Air Traffic Control

When Attack One is dispatched to an intersection off the interstate for a “bicyclist struck,” the urgency in the dispatcher’s voice is obvious. The initial response does not include extrication equipment, but about a minute later the 9-1-1 center adds a rescue and advises Attack One that there’s a report the patient will require rescue. The crew prepares the trauma equipment.

“I hope the person is wearing a helmet,” the paramedic shares with the EMT in the driver’s seat.

The approach to the scene is a little difficult, with a large number of bicycles and cars parked on the interstate exit ramp. There is no traffic moving, and it’s difficult to tell how many vehicles are involved. But it is very clear there is a victim, who is located in the guardrail device at the corner of the intersection. A number of persons surround him, including many in clothing that indicates they’re in some form of sports competition.

The apparent patient is a man who has been thrown into the guardrail mechanism and traffic light controls that sit next to it. It is obvious he was a competitor in a bike race and had been struck in the intersection and bounced across five lanes of the roadway and into his current position.

Another bicyclist reports the man was just ahead of him and was struck crossing the intersection. He had momentarily taken off his helmet and was apparently trying to repair it, which distracted him from seeing the red light and the oncoming traffic. He went up onto the windshield of an SUV and then was thrown across the road. He has been unconscious since it occurred.

The paramedic thanks the man for that critical information, and the man retreats to join about a dozen other individuals filming the event on a range of smartphones, head-mounted devices and cameras mounted on the fronts of their competition bicycles.

The crew members are immediately in rescue mode. The patient is a man around 40, trapped between metal pieces of the road guardrail and fencing and cover of the traffic control device. His torso is mostly upright, but his head and face have open wounds, and he is breathing poorly. He has obvious fractures of his extremities. The EMTs get no verbal response, but his arms withdraw when they are pinched. The crew quickly applies a cervical collar, and the paramedic hands them a bag-valve mask to assist ventilations. They feel a rapid pulse at the carotid artery but cannot feel radial pulses. There is delayed capillary refill and pale skin. His left lower leg is grossly deformed.

The paramedic develops a rapid action plan and outlines it for the crew.

“I’m going to request an air ambulance, and when the rescue vehicle arrives, they will need to do some relatively quick work trimming back the fencing and guardrail supports so we can free him,” he says. “We will get his airway in place now, start an IV line while they’re working, and prepare to immobilize him on a board and slide him out under the guardrail.”

The man has periods of irregular breathing rate and volume. As the paramedic sets up for the airway, the EMT crew members use the bag-valve mask and high-flow oxygen to assist breathing. The facial injuries make it difficult to get a good seal. The victim’s jaw is clenched, and he has open wounds on his scalp that are bleeding and appear to be covering some depressed skull fractures. There is no blood coming from his nose.

The paramedic recognizes that this patient’s airway is going to be difficult to stabilize. They have limited access to him, though fortunately his torso and head are upright. With the difficulty getting a seal, the paramedic inserts a nasal trumpet through the man’s left nostril, stretches the nasal cannula over the nose and cranks the oxygen delivery up to 15 liters. The patient is breathing irregularly but can inhale high-level oxygen through his nose, and the EMTs can bag to assist that without having a complete seal.

With a couple of minutes to set up, the paramedic wants as many options as possible. He pulls out an endotracheal tube that can be inserted through the nose, with a smaller size to accommodate that smaller port. He gets out a larger endotracheal tube with a stylet inside that can be used for intubation through the mouth. He also prepares a device for a needle cricothyrotomy if no airway can be secured through the nose or mouth. The pulse oximeter was initially not able to get a reading on the arm available for monitoring, so an end-tidal carbon dioxide monitor will assist in determining airway position and allow ventilation at a rate that won’t worsen the head injury.

The extrication crew is just arriving and setting up for the cutting operations, which will take a few minutes to complete. There is enough space for the paramedic and one EMT to work at the head of the patient, and the other EMT sets up all the airway equipment to pass to the paramedic. The rescue operation will take place around the patient’s needs.

The paramedic sets up to try an oral airway first. He attempts to insert the blade for the video intubation, but the patient’s jaw will not open wide enough. He leaves the blade in the mouth and moves the cannula so it delivers high oxygen flow through the mouth. He then uses the nasal cannula to lubricate the left nostril (which is much larger than the right) with a generous amount of jelly. He pulls that tube out, lets the EMT assist ventilation for about a minute and then uses the nasal endotracheal tube to attempt intubation that way. The tube easily passes into the space above the larynx but will not pass into the airway. When it finally feels like it does, the carbon dioxide detector gets a value of zero, so the tube is in fact in the esophagus. It is withdrawn back to a position just above the larynx, and the EMT does another minute of bag ventilation.

The patient remains unresponsive, and his breathing rate has decreased further, so the paramedic uses the third device, which is inserted using a needle into the cricothyroid membrane in the neck. The EMT holds the neck stable as the paramedic grasps the area of the larynx, stretches the skin taut over the membrane and inserts a needle into the air space. A larger device then slides in and is attached to the bag-valve, and the EtCO₂ monitor confirms the tube is in the trachea.

It is not easy to stabilize this device with the patient still upright and needing extrication, but there is an opportunity to use the cervical collar for stabilization of the ventilating tube. They attach oxygen and set the ventilation rate to maintain a carbon dioxide value of around 30–35 mmHg.

The extrication crew has cut enough away that the patient’s legs can be disentangled and a long backboard slid under him. They maneuver him carefully onto the board, with one EMT focused only on keeping the tube in the neck stable and in place. The lower extremities are both deformed, and both arms also have fractures. The patient has almost completely stopped breathing, and his blood pressure can’t be obtained. His stomach empties into his mouth as they finish strapping his torso to the backboard.

“Thank goodness we got that airway in before all that emesis came up,” the paramedic states. “Make sure that tube stays in place.”

The helicopter is circling the scene, preparing to land, as they place the patient on the backboard. But then the helicopter pulls abruptly away, and the rescuers notice the sound of a different aircraft.

“Command, this is Helicopter One. There is a drone in our approach path. We cannot land when a drone is operating. Please get the operator to get that device out of the air!”

The airway is stable with the patient on the board, and the paramedic must now find a site to get intravenous access. All four extremities are injured, with open fractures of both the left lower leg and the left forearm. The right hip is dislocated, and the right wrist is fractured; thus the only possible intravenous site is the right antecubital fossa. With the helicopter landing delayed, the paramedic has a minute to start a large-bore IV line and pressure-infusion of saline.

Law enforcement at the scene works with command to find the operator of the recreational drone, who, after a brief argument, brings it down. The engine crew having established the landing zone, the helicopter is advised that landing is now safe. The drone operator makes his way in handcuffs to a police cruiser.

The pulse oximeter now begins to pick up a value for pulse rate and oxygen saturation on the right hand. The patient begins to withdraw from painful stimuli. The left leg fracture is grossly realigned on the backboard and stabilized, and the pulse oximeter records a pulse in the left foot. By the time the ground crew and flight team perform a transition of care, he’s received a 2-liter bolus of saline.

After each movement and into the helicopter, the position of the tube in the neck is rechecked, the carbon dioxide monitor confirming values in the target area.

The patient is stable during the flight to the trauma center. The trauma team finds even more injuries, and the patient goes on to the operating room for the first of many procedures to repair him.

Case Discussion

This patient had severe trauma and unusual circumstances that required airway management prior to extrication. The airway needed to be captured before movement, and the rescuers used a simple bag-valve mask to supplement ventilation and provide oxygen initially. The paramedic needed to move sequentially through attempts at oral and nasal intubation before a device was ultimately fitted through the patient’s neck.

There are now a large number of airway devices developed and marketed for EMS use. They include devices for visualizing the airway, for placing a tube in or near the larynx, for placement through the neck, and for securing whatever is placed. All devices require thorough training for use. Behind each of those devices are monitors that measure oxygen saturation and carbon dioxide levels, to ensure the patient is getting the benefit of both ventilation and oxygen delivery and that tubes are in the right place initially and as the patient is moved.

It is worth repeating from an earlier column on airway devices: Airway devices have a critical role in EMS and emergency care for a wide range of patients. The selection of rescue airways is an important one, not for the airway that is ultimately selected but for the training in proper use and patient selection that must be made.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.