005: 5 Lessons Learned From My First Surgical Airway

Prehospital Surgical Airways: The Truth Behind the Procedure

The truth is, very few paramedics have ever actually performed a surgical airway on a patient.  In the past 15 years, I've met only a handful of paramedics who have. I've actually met more providers who told me stories about patients who they say they should have cric'ed, but didn't for one reason or another didn't, and their patient died.

Now, I'm not saying in every one of these cases the patient died because the provider didn't perform a surgical airway.  But when we as care providers fail to perform a potentially life saving intervention for no real identifiable reason, one must ask why? 

Why don't we cut to air?

In trying to answer this question, I've talked to a lot of paramedics and nurses from across the country and have identified 4 common reasons why prehospital providers fail their patients by not performing the surgical airway. In no particular order, here are the 4 common reasons I've identified.

  1. "I didn't think about it."

  2. "I was nervous about cutting their neck because I've been told it's very easy to cut the carotid arteries and didn't was to kill my patient."

  3. "Performing a cric is considered a failed airway, and I didn't want my partner to think I'm a bad paramedic because I couldn't intubate them."

  4. "I was afraid if I screwed it up I'd get in trouble."

Where do these beliefs come from?

When I was going through paramedic school in 2001 the amount of training we received on surgical airways was scant at best.

Over the years that have followed, different devices have been invented like the Pertrach, Melker Cric Kit, and the QuickTrach, all intended to make the procedure of emergency crichothyrotomy safer and easier for the prehospital provider. 

We're told these devices are intended to make the procedure easier, and less risky.  We're told that EMS providers don't perform enough surgical airways to become proficient at this "risky" skill.

It is my belief that this mentality by managers and medical directors has resulted in too many providers believing that the procedure is too hard to be performed in the field when the lives of our patients are at stake.

The truth is, the cric is not the only skill we're expected to perform as Paramedics that we just don't do enough of to become truly proficient at.  For example, when was the last time you cardioverted an unstable SVT on a conscious patient?

That doesn't mean we can just forgo taking care of our patient until we reach the hospital.  It means we practices, over and over, until we develop the muscle memory necessary to perform the skill flawlessly.  Then, the only challenge remaining is the challenge of deciding to do the skill.

Furthermore, there seems to be an unspoken belief that if you have to cut someones neck to secure an airway then somehow you've failed.  That you're skills at intubation are not up to standard and that you're a incompitent provider.


But why the heck would anyone think this? Well, one reason might be where we find "surgical airway" in all the airway algorithms.  In the "Failed Airway Algorithm." This idea of a surgical airway being a "failed airway" maneuver further deters paramedics from acting.

So how do we overcome these surgical airway road blocks?

The struggle to move beyond the stigma of being a failure if you have to cut in order to secure an airway is both a personnel one and a cultural one.

As individuals, we must learn to put our egos aside and do what we've been trained to do in order to take care of our patients. We must realize that even if others do think less of us (which doesn't happen), it's our patient that takes priority.

Remember, it's not about Us, it's about Them.

As an industry, we must begin to see the "Failed Airway" as a failure on the part of the patient, not the provider.  The provider didn't fail to performing other airway maneuvers with skill and professionalism, the Patient failed to respond to those maneuvers.

This is true even if other airway maneuvers aren't attempted.  Remember, there are times when a surgical airway is the only viable option, and attempting any other airway maneuver would put our patients at further risk and are inappropriate.

Remember, each of us are professionals and we're all tasked with using sound clinical judgement, drawing on our past experience and training to make the best decision possible in the "heat of battle."

What I learned from my first surgical airway

It took nearly 13 years for me to finally pull the scalpel from the kit and use it. 

Fortunately, I can honestly say there was never a time in my career when I should have cut to air and didn't.

That said, I did learn a very valuable lesson from my first field cric that helped me the next time I was faced with a patient in need of the blade.

Here's what I realized about surgical airways, and what I want you to remember.

1. Performing a surgical cric is NOT a failure on your part. The patient failed.

As mentioned above, performing a surgical airway is NOT a failure on your part as the provider; it's a failure on the part of the patient to respond to other airway interventions. The real failure is in not using every single tool available to help your patient.

If you let your patient die because you were too afraid to use the scalpel, that's when you've failed.

When you identify a patient in need of a surgical cric, decide quickly to cut, and move decisively to the surgical airway.

2. A surgical cric is not as hard as you think.

Despite everything you've been told, performing a surgical airway is not a hard procedure to perform. 

If someone tells you it is, they've either never actually performed one, or they tried to use one of those silly gadgets designed to make the procedure safer and easier.

There are two videos on my "Video" page under "Airway" that demonstrate how easy the procedure is with nothing more than a scalpel, a Bougie, and a 6.0 ET tube.

The take-away point here is Don't Allow Your Brain To Make A Simple Procedure Hard.

3. A surgical cric is not as scary as you think.

Performing the surgical airway is not scary. 

No alien is going to jump out of the patient's neck.  There isn't going to be a massive gushing of blood, although there will be some bleeding, and if you're performing a surgical airway on someone who's still trying to breath there could be some spraying of blood as the patient exhales through the hole you just cut, so be sure to wear proper protection.

You're not going to cut all the way through the patient's trachea, see EMCRIT Podcast 119 Surgical Airways with Rich Levitan.

What can be a bit scary is the scene, or the trauma that has necessitated a surgical airway, or the the fact that your patient is probably dying in front of you.  But hey, that's the nature of what we do right?!

Think of it this way. What's the most probable outcome if you don't perform the procedure?  You're patient will probably die.  It's like CPR.  Is CPR a scary procedure?  No it's not because the patient is already dead. 

Give your patient the best chance to live and use the blade.

4. Your peers aren't going to think less of you for performing a surgical circ.

After my first surgical airway, the feedback I received was all positive. 

My Nurse/Medic partner praised me for actually "pulling the trigger" and making the cut.  My medical director, who was the ER doc on duty where I took the patient, praised me for doing the procedure, and everyone of my peers wanted to talk to me about the call and learn from the experience.

In the days to follow, I heard from several peers who told me stories of not doing the cric and regretting it later because they felt they hadn't done everything possible for their patient.

5. You must be mentally ready to perform a surgical cric on EVERY call.

See, for all of the reasons mentioned above, the hardest part about performing the surgical airway is not cutting someone's neck, but rather making the decision to cut and then acting.

Once we put aside all our ill conceived fears surrounding this life saving skill, we can finally get down to business.

Once we realize that performing a surgical airway is not a failure on our part, that the procedure isn't as hard as we're made to believe, that it's not as scary as we imagine, and that our peers won't think of us as a failure, we must now be mentally prepared to perform the procedure on every call.

But the time to prepare is not when we're staring down at a dying patient. The time to deal with this is NOW.  Yes right now! Because you just don't know what your next call will be.

Another Great Resource for Surgical Cric Education

Surgical Airways by Scott Weingart (EMCrit.org)

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