As part of Airway Day, we also go to practice doing cricothyroidotomies (you may know them as tracheotomies, though technically cricothyroidotomies are a subtype of tracheotomies). Trach generally refers to a surgical tracheotomy which take longer and are usually left in longer. In that a surgeon will cut between the Adam's Apple (if you have one) and breastbone, separate the muscles, split the thyroid, and cut through the tough cartilage of the windpipe. In the crich, I swear it felt like all I did was grab a scalpel, feel above, feel below, and oh so delicately jab that sucker in the soft spot of the crichothyroid membrane. (You can also do this with a needle and catheter instead of a scalpel.
We did this on dummies of course. Though I think if I were going into emergency med we'd have to practice on cadavers too. Shudder. The dummies have this jelly-ish plastic "skin" wrap that goes around their necks and velcros together in the back. You can see where other people cut, so you have to keep taking it off and rotating it after someone practices. When it's your turn, you feel for the thyroid cartilage (aka Adam's apple, and yes, even girls have it though it's harder to find), then you feel below for the cricoid cartilage. In between should be a soft spot the width of a finger--that would be the cricothyroid membrane. You can try this on yourself, but for some reason it really freaks me out. I think I'm scared my finger will go all the way through. Then you hold the cricoid cartilage steady, get your scalpel, and make a small vertical incision through the skin and membrane. Some surgical texts teach to cut horizontally then vertically, but the newer thinking is just to cut vertically and be done with it. If you wimp out your first go through, just keep going over it a little deeper until you're in the airway.
Next you have to have a clamp or your finger hold the incision or else it will clamp up. Then hopefully some helpful person will hand you the tube to slip in there and voila, an airway!
Here's a fun part of medical school: It's very easy to forget that step, and nearly all of us did. The first or second guy made the incision, then reached for the tube without holding it. He then looked around and, thinking no one saw him, saw the cut on the neck wrap and slipped his finger back in like he'd had it there the whole time. The kicker is that when I made my cut and forgot to do that, he's the kind of guy who would (and did) yell "OOOOHHH you didn't hold it! You're patient is dead!" I wanted to say "Look here jackass, killing a patient with no one watching is still killing a patient." but he's the type of guy who had already gotten a vanity license plate with "Dr. LastName" on it, and I figured his self-esteem was fragile.
Ok, so we did demonstrate a little on each other.
So that's what you see all the time on TV; someone is choking, has a bee sting, is talking to loudly at a restaurant, and some DIY-er takes a steak knife, straw, ballpoint pen, insert whatever other filthy rigid hollow instrument you want, and saves the guy by jamming it into his throat. Alright, now I'm trained, so I had to ask the question:
"Um, so when would I be able to do this in public without getting arrested or sued?"
Unfortunately for me the answer was, "Well, never really." Dang it. Real indications for it are
- Major injuries to the face or jaw, such as multiple fractures of the jawbone or severe fractures of the patient's midface. In many cases of facial injury, the airway is blocked by broken teeth or fragments of bone from the jaw and cheekbones.
- Burns in or around the mouth.
- A neurological disorder or damage that has caused the patient's teeth to clamp shut.
- Fractured larynx. Fractures of the larynx most commonly result from automobile or motorcycle accidents, but also occur in cases of strangulation or attempted suicide by hanging.
- Larynx swollen shut by allergic reaction to bee or wasp venom.
So could I do this? Yeah, I feel completely comfortable with the procedure now. Would I do this? Hmmmmmmm. I'll take that on a case by case basis.