Thursday, September 17, 2015

What comes after the Heimlich maneuver?

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyone's skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aaron's Tracheostomy Page and it bills itself as "The Internet's leading tracheostomy resource since 1996."

Here's an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers don't need an airway in a hurry and they don't bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwell's outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?


artiger said...

Well Scalpel, now you've done it. Prepare for some posts from people who think you can pick up any skill from watching internet video, as well as being accused of being a member of the secret society of medicine that is cloaking our methods to prevent patients from handling all of their problems without any assistance from us, training and judgment be damned. Autonomy is certainly important, but unless a patient can perform a self-cricothyrotomy, it doesn't enter into the equation here.

Vamsi Aribindi said...

Hmm... I don't know if bystanders should attempt anything, but that paper on inexperienced medical students and resident doctors failing made me think of this:

The Chief of Infectious Disease at UCLA borrowed a pocket knife and a pen and performed field tracheotomy, while the director of the CDC monitored the pulse. I bet neither of them had so much as seen the inside of an OR in 3 decades. I suppose they just don't make doctors like they used to.

Vamsi Aribindi

Skeptical Scalpel said...

Artiger, I hadn't thought of the repercussions from the doctor yourself at home crowd.

Vamsi, good story. Thanks. They were not your typical bystanders.

The Doctor Isn't In said...

SS I can't count the number of times I was called into either the ED or the OR to fix up one of those "but I had no choice he was going to die otherwise" Crychs only to find that now the person was voiceless had a tracheal/esophageal "fistula" or was already bilaterally full of blood in the lungs. And these were supposedly "trained experts"
Lets be realistic the Good Sam act allows a layperson to assist someone in emergent danger and protect them from liability IF (and this is the important part) they have had training in the procedure. Watching Grey's Anatomy on TV or ER or reading an article isn't really "training."
A layperson who has never had a CPR class who decides that he can take both hands form a giant fist and crashing it down on the sternum is a good thing because it happens on Marvel Comics is both dangerous and insane.
You and I both know that what we do is at BEST difficult and when life is ticking away thrusting a Mont Blanc into an "approximate area" isn't going to give any value to the patient even though the responder can for years tell any story he chooses about the event.
In reality a far better approach is to go into the bar and get as much ice as you can and pack the victim from head down in as much as you can get. You actually have a better chance of allowing them to survive then attempting a pen-otomy.
Dr Dave

Skeptical Scalpel said...

Dave, thanks for the reality check.

Les said...

Jane E Brody doesn't seem to realize that the cricothyroidotomy instructions she links to are taken from The Worst Case Survival Handbook by Joshua Piven and David Borgenicht. The book also includes instructions on "How to Evade a Robot Enemy" and "How to Escape an Alien Abduction" because you just never know....

Skeptical Scalpel said...

Les, thanks. That's some fine reporting by the NY Times.

DavidP said...

If the Heimlich maneuver fails, I was taught to lie a conscious patient on the ground face down and give a really solid shove on the back. Cutting into the patient is way outside the scope of first aid training and could a non-doctor/non-paramedic could legitimately be sued for any harm resulting from untrained cutting.

William Reichert said...

I would also add that a struggling patient might make this surgery
a lot more difficult than otherwise. A non struggling patient might suggest that the outcome is already in doubt and in that case
you would incur the wrath of the malpractice lawyers.

William Reichert said...
This comment has been removed by a blog administrator.
Skeptical Scalpel said...

David, I think back slaps would be preferred maybe even before the Heimlich and certainly after if they had not been tried. I'm not sure about Good Samaritan laws in every state, but I doubt a plaintiff could win a case if the victim would have died anyway.

Post a Comment