You’re sitting in your station playing one of your coworker’s new High-Tech Advanced Video Game System on shift one day. It’s so freaking cool you think. Man, I gotta get me one of these. You’re just getting the hang of really splattering those aliens on the walls of the rogue spaceship when: “Doooo DOOOOOO!!” go your tones over the radio. “Attention Medic 39, Medic THIRTY nine! You have a medical call for a 37 year old man choking, not breathing, at 1236 Kicking Turd lane. Caller reports that the person is losing consciousness and that the Heimlich Maneuver is not effective” So, being that this is one of those “low priority nuisance calls” that some grumblemedics complain about, you get up and begin to saunter slowly to your truck. Wait, no you didn’t. You run out there like a man on fire with your gut hanging up in a knot. Airway calls suck. They’re hard, and the stakes are high as heck. You’ve got to know your crap and you’ve got to do it well. Because, as we all know, without the “A” for “Airway”, the “B” for “Breathing” and the “C” for “Circulation” tend to go buh-bye rather quickly. You hit the lights as your partner brings up the address on the GPS Computer. It’s about a 3 minute ride normally, but today the Gods of Roadway Construction are not playing nicely in the sandbox and it takes a minute or two longer. Along the way you get so many “Construction Worker Manly-Waves” that you think you might go apply for a job as one of them guys that hold the “Slow/Stop” signs. I’ve heard they get paid well. Probably better than we do and they don’t have to go unplug some guys airway before he dies. Man oh man, I can’t believe that we get paid so low… I mean “Dude! We’re here!” Your partner yells incredulously. “You gonna get out of the truck or keep day dreaming?!” Oh, yea, the call… You hop out and grab the front of the cot that your partner has loaded with your full complement of bags and the suction device (bless her heart – cuz in this scenario it’s me working with Gkemtb). She’s so thoughtful and cute (My brain needs to get back on the scenario here) and you wheel it into the supper club where people are frantically waving you inside. Hurrying now, you arrive at the side of a 38yo male laying supine with vomit coming down the sides of his face. His skin is turning a nice shade of pale blue and he doesn’t appear to be breathing. “I’m a nuse” says a lady doing the floor version of the Heimlich, or abdominal thrusts as AHA calls them. “Nothing is working. I think that he’s choking on a big piece of steak but I can’t get it out!” No time to lose here, the guy’s still got a pulse but he’s been apneic for quite some time now and that pulse isn’t going to be lasting very long. You quickly dig out your airway tool kit and get out an appropriately sized laryngoscope and Macintosh blade. Grabbing for the Magill forceps with your free hand, you peer into this guy’s airway. “Crap” you think. The guy’s got a piece of steak in his trachea deeper than you can grab with the Magills and it’s huge. How’d this guy get that down there? Wow. Thinking further down into your bag o’ tricks, you grab a 7.0 ET Tube and try to intubate the guy to push the steak down into the Right mainstem. It doesn’t work because the steak won’t move and you don’t want to negate your next and only option. “Get me the cric kit” you say confidently to your partner, the “nurse” and the crowd of certified bystanders. Even though you’re scared as all heck because this will be your first one that isn’t on a silicone dummy that’s been cut on more than a Goth… (nope, too mean) a cadaver in a Central American Medical school. “I’ve got a pocket knife, a lighter, some vodka, and a pen” says a drunk guy standing next to you. “I can do it, MacGyver showed me how!” You thank him for his ingenuity but decline his offer. Working quickly, you assemble the shortened ET Tube, the scalpel, the skin retractors, and the syringe. Remembering to prep the anterior neck with the povodine/iodine swab, you find the cricothyroid membrane by feeling approximately 2 fingers down from the thyroid notch. You slit the skin vertically down the mid-line of the next above the area and spread it apart with your fingers, and then the skin retractors. “Bleeaaarggrgeh” Throws up the “nurse” (who works on the Chronic Podiatry Unit at St. Crappy’s) along with several members of the Certified Bystander Brigade. “Wow, there’s more blood than I thought there’d be” You think… but you say “Hand me some 4 by 4′s”. You swab the area, see the membrane and open it up by stabbing it with the scalpel and twisting it in the new hole. After it’s opened, you insert the shortened ET Tube, inflate the seal bag, and ventilate. “Holy Crap it worked!” you say, when you were trying to only think it. The patient still has a pulse and everything. The time felt like hours, but all of the above happened in only a few minutes. After some bagging with high flow oxygen, the patient’s vital signs begin to normalize and his ETCO2 begins stabilizing. You leave the fire crews to clean up the bloody mess you’ve left on the floor (after all, following that dazzling display of paramedical magic, should they not be left to clean your leavings?) During the transport you start an IV, and drive lights and sirens to the closest ER. The patient begins to wake up, and you sedate him a bit with Versed to take the edge off of his consciousness. After the call, you run all freaking night and don’t get hardly any sleep, let alone a chance to speak about the call with your partner. When you finally get to sleep it comes hard and fast. You awake to your cell phone playing the tune that you thought would be peppy and fun to wake up to and set as your alarm but now makes your skin crawl when you hear it. You’ve got to get up, fill out your end-of-shift paperwork, shower, change, and get to your other medic job. That sign-holding gig is starting to look better and better these days. Your other medic job is for another city in an area with some stricter “Mother-May-I?” protocols that don’t hardly let you do anything without calling first, and then they deny pretty much anything when you do. It’s annoying, but it pays well and your kid’s looking like he might need braces soon. I heard they gave out an award to the dentist who devised the procedure for emptying an entire savings account through a child’s mouth. Maybe that’s a good gig… I wonder how long I’d have to go to school…. Anyway, while you’re sipping coffee and checking in your truck at the other job the tones go out for a male subject choking. You get there and are faced, unbelievably, with the same exact patient presentation you had the day before. Only this time, your stupid medical direction WON’T ALLOW YOU to perform any type of airway adjunct past intubation or the combi-tube. You try all of your other airway tricks and realize that your patient NEEDS his neck cut or HE IS GOING TO DIE. You’ve got the skills and the knowledge, and you can improvise the tools to cut the neck with the scalpel from the OB kit and by shortening the ET tube with your trauma shears. Do you do it and get in Really Big Trouble and harm your career? Or… Do you let the patient die because of EMS politics and the stupid protocol system? I know what I’d do, but I’d like to get your opinion.
