Needle Cricothyrotomy
Perhaps the most useless medical skill still taught today
Back in the days on wooden ships and iron men…More than 20 years ago now, I was in paramedic school.
One of the psychomotor skills we had to learn and be signed off on as having performed it on a real person was cricothyrotomy.
If you are not involved in medicine, particularly emergency medicine, trauma surgery, or anesthesia/intensive care, you have probably seen a medical or even non-medical tv show where this procedure is performed.
You very likely have seen it done on tv so frequently that you must believe this skill is a regular occurrence, performed during life-threatening emergencies, where the patient cannot breathe and time is of critical importance.
The only truth to the whole even that we have all witnessed Hollywood or Amazon or whoever is producing the show is the part where the provider realizes that this procedure has to be done and is absolutely terrified. Mostly because this procedure is so infrequently performed and in the modern day is often only taught or practiced on a simulator.
A day long remembered
There is absolutely no way I will ever forget my first experience with this procedure. It was during my paramedic training. I attended a surgical training class led by an old school trauma and burn surgeon and medical legend, who since he is still living, I will refer to him as Dr. F.
There were approximately 10 people in the class. Nine (9) of them were brand new surgical residents and me (at the time a paramedic student.)
Dr. F gave a short and what I would come to know as an informally standardized lecture on when and how to perform a cricothyrotomy on a patient. It was certainly not a long-winded speech and I suspected he had given it to so many people, he had reduced it down to the bare minimum of words needed to convey the points he wanted.
After this speech, we would each practice this skill on what was at the time, a “high fidelity” surgical simulator. It was basically a rubber neck, with no head nor torso attached.
I had heard countless stories of the legend of Dr. F and being the only paramedic student in the class, to say I was terrified would have been an understatement. He was still working in the hospital and they had already named part of the building after him.
I had countless times walked past the picture of him in the burn unit next to Pope John Paul II. Dr. F is still a legend in the burn community, even after many of his contemporaries have since passed on.
Few of us will ever make the world-wide impact Dr. F continues to do and I am proud to have been taught this 1 tiny procedure from him.
I made sure I was last in line to the simulator. Being in a class with 9 surgeons, even if they were newly learning, was just scary. I felt like a little league spots player in a room full of pro athletes.
There but by the grace of God go I
As the new surgeons took their turn practicing their new skill, Dr. F offered many “constructive” criticisms…That was to say he was making many pointed and dramatic comments while emoting about how these new surgeons were going to kill everyone they ever touched because of their obvious inability. I have no doubt the critiques were meant to be humorous, but for us mere mortals in the presence of what was essentially a Saint, if not God himself, every witty comment cut deep.
The poor surgical resident in front of me was absolutely terrified by the time it was his turn. I could see him shaking in fear after seeing and listening to what had happened to his peers before him. I am not criticizing him, I was probably shaking too...Trying to remember not to do all the things those before me did wrong, so I could try not to make the same mistakes.
What a fool I was even hoping I wouldn’t totally mess up when it was my turn…
I never knew the names of any of my “classmates” for this event. I was essentially supernumerary. Not part of the group, just some random person permitted to attend and play with the toys too.
The surgeon in front of my was Asian, physically shorter than me, and as he stepped up to the simulator, with a perfectly laid out set of surgical tools next to it, he tried to put on the surgical gown and gloves in simulated sterile technique, and Dr. F was quick and sharp to point out that he managed to contaminate the sterile field in ways no person had ever before or was believed not to be possible.
This made our human sacrifice…Err..I mean “classmate” even more nervous, if that was possible. To his credit, he didn’t urinate or soil himself. I won’t say I would or wouldn’t have, but under such a withering barrage of negativity that would make a marine drill sergeant ask Dr. F to ease up a little, I could see it as a real possibility.
With his confidence thoroughly destroyed, my classmate picked up the scalpel on the instrument tray and took his position, forgetting to use an antiseptic to “sterilize” the plastic simulator. Dr. F was quick to point this out in the most unkind way imaginable. Which scared the would-be surgeon so much, he dropped the scalpel on the ground…Reflexively bending down to retrieve it from the floor.
”Oh, my God!” Exclaimed Dr. F, arching his back and covering his entire face with both hands…
”If you drop something it’s gone, you never pick up anything you drop off the ground!”
The new surgeon continued, so shaken, he seemed to make a mistake with every move or even hesitation he made, which was immediately critiqued by Dr. F.
I don’t know if that poor guy quit surgery right after that class, but I wouldn’t blame him if he did. By the time he had “finished” with the simulator, I couldn’t tell you even 1 thing he did correctly.
My last words as I stepped up to the gallows
As I stepped up to the simulator for my turn, I could see the look on Dr. F’s face. As if to say: “Well…Its your turn to show me a way to mess this up that I have never seen or dreamed of before…”
I don’t know why, but my first words were “I’m sorry sir, I am just a paramedic student, and have never done anything like this before…”
I don’t know what I had hoped apologizing for my future mistakes had hoped to achieve, but I must say I was very happy with the result.
Dr. F’s affect changed immediately. His face and tone softened, and he began to speak to me like a father teaching his child how to ride a bike for the first time. It was full on Mr. Hyde reverting back to Dr. Jekyll…
He walked me step by step through putting on a sterile gown and gloves. Performing the tasks himself, step by step as he stood beside me, so I could mimic him without seeing him do it across from me, then trying to figure out how to do it as a left-handed person trying to figure out the difference from a mirrored right-handed person performing a manual task.
I didn’t mention it, but I think he realized I was left-handed from watching me, because he made a conscious effort to do things left-handed too. He even showed me where I had to stand, which was different to the right-handed surgeons before me.
He coached me through every step, first demonstrating it himself, then me copying him. As he did, he gave me random pointers, like the common variations to the anatomy I could expect to see, how to manage them, as well as what tools were needed vs. what tools were superfluous.
I had never had any surgical instruction prior to this and I have never had any with the care and quality of Dr. F since. Including working in Cardiac, Vascular, General, Trauma surgery, as well as learning to perform C-Sections in OB/Gyn.
It was easily the best class of my life. Though I think my classmates certainly did not feel the same. They barely spoke to me before and certainly didn’t speak to me after…
Brave men and their proud ships
Nobody ever admires brave men and their proud simulators…
Following this simulation class, we then signed up for a time to go to the operating room (OR) in order to perform the procedure on real patients. Back in those days, no credit was given for simulation. Until you performed a procedure on a real patient, you were not signed off as having been instructed or competent to perform a procedure.
Obviously we did not all go on the same day as there were not 10 patients in a given week, much less a day, who needed a tracheotomy placed.
I did not make an error, the topic is about cricothyrotomy, not tracheotomy. Performing an actual emergent cricothyrotomy is perhaps a once in a lifetime event, for an extremely small number of people. (I boasted 3 before I realized it was a completely waste of time and effort.) However, I tracheotomy is performed frequently in hospitals everywhere around the world, every day. Most often in an intensive care unit, not even in an operating room.
Because of the nature of the procedure, it is possible to perform a cricothyrotomy (cric) and then convert it to a tracheotomy (trach). So that is how it is practiced to get it signed off. First the patient consents, then a student performs the cric, having then officially performed the procedure and properly documented, moves out of the way, while a more qualified doctor (surgeon or anesthesiologist) converts the cric to a trach out of sight of the student.
During my turn, Dr F was there to make sure I did it correctly. Like many people “operating” for the first time, I had destroyed the sterile field multiple times, which the OR nurses were quick to scold me for. (In fairness some of those times I could swear they were just tormenting me and I hadn’t.)
I made the rooky mistake of not cutting the skin deep enough on the first cut and unsuccessfully trying to get the scalpel blade in the previous superficial knife wound, while blood oozed everywhere, making it harder to see and even harder to work.
Dr. F kindly coached me through it. Explaining how to use gauze to quickly dab the blood just long enough to see before it covered what I was doing again. Re-dab the blood then do what I needed.
When it was time to actually insert the tube into the cricothyroid membrane, I couldn’t get it at first. I was not using enough force because, again in a rooky mistake everyone makes, I was afraid to “hurt” the person whose neck I just sliced open with a knife…(The irony of this is not lost on me, especially coaching many young surgeons through it myself.)
Dr. F said firmly “People are tough, you have to press like you mean it! Twist the tube in if you have to, use your body weight…”
Pop! was the noise when I essentially twisted the tube through the membrane. It took a lot of force, were it not for Dr. F telling me how, I would never have even considered using so much pressure. I was basically leaning my weight on the person and twisting this tube like a screwdriver into the person.
I of course asked “why don’t we just cut it with the scalpel?” to which Dr. F kindly explained to me “it doesn’t heal properly if we do that, blunt dissection is the preferred method.”
With my part done, I left the OR and Dr. F signed my papers.
I had officially done my first cricothyrotomy! Having done it once, especially with the kind instruction and encouragement by the legendary Dr. F. I was certainly ready in my mind to do it again…
The trach epiphany
Later in my career, after becoming a doctor and working in cardiac and vascular surgery as a “junior” doctor for nearly 2 years, my greatest mentor and supporter in Europe had helped me also simultaneously work in a cardiac anesthesia unit, so I could make progress towards getting the discipline of critical care surgery recognized on this continent. (Which I have never succeeded at, because of the political animosity between physicians and surgeons here.)
During my time working in the Cardiac Intensive Care unit, which was entirely staffed by anesthesiologists, we had to perform many trachs.
In my first experience I was even asked “do you want to be the anesthesiologist (aka work with the sedation) or the surgeon for this procedure?”
To which my response was to put on my sterile kit and wheel the instrument tray towards me. I was nervous using propofol, but I was very comfortable using a knife at the time. Now they are just potatoe and potato.
During that event, we were using a Seldinger method to perform a trach. The nice thing about Seldinger is, if you can do it to 1 part of the body, you can do it to any part of the body…I is the very same technique for inserting central IV lines.
But for a trach you still need a scalpel to cut the skin…
It was so much easier performing the trach compared to the cric! It was easier to find the landmarks. It was easier to make the cut in the skin. It was preferred to make a larger cut and it was easier to see and identify the anatomy. It was easier to insert the needle and guide wire. If it didn’t dilate properly, it was easy to just take the scalpel and cut the trachea directly.
Soon after I stopped using the Seldinger technique as it just added useless extra steps.
A true surgical tracheotomy can be done with only 4 tools in under 2 minutes, there is no need for the extra wires and dilators.
Why the hell are we not just teaching and doing trachs?
It is superior in every way. Easier. Less tools. Faster. You can actually see the anatomical structures to not accidentally damage something you really don’t want to, like the carotid arteries if your tools slip when you are leaning all your body weight into a tube you are twisting into somebody’s neck…
The cricothyroid LIGAMENT is dense connective tissue! It is the strongest of muscle tissue! Bluntly dissecting that is manual labor and it is surrounded by important structures, like the aforementioned carotid arteries and recurrent laryngeal nerve!
The anatomy doesn’t change with a trach, but with a trach, you can see it, it is not “firing blind” so to speak…
Sure some bookworm, who has never done this before or maybe saw it once in the most perfect conditions, will say you should be able to visualize the cric ligament, which is white, on a good day, without blood, which turns everything “pink on the inside” and everything starts looking the same...
The world is rarely perfect and if you are performing emergency crics and trachs, things are already bad, because you are in a “can’t intubate/can’t ventilate” (CICV) event, where somebody cannot breathe and is going to die in 4-8 minutes unless this is fixed!
Actual emergencies are rare. They induce a sympathetic response (adrenaline rush.) The body loses fine motor control. The brain can focus on individual tasks less well.
In an emergency, a person needs to be comfortable. To be trained to be calm. They need to remember simple things. They need to perform as few simple tasks as possible. It really helps to be able to see.
What they don’t need are complicated instructions and systems to remember and perform. Each step, each tool is a potential failure point.
Then, at the very end…it has to be converted to a trach anyway…So it is a surgical procedure to convert to another surgical procedure…Talk about superfluous!
So why does the cric or Seldinger trach even exist? They are in all respects antithetical to the CICV patient as well as the provider trying to save a life in an actual time critical emergency! By making it as complex and difficult as possible…
The answer is as simple as it is sad…
Because somebody who has either never been in such a situation and had to perform under life and death consequences, either read about it in a book or heard it from their father’s, brother’s, cousin’s, sister’s, former roommate. AKA somebody so far removed from the actual event, that the rendition they heard probably in no way resembles what really happened. They were also probably fed a diet of fear of “killing the patient if something is done wrong,” that they have an absolutely delusional understanding of the entire process.
Hold my beer
Just when you might be thinking: “That’s fucked up…How could it be worse?”
Let me introduce you to the most dumb-ass, window-licking, helmet-wearing, profoundly retarded cretinism, ever developed in Emergency Medicine…
The needle cricothyrotomy…
So let me start by describing what exactly a needle cric is…
Instead of using a scalpel, tube, and related tools to perform a “surgical cric,” some doctor (probably an emergency doctor if I had to guess…) in desperate need of an encephalanalectomy (surgical removal of one’s head from one’s ass) heard about a medical device called a jet insufflator. Which is often used by anesthesia to use high pressure air to ventilate somebody’s lungs.
This devise works by essentially using a high pressure air hose connected to a small diameter metal tube, which intermittently “shoots” a jet of air into somebody’s lungs.
This small tube is often connected to a needle or inserted supraglottic. In other words, about the glottis, (above the false vocal cords.) and air or exhalation happens passively. Which means fresh oxygenated air is shot in. Used carbondioxide laden air passively leaks out
You should be able to see the problem right away…We are performing emergency crics and trachs in a CICV situation. CAN”T INTUBATE and CAN’T VENTILATE.
In other words, we cannot get air into the lungs because something is physically blocking it! We cannot move air into the lungs…
Now logically, if you cannot move air into the lungs, because there is a blockage, how is air supposed to move out through the same blockage?
Apparently the proponents of the needle cric have not considered this problem of physics…
In the emergency setting, it gets worse…
They often do not have a jet insufflator and probably better for everyone involved, because “if you build a machine even an idiot can use, only an idiot will use it.”
So emergency providers, to include paramedics, nurses, doctors, NPs, PAs, et al. have come up with a way to Jerry rig a completely ineffective at best and likely iatrogenic solution…
Their plan is to take a large caliber intravenous catheter, penetrate through the skin and cricothyroid ligament, hoping beyond hope they don’t accidentally push the needle through the entire trachea, creating a tracheal esophageal fistula, which eventually can result in pneumosepsis or at worst an acute respiratory distress syndrome as stomach contents can now communicate with lung tissue. Followed by withdrawing the needle and leaving the soft Teflon catheter in place to function as an airhole…
So riddle me this Batman…
What happens when muscle is injured? You know like your low back pain or leg cramp?
If you said “it contracts in a painful spasm” you are our winner!!!
So what do you imagine happens to neck muscles and dense connective tissue (which are similar tissue to muscles) is injured by say…a sharp metal needle poking it?
Would it be fair to conclude it is going to spasm?
Who cares right?
Well…if you bend or crimp that small diameter Teflon tube you are trying to squeeze air into the lungs through…How much air do you think will go in?
Once that little Teflon tube is crimped, what is the plan to reopen it? Another needle beside it? Moving ever closer to the carotid arteries and laryngeal nerves as needed? This plan is breaking down fast…
But wait! There’s more!
Once this blind needle stick and Teflon pipe is miraculously inserted into the trachea, through the skin and dense connective tissue, you know the tissue I described above having to use the full weight of my body while twisting a tube to get it in…You cannot simply connected to a bag valve mask device as the procedure then calls for…
The next steps become you must rig a contraption made from parts of an endotracheal tube to connect to a syringe, to connect to the IV catheter, which we hope has not crimped yet, so you can squeeze air into the lungs…If it miraculously is still working…
But we’re not done yet!
When you start squeezing air into the the lungs and we are faced with that “can’t get air in” part of the CICV dilemma, where does all that positive pressure ventilated air go?
Pop! Goes the lung tissue!
Or as we like to say in medicine, pneumothorax…in Layman’s terms, a collapsed lung…
We doesn’t permit breathing…
Assuming any of this works and your multiconnection potential failure points don’t and your soft Teflon tube remains uncrimped…
Surgery could always fix your tracheal-esophageal fistula later if you survive…Plus, if you don’t survive, providers will say “they did all they could!” and nobody will be the wiser…
(Pro Tip: One of the clinical signs of a pneumothorax is when squeezing a bag valve mask gets progressively more difficult…)
So go ahead and tell me how you feel the difference between the resistance of trying to squeeze a lung-full of air through a tiny Teflon tube, and a pneumothorax…I’ll wait...
While your at it…Tell me how you feel the difference between the tube being crimped and a pneumothorax, I mean aside from “Can’t Ventilate” which is exactly the situation that kicked off this whole epic dumb-assery…
Still waiting…
Act now!
So what does all this half-assed Jerry rigging buy you?
Under the most ideal possible conditions, you will squeeze a few breaths of air in buying a few, aka less than 10 more minutes of air. Before the resultant pneumothorax and subsequent tension pneumothorax, cuts off all gas exchange and compromises circulation of the aorta…AKA shuts down the most important artery in your body…
But let’s be real for a minute..?
You are doing this in an emergency, during an adrenaline rush, with improvised tools never designed for what you are using them for…You just lived out your adult Lego emergency fantasy…
You might even be squeezing that ventilation bag quite rapidly, shortening your time before that inevitable tension pneumothorax…
Of course providing you didn’t totally penetrate the trachea into the esophagus and you are actually ventilating the stomach…
Yes, I know about enteral ventilation via anus (EVA), but let’s not pretend this is actually the plan…
Don’t take my word for it, set up an experiment…
1. Go to the butcher shop. Get yourself a steak and ask the butcher for a trachea attached to a set of lungs…They usually give them to healthcare providers for free or very low cost.
(Disclaimer, I have always gotten them for free myself.)
2.Now seal off the trachea so air cannot escape out the top, just like a CICV scenario.
3. Now run around your block a couple of times until you get the adrenalin rush of an emergency situation and the loss of fine motor control that goes with it
4.Plunge your needle through that steak. Remove it leaving only the Teflon catheter.
5. Connect your improvised contraption to that catheter and ventilate away…
I am not going to wait for you to tell me how it works, because I have already run this experiment numerous times for numerous students.
Needle cric is really as stupid an idea as it sounds here…
We can only ask “why?”
Because somebody decided this idea was “safer” or “easier to train” and published in a book back in the 1970s…
Because non-surgeons are forever trying to come up with the most convoluted and fucked u p ways to avoid learning or doing “surgery things…”
Because everyone wants to “do something” in an emergency without actually having responsibility for what they do…
Because emergency providers are too afraid to perform deliberate procedures that might help in the rare times they are treating the most life-threatening actual airway emergency. (CICV)
Because some desk-jockey somewhere needs to justify their salary and position by dreaming up the most monosynaptical fucktarededly complex way to avoid taking a knife, cutting a hole in somebody’s throat, and sticking a plastic tube in that hole.
By contrast…
A surgical tracheotomy takes only a scalpel, an endotracheal tube OR purpose built trach tube. (Literally 2 pieces of purpose built equipment) You don’t even need something to hold it in place, it stabilizes itself…Though you can tape or tie that tube if it makes you feel better. Contrary to inexperienced opinion, you don’t even need a guidewire or bougie.
That tube has a world-standardized, purpose built, large caliber, adaptor, to connect directly a ventilation device.
The hole is large enough to allow passive exhalation through it…
If you are a medical director or teacher teaching needle cric still
Please just stop…
You are not helping anyone and look like an imbecile. You might fool people watching tv. You might fool inexperienced colleagues…
But you are not fooling anyone who actually manages(d) CICV patients.
If you are managing CICV patients with actual effect techniques
Keep on Keeping on…Strong work.
PS
Yes I know some people call it “can’t oxygenate/can’t ventilate.” it is differentiation without distinction as lawyers say…aka, doesn’t matter in any practical way.