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A tale of a needle cric

6467hypodermic_needle

Hi folks

Here is a transcript of an interview I did with a senior colleague (Bill, cause thats not his real name) , in fact my mentor and teacher in retrieval medicine. He is a humble man and did not want the recording public but permitted me to post the written transcript. We hope you find it helpful for your own learning.

 

Me : “So tell us about this airway case you had, it sounds terrifying!”

Bill : “Ok yes it was scary. I was out in a remote clinic and a mum brings her 7yo daughter in with breathing difficulties. I was busy seeing another patient and she was first seen by the nurse who put her on a bed and when she laid flat, the girl stopped breathing”

Me : “So you were caught by surprise then?”

Bill : “Totally! The nurse shouted for help and I came running. I saw the girl on the bed, blue and making breathing efforts but no sounds of breathing. I clearly remember the mum of the girl screaming and screaming as I entered the cubicle. I went to head of bed and tried to give oxygen via a BVM but there seemed to be no air movement at all. I had no history, really didnt know what had caused this but the girl was blue and her breathing efforts were fading. I tried to intubate but couldnt see anything recognisable, thats when I thought maybe it was epiglottitis…”

Me : “Did you call for help?”

Bill: “What help? we were in a remote clinic. The nurse was only one else there. RFDS plane was somewhere else and best chance of getting to us was at least 1 hr away I thought. She was going to be dead in the next 5-10 minutes..”

Me : “So you couldnt intubate, couldnt mask ventilate..did you consider a LMA next? We have those Fastrach intubating LMAs..”

Bill: “Not in all the clinics and it wasnt available but a Classic LMA was. I thought no point if epiglottitis so I then realised I had to access the neck..that was the only thing that was going to save her. I asked the nurse to give me an 18G IV catheter, felt her cricothyroid membrane which was not hard to locate but it kept moving as she was still struggling to breathe!”

Me :” So what did you do?”

Bill : “I decided it was now or never so kept my finger over the cricothyroid membrane area even though it was moving slightly with each attempted breath and punctured the skin at the tip of my finger. It went in and I advanced, aiming towards the sternum then felt a give and a small release of pressure could be felt when I realised I had entered the trachea. I had no time to put a saline filled syringe onto the cannula, but it slid off the needle easily so I was fairly confident it was in the trachea..”

Me :”So what next..the cannula is supposedly in the trachea now?”

Bill: “There was no time to set anything else up..we had no pre-assembled kit..I just recall the sound of the mother screaming so loud behind me..she was not even screaming any words or a name..she just kept wailing and screaming in this desperate high pitched cry..so I told the nurse to pull off the oxygen tubing from the BVM and hand the free end to me and I just had the idea to place the free Oxygen tubing end directly over the cannula hub that I was holding with my other hand..”

Me : “had you been taught that by someone or read it somewhere in a book?”

Bill: “No to be honest. It was out of desperation. I knew I had to deliver oxygen but all the techniques I had learnt were going to take too long to setup”

Me :”So at 15L/min flow you manually held the oxygen tubing to the hub of 18G cannula..for how long on and off?”

Bill:”See we didnt even have time to put monitoring on like pulse oximetry so I just guessed..it was about 1-2 seconds on then 3-4 off..I was shaking with adrenaline and probably did it much quicker rate than that ..I cant really recall..But I knew it was working when the girl started to become more alert, less blue and she started moving her head and neck..struggling!”

Me :” Really?! What did you do then?”

Bill: “I was surprised by this as did not expect to now deal with an agitated patient! We did not even have time to get any IV access…I recall yelling at the nurse to draw up midazolam that we gave IMI..and that seemed to help”

Me: “So what now..you couldnt have been standing there doing that needle cric oxygenation for very long?”

Bill: “Well when the mother could see her daughter waking up and responding, she stopped screaming and was just then sobbing on the floor..we got her in a chair..her husband came in and helped her up. I could see the girl looking much better..we got monitoring on and the pulse ox reading was 95%! We activated the RFDS retrieval team and luckily they were not that far away, on another job. They immediately diverted to our location. Boy was I so relieved to see more help arrive through those dusty front doors! Yes I had kept doing the needle cric oxygenation for I reckon about 40 minutes until they arrived and we eventually were able to intubate her orally.”

Me: ” Fantastic save, mate! What was the outcome?”

Bill : “She did have epiglottitis and she made a full recovery. I had nightmares about that day for quite a few years afterwards..but now I wanted to share that story so that others might have something to go by in case a nightmare like that happens to them”

Me : “Thanks Bill..you are a legend!”

 

Here is a video of a demonstration of this technique

 

Thankyou to Dr Scott Weingart and Dr Tim Leeuwenburg for peer review of this article.

2 Comments Post a comment
  1. Northern Australia Para #

    Thanks for this post. Sounds like quite a situation. The video was fantastic too. Didn’t think it would be that easy and all using equipment I already have in my ambulance. Thanks again.

    May 5, 2014

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