Tag Archives: Airway management

Tac Technique Tuesday!

We’ve recently looked at wound packing as one of the more effective methods to control hemorrhage.  This week let’s look at surgical crichoidthyrotomy as an airway option in tactical environments.

Surgical airways are recommended by both C-TECC and CoTCCC relatively early in the airway management flowchart, below NPA and positioning and above placement of an ET tube.  Unlike the civilian setting where equipment is readily available and one monitor/patient is the norm, the Tactical Field Care (TCCC) and Indirect Threat Care (TECC) phase recommendations recognize that time and equipment constraints may not allow us to use tools like ETCO2 waveform capnography to confirm tube placement, or even Direct Laryngoscopy or Video Laryngoscopy to place a tube.  In those settings, a scalpel-bougie crich may be your best bet for definitive tactical airway management.Crich

Watch this video of Dr Dennis Kim demonstrating a very deliberate surgical method on a cadaver, and think about doing this in a dust-storm in Iraq (or a blizzard in the BC Alpine), or in the pitch black with IR illumination and NVG’s while balancing the equipment on the cleanest surface you can find, your jumpkit or your lap.


If they are done quickly and smoothly out of prepared stripped-down kits they are significantly easier and safer than ETT placement.  There is no technology to depend upon.  No Laryngoscope, no waveform capnography to confirm placement.

Equipment is simple: A scalpel, a bougie, and a cut down #6 ETT with 10 ml syringe attached.

If necessary, make a vertical incision to mark your midline.  Cut the skin laterally across the neck to expose the crichoid membrane.  Pierce the membrane, extend the incision and do not remove the scalpel.  Insert the bougie over top of the scalpel blade into the tracheal lumen. Remove the scalpel and pass the tube over the bougie.

The technique starts at 2:30 in this video!


If you compare the two techniques, you’ll see that the scalpel-bougie Crich is the easier, safer method.  By keeping the surgical tract open continuously, via scalpel, then bougie, then tube, there is a major reduction in the chance of losing the tract.  Losing the tract in the dark, in the dust, in the snow, isn’t an option. This is your last ditch airway procedure.  It must work!


Tactical & Medical Decision Making

Not all tactical tools are tangible, some are cognitive.

This runs to 20 pages including bibliography, but it describes several essential skills that any emergency medical provider needs to have.

The OODA loop is something that we use in the classroom in order to give students a model of constant reevaluation of the patient condition, the conditions they’re operating under, the courses of action open to them, and the most efficient treatment, movement, or evac options.

To truly master Emergency Medicine, much less the tactical environment, you need to understand the OODA Loop. Yours should be tight and fast. But sometimes you need a far quicker response, and only training and simulation can build instant RPD through what this author calls tactical decision games (TDG) or decision making exercises (DME).

This is the core of current EMS education.

Simulation creates an experiential learning environment where the students can develop that mental database of Action : Response for everything from snoring respiration : jaw thrust or massive extremity bleed : tourniquet intuitively, not just academically. Where they can find themselves suddenly on the ground applying a tourniquet to their own leg intuitively knowing that placing the tourniquet chasis This way instead of that way will give them a better initial pull on the strap.  The same repetition that has someone doing a tap, rack, and engage on one stoppage but a reload just from the feel of the recoil.  That’s recognition primed decision making.

Klein says “…Their experience let them identify a reasonable reaction as the first one they
considered, so they did not bother thinking of others. They were not being perverse. They
were being skillful. We now call this strategy recognition-primed decision making.”2

AIME part 2

Now that we’ve wrapped up the AIME instructor school, it’s time for the insidious part of the course to kick in.

As I go over the slide set and think about my wording, the best way to simplify a concept for our learners, I start thinking about all the new ways of looking at the related problems of ventilation and oxygenation in sick patients.

AIME uses the new paradigm of the Airway Vortex (more to follow on that, I’m sure) to look at the problems, and is almost infinitely scalable to all levels of providers. One of the great things about AIME is that it has everyone from EMR to Anaesthesia speaking the same language.  When I tell the Emergency Physician In Charge (EPIC) that I’ve got a failed airway, she knows exactly what I mean, because she knows what the definition is (SPO2 <90% despite maximal efforts) and she knows what’s in my tool box (a fair amount, including NODESAT, PEEP, CPAP, and some other acronyms, too).

Airway Management Training

For the past week, Devon, Ian and I have been in the classroom.  Well, okay, Ian’s been in there for a heck of a lot longer as a member of the design team. Devon and I joined him this week after attending an early pilot of the course.  We’ve been in there working on a new BCAS course offering, AIME 2 for BLS.

There are few topics in EMS education that excite me like airway management.  It is so fundamental to what we do as health care professionals, but beyond the “look, listen, feel” we all learned in our first CPR course, it’s rarely touched on except to give us new pieces of plastic as we ascend the skill and license ladder.  We spend hours working on BC, we sometimes forget the A.

AIME is one of those courses that fundamentally changes how you practice prehospital care.  It twists your viewpoint around and shows you what you could, and must, do better.  It puts a mirror on years of ingrained practice and asks “is that the best you could do for that patient?” over and over. And it’s kind of uncomfortable.  It’s that perfect kind of uncomfortable that makes you perform at your best.

The AIME instructor selection process is brutal.  It is draining, it is soul crushing at times.  You bring all of your EMS and educational skills to the table and you have them picked apart by true experts.  Think you know how to run a skill station? Let’s see what the PhD education expert has to say.  Think you know prehospital airway care? Let’s see what the expert EMS physician thinks about that.  And if you think you know the course content? We’ve got a guy for that too.  It is grueling.  At the end of the day, though, you walk out far more confident in your skills, both as an educator and as a provider.