the patient’s airway. Once we had gotten as much of the blood out as we could, we began to provide oxygen with a BVM by endotracheal tube. There was not much blood from the incisions, as the patients status had deteriorated during the procedure, and his heart rate was now only about 30 BPM. We quickly began providing the oxygen and his heart rate began to climb. The patient was then prepared for transport and was airlifted to a level one trauma center for further treatment.

It was later reported that this patient did not live throughout the night. His injuries were to severe, and there were just too many to sustain life. However, the remaining patients did all survive, and despite many severe injuries, reports that all patients should fully recover was a great relief to all of us that responded that night. I am sure that the families of those that died in the accident felt great losses. It was a tragedy that had occurred, and it left a scar on not just the families of those lost, but on all of us at the scene that night.

It is one of the literally hundreds of accidents that I have seen and responded to, and it is one that I will remember throughout my life. I still work as a paramedic today, but only on a part time basis. Emergency medicine was my life for the last 15 years, and I have decided to discover a new life outside of it for a while. I now own my own web site hosting and web designing business, and have found a new passion to keep me occupied. This now gives me the time I need to enjoy my family and to do some writing about my experiences. I hope to provide more incite into the life of emergency medicine in coming days, and to give people a better understanding of the trials that all of us in medicine face when we’re under pressure.