The Cric Under the Pile

December 16, 2020 started like any other day. I was scheduled to work 0700–1900 and had a few uneventful calls in the morning. In the afternoon snow began to fall. As we were en route to UPMC Williamsport, Lycoming County was dispatching units to our west to go to Interstate 80 for a multivehicle crash with injuries.  

Once we were free from the hospital, our mobile intensive care unit (MICU) was dispatched to cover neighboring Clinton County, as most of its ambulances were now requested to go to the I-80 crash, which encompassed some 66 vehicles and had multiple fatalities. Clinton County normally only has two ALS units for around 50,000 people, so any multi-injury crash strains its resources.

The roads were becoming treacherous, and it took nearly an hour to reach Lock Haven, the Clinton County seat. I’d never been more thankful to have my partner, Mike Betts, driving. Mike has been an EMT for more than 30 years and driven every type of vehicle you can imagine. Our unit only stood by for a few minutes before the calls started coming.

A little after 1900 we had just freed up from Lock Haven Hospital when we were requested to bring Bair Hugger warming units to the crash scene, approximately 20 minutes away. This was four hours after initial reports of the crash. The snow was getting deep even on the Interstate as we approached. We were in constant communication with Clinton County dispatch and scene command. Radio traffic over the last few hours had been filled with confusion and frustration around units getting to patients. We were requested to turn around at a crossover and back toward the scene. I-80 had already been partially shut down. Our unit was one of the last to go eastbound before it was closed completely. 

As we backed over a mile toward the entrapped patient, scene command asked if we carried etomidate. We hesitantly answered yes. Both my partner and I began to realize the patient we were coming for must be gravely hurt. 

Entrapped and Decompensating

As we backed slowly toward the scene, the severity of the accident became real. Fire trucks, police cars, and ambulances were all pulled into the right lane. Exhaustion was evident on responders’ faces, as it had now been more than 4½ hours since they’d arrived on scene. 

A firefighter guided us back into the final stretch, then told us we’d have to continue on foot. I stepped out of the ambulance and saw carnage. Tractor trailers were thrown about like toys. Vehicles littered the highway, covered with snow. We carried our bags a few hundred feet through a maze of twisted metal. The intense snow kept the sight of the entrapped patient covered until we got close. We found a group of EMS providers and firefighters huddled under a tarp and providing care to a female protruding from a mangled Jeep. Only a logo near her head identified the twisted vehicle's type. 

Paramedic Evan Ripka of the Goodwill Hose Company Ambulance Association gave us a quick report: The woman had been entrapped for more than four hours; he’d been with her for the last three. She was initially responsive but confused and complained of severe pain but could not localize it. Visible assessment revealed a presumed fracture to the right upper arm and a large hematoma to her forehead. Providers and bystanders had contributed jackets and blankets to help keep her warm. 

Unable to get initial vitals, responders had obtained IO access in the right humerus, delivered a lidocaine flush, and began 0.9% normal saline. Due to the temperatures, the drip set began to freeze, and crystals formed in the saline bag. Hot packs also began to gel after being activated. They ultimately placed the bag into another provider’s shirt, against skin, to keep the fluids from freezing. They gave her fentanyl for pain.

On our arrival Ripka and his team were assisting respirations with a bag-valve mask. He’d given multiple doses of push-dose epinephrine. The patient was semiresponsive and moaning but still severely hypotensive and tachycardic. Her hands and arms were so cold that pulse oximetry was not reading, but her EtCO₂ levels were in the mid-20s. 

Ripka told us that since the patient was still heavily entrapped and decompensating, he wanted to intubate her. His agency didn’t carry etomidate, so we’d been requested. I agreed and began to prepare. We drew up 30 mg of etomidate and 5 mg of Versed as we had the normal saline switched to lactated Ringer’s. We explained to the patient that we were going to put her to sleep to help her breathe. 

Ripka set up to intubate using my video laryngoscope. I slowly administered the etomidate. The patient went completely unresponsive, but vomit and dark red blood began to come out of her mouth and nose. We quickly suctioned her, then Ripka tried to insert the blade into her oral cavity, but her jaw was clenched shut. Knowing etomidate has a very short half-life, I quickly called medical command for advice. 

We gave Versed per the doc's recommendation, and this time the patient’s jaw unclenched slightly, and Ripka was able to insert the blade of the McGrath. Our view of the cords was poor. The patient had very anterior landmarks, and her mouth had a lot of bloody vomit. We saw the cords clearly for a few seconds, but not long enough to get the bougie in before things filled with vomit. We abandoned this intubation attempt, and the patient’s jaw clenched again, leaving no room for another try. 

Now the patient was completely unresponsive, with bloody vomit leaking from her oropharynx and her jaw completely clenched. We considered a King LT but feared the balloon would tear. A Life Flight ground unit that could administer paralytics was occupied at the other end of the crash. Ripka and I looked at each other, and I said, “I think we need to cric her.” He agreed. 

Emergency Cric

As all these actions were occurring, the rescue crews were making slow progress. The patient’s Jeep was underneath two tractor trailers. The engine of a third was lodged into its front. They’d tried to extricate her before our arrival on scene, but the rescue crews needed a heavy wrecker to lift the tractor trailers. One arrived around the same time as my partner and me. As Ripka and I and our BLS partners were attempting to manage the airway, rescue was coordinating with the wrecker to move other vehicles out of the way so it could reach the tractor trailers crushing the Jeep. 

Ripka and I prepared the cricothyrotomy kit. I’d only used it in practice. Between the cold and the intensity of the situation, my hands were shaking. The patient had to be suctioned often, but luckily her angle had her airway pointed toward the ground, so the bloody emesis was leaking out of her oropharynx instead of down into her lungs. 

Identifying landmarks was not easy. Gravity, positioning, and the limited anatomical area made this extremely difficult. Ripka held the skin of her neck taut. My first cut was vertical. I had to cut deeper to clear the large amount of subcutaneous tissue blocking the cartilage. The next cut was smaller and horizontal. I wanted to ensure it wasn’t too big and avoid the possibility of lacerating arteries on either side of the trachea. This cut started to bleed as soon as I inserted the scalpel. But once the cricothyroid membrane was perforated, bubbles appeared in the blood. 

I held the pinky of my left hand in the hole while Ripka handed me the bougie. It took two or three attempts to place it. Thinking back, I should have made the horizontal perforation slightly larger. The large amount of subcutaneous tissue made it difficult to place the bougie in the trachea, but once I felt the trachea rings, I know it was in the correct spot. Ripka handed me the endotracheal tube, and it slid over the bougie and into the trachea without issue. We placed the EtCO₂ sensor and began to ventilate. A good waveform was present on the monitor, and the patient had bilateral lung sounds. 

Ripka secured the tube, and we continued to ventilate. Rescue had cleared the outer vehicles and was now working on moving the tractor trailers crushing the Jeep. 

Extrication Plan

As we ventilated our crew discussed our plan for when the patient was extricated. First we had to figure out which hospital to go to. On any normal day the most definitive patient care would be at Geisinger Medical Center, a Level 1 trauma center around a 50-minute drive from the scene. Other hospitals were closer but didn’t have trauma capabilities. UPMC Williamsport was also closer than Geisinger and was nearing accreditation as a trauma center, so most trauma services to at least stabilize the patient would be available there. 

We decided to transport to UPMC Williamsport for a few reasons: Eastbound I-80 had been closed for over an hour, and the snow had been piling up. For Geisinger we’d have to transport on (likely unplowed) back roads all the way to Danville. Since we were already in westbound lanes, we had an easier route to Williamsport. We considered this the best-case scenario. We all thought she’d go into cardiac arrest once hitting the stretcher, and if she did that on the way to Williamsport, we could go to the closest facility in Lock Haven or Jersey Shore. 

Progress was slow but steady. The tractor trailers were removed from atop the Jeep, and now rescue teams were beginning to pry apart the mangled pieces entrapping the patient. My partner, Mike Betts, served as liaison between rescue crews and the treatment team. He kept a particularly good eye on the engine block lodged on the front of the Jeep above where we were working. It was held in place by a chain wrapped around a guardrail. If that let loose, most of us treating the patient would have been crushed. 

As we awaited extrication, the patient’s blood pressure dropped again, so we gave more epi. I contacted medical command to update our progress. I reported the patient had to have a surgical airway placed and we would transport to UPMC Williamsport. We gave another dose of calcium chloride per their orders. 

Transport

Just before extrication (almost an hour after the cricothyrotomy) Alex Lieberman, a paramedic from Centre LifeLink, and his EMT partner, Scott Packer, brought their stretcher and ALS gear to us. Their timing was perfect, as our monitor was about to die, and we desperately needed another battery. Their ambulance was now the closest to where we were working, so we all agreed they should transport the patient. Ripka and I rode with them. 

At 2134, six hours after the accident, we pulled the patient out of the Jeep and onto the stretcher. I quickly reconnected the monitor cables and was pleasantly surprised to see her pulse and end-tidal levels remain the same. We wheeled the patient under tractor trailers through heavy snow down the freeway a couple hundred feet to Centre LifeLink’s ambulance. Her left leg was bleeding heavily, so we placed a tourniquet. 

We departed the scene at 2151. Ripka, Lieberman, and I worked flawlessly as a team. We cut the patient’s clothes off and began to stuff heat packs around her axillae and groin. I had never felt a person so cold who still had a pulse. Lieberman got IV access in her right arm. Ripka started conducting a full trauma assessment. I was just about to place the patient on the ventilator when the ambulance had a sudden shudder and stopped. 

Packer shouted back that we’d run off the road and were in a snowbank. We rocked back and forth, trying to get enough traction to get out, but didn’t make much headway. I remember saying “If we don’t get out in the next five minutes, let’s unload her and put her in my truck!” Those five minutes came and went, and we had the back doors open to unload the patient when a truck pulled up and offered to pull us out. We were all grateful for this giant act of kindness. If only that guy knew how critical this patient was.

At the Hospital

Back en route to the hospital, the roads were downright awful. We went 25 mph at most up Interstate 220. I put the patient on the ventilator. Lieberman began to administer IV antibiotics for the open fracture of her left leg. 

Reassessing lung sounds revealed the patient had no breath sounds from her left lung. Both Ripka and Lieberman confirmed this. This was a huge change in only the last few minutes but didn’t surprise any of us. Lieberman decompressed the chest with a needle. We heard and felt an obvious pop, and breath sounds quickly returned to the left side. 

I updated the ED on the patient’s condition twice more on the way to the hospital. She was still so cold, even with the Bair Hugger system surrounding her with hot air. Through the transport we were still unable to get NIBP readings, and auscultating blood pressure was impossible. Finally, toward the end of the transport, we obtained a manual reading of 90/60 mmHg, so we titrated the saline to KVO. The patient slowly began to open her eyes and follow commands to blink. 

We backed into the hospital parking stall at 2312, an hour and 20 minutes after we left the scene and an estimated eight hours and 18 minutes after the crash occurred. We unloaded the patient and wheeled her to the trauma bay. I had never seen such a large trauma team for one patient. 

The Good and Bad

It’s been a year since this incident. I have done a lot of reflecting. I have checked on the patient’s progress multiple times; she was discharged a month and a half after the accident. She’s kept in contact with Ripka, Lieberman, and me. To see her be able to walk and begin to slowly return to her old life is nothing short of a miracle. 

What went well: Everybody worked so well together. I’ve been on scenes where first responders were more concerned about their egos than safety. This was not one of them. There were people from so many different agencies with different levels of training doing what they could for this woman. Between rescue, EMS, law, and wrecker operations, everybody worked with the same goal, to get this patient out alive. I had never met Evan or Alex until that day, but we all knew we had to give the best care possible to this gravely injured patient. 

What I wish we’d done differently: When we were on scene, we should have taken the time to get more manual blood pressure readings. It’s so easy to slap the automatic cuff on and recycle the pressure, but those readings are inaccurate sometimes. Otherwise I can’t think of anything specific I wish we’d done differently. Most of this call was so situational, a true “once in a career” circumstance. 

Sometimes being a paramedic gets frustrating. You feel like a glorified taxi. You are the forgotten, underpaid, and underappreciated stepchild of the healthcare system. But incidents like this change your perspective. Calls where you make a true difference in life-and-death situations make this career so emotionally rewarding. Nobody who makes paramedicine a career does it for money, good hours, or pleasant working conditions. You do it to make a difference. My advice after this: Stay humble, do your job, and appreciate having a career where you can make a positive difference in people’s lives.   

Sidebar: Rough Timeline of Events, December 16, 2020

• ~1500—A massive multicar pileup begins on icy Interstate 80 in Clinton County, PA.
• 1900—EMT Mike Betts and paramedic Joseph Hanstine are dispatched to the scene at end of their shift to assist on-scene crews.
• 1930—Betts and Hanstine arrive on the accident scene but must access the patient on foot.
• ~2000—Betts and Hanstine arrive at the entrapped patient's side.
• ~2010—Intubation is attempted.
• 2030—Cricothyrotomy is performed.
• 2134—The patient is extricated and placed on a stretcher.
• 2151—EMS departs the scene.
• 2312—Arrival at UPMC Williamsport Hospital, more than eight hours after the crash occurred.

Joseph Hanstine, NRP, is a paramedic at Susquehanna Regional EMS in central Pennsylvania.