Time to Improvise: Five EMS Airway Equipment Hacks

The nature of emergency services demands a level of improvisation and quick wit. No textbook could cover all the random situations paramedics and EMTs find themselves in each day. 

However, the more we stir the conversation around overcoming unexpected situations, the better we will respond. Pilots are trained to crash-land jets. In the same way, paramedics should be trained to crash-land the equipment in their ambulance or improvise solutions when things fail or go wrong. 

Here’s how to do that in some common situations. Note: These solutions have worked for me, but using equipment in ways not intended by the manufacturer may result in failure or injury.

1. Improvising a light for your laryngoscope

You’re preparing to intubate a patient who has sustained severe head trauma. You click the Mac blade onto your laryngoscope handle—it’s dead. Vomit and blood are filling your patient’s throat like the lower decks of the Titanic. They’re sinking fast, and you can’t see a thing. What do you do? 

The laryngoscope is a simple tool with a simple weakness: batteries. Batteries die, and sometimes they die when you need them to work. 

Transillumination is a solution. Using any bright flashlight, you can illuminate the larynx and vocal cords by shining the light outside the throat, underneath the mandible, just above the thyroid cartilage.¹ 

With one hand you manipulate the (dead) laryngoscope, and with the other you adjust the flashlight. Once you find optimal lighting with the flashlight, have a partner hold it in place. A good flashlight creates a workable glow around the vocal cords.

Tip: Use more than one flashlight if possible—the more light, the better the view. 

2. Improvising a BVM adaptor for needle cricothyrotomy

When I was a paramedic student, a major curiosity was connecting a bag-valve mask to a needle for cricothyrotomy. Though this is a rare procedure, paramedics should be familiar with an effective technique. 

The first method requires three ingredients: a 7.0 ET tube adaptor, a 3-mL syringe, and a 14-gauge angiocatheter. After removing the plunger, you’ll find the tube adaptor fits snugly within the syringe. The syringe then locks onto the needle.²  

The second technique requires two ingredients: a 2.5 ET tube adaptor and a 14-gauge needle. The adaptor fits directly inside the hub of the needle. If you want, you can place a small IV extension lock between the needle and the ET adaptor, giving you more surface area to secure the needle-cric in place. 

3. Improvising a pediatric BVM

Early in my career I worked in rural counties where many Amish families lived. Unfortunately, it wasn’t uncommon for trucks to plow into horse-drawn buggies, sending kids all over the road. It’s important to be prepared to stretch equipment to its limits during mass-casualty events.

Typically the BVM comes in three sizes: infant, child, and adult. Seasoned EMTs and paramedics know that even adults shouldn’t receive the full 1,500 mL of air generated by a large bag-valve mask. But what if you need to use the adult bag for an infant? This is dangerous.

Here’s a potential solution: If you need to use an adult BVM for an infant, an easy way to reduce the amount of air produced is to squeeze a different area of the bag. By squeezing the front of the BVM, you greatly reduce the volume produced. Also, to automatically reduce the size of the BVM, fold part of the bag into itself.

Regardless of the size of the BVM, try ventilating by feel. Everyone’s lungs have a different tolerance. As you squeeze the bag, try to feel the resistance build, then release. 

4. Improvising two-handed ventilation for a solo rescuer

As often taught, two-person BVM ventilation is superior to one-person. In two-person ventilation, one person dedicates both hands to holding the mask seal (usually with the T-E grip), and the other squeezes the bag. Unfortunately, two-person BVM ventilation isn’t always possible in the prehospital setting. EMTs and paramedics must know how to perform one-person ventilation effectively. 

Here’s a technique that offers the benefits of a two-handed mask seal without requiring a second provider.

First, rethink the C-E grip. Instead of compressing the edges of the mask, create an “OK” sign and bring your thumb and index finger closer to the center of the mask. This altered grip reduces leaks by creating a uniform pressure around the facemask.

Second, use the “H-E” grip. The H-E grip allows you to create a two-handed mask seal without a second rescuer. Like the two-handed “T-E” grip, which incorporates the palm below the thumb or thenar eminence, the H-E grip uses the hypothenar eminence, below the little finger. 

For the H-E grip, move your hand from the top of the bag to the bottom. Now, using the portion of your palm just below your little finger, apply pressure to the edge of the mask while continuing to grip the bag. The H-E grip allows you to use one hand for two jobs: squeezing the bag and holding the mask seal. 

You’ll find the H-E grip does slightly alter your ability to squeeze the bag; however, this turns out to be a good thing, as it inhibits overventilation.

5. Improvised wrench for an oxygen tank 

Paramedics work in dark ditches and barely lit hoarder homes. Losing an oxygen wrench is unfortunately common. Many small oxygen tanks now come with them built in; however, most tanks still require separate wrenches. Here’s a solution that will prevent you from dealing with the lost-wrench problem.

Cheap trauma shears: Use the area between the handles of the shears and squeeze them around the nut on the oxygen tube. The scissors give you just enough leverage to open the tank. However, to increase grip and torque, apply some medical tape around the handles of your shears. This tape will slightly mold around the oxygen nut, allowing you to open the tank with ease. 

Final Words 

When I was a kid, I took piano lessons. Before recitals my teacher would say, “Don’t let your fingers memorize the song.” She explained that if your fingers memorized the song, you wouldn’t really know the song—your fingers would. If you played a song by muscle memory, then if you were nervous and made a mistake, you’d be awkwardly lost, unable to find your way back to familiar ground. 

The same thing happens to paramedics and EMTs. We’re so habitual in certain routines that we freeze when something unexpected occurs. To become competent providers, we should strive to know our equipment and skills beyond muscle memory. We should strive for mastery. That way, when something fails, we’re ready to improvise.

Sidebar: Additional Equipment Hacks

Airway equipment and procedures are not the only areas that can benefit from tricks and modifications. Here are some ideas for trauma and bleeding control.

Improvising extra hands for bleeding control 

You’re called to a nightclub after reports of multiple people stabbed. As you arrive a police officer says they’ve just secured the scene. Three victims are still inside. Grabbing your trauma bag, you and your partner follow the officer into the dark building. 

After some quick triage, you confirm three patients and begin care of a college-age female. The assailant stabbed her in the neck, left thigh, and upper left arm. All wounds are bleeding heavily, but the thigh looks like it needs a tourniquet. 

What do you do? Should you ignore the other bleeding sites while applying the tourniquet? Here’s a possible solution.

With one knee apply pressure to the thigh. With the other apply pressure to the upper arm. If the patient is able, direct her to use her free arm to apply pressure to her neck. Your hands are free, and you apply the tourniquet to her thigh. Next, while keeping a knee on the left arm, you pack the wound in her neck. Finally, apply a pressure bandage to her upper arm. 

Key takeaway: You have more than two hands for direct pressure. You have both hands, both knees, and the patient’s hands (if they’re able). Use all your resources. 

Improvised tourniquet 

Shootings, stabbings, and car accidents are all instances where you may need extra tourniquets. Also, cheap tourniquets can break. In these cases you must be ready to improvise. Here’s how:

First you need sturdy material at least two inches in width—a triangular bandage or rolled t-shirt can work. Anything too thin, like paracord or rope, will dig into the flesh, causing further damage. 

Second, you need something to act as a windlass, similar to a SOF tourniquet or a CAT. The windlass gives you a mechanical advantage. A flashlight can work, trauma shears, or even a sturdy branch. 

Third, roll the material to create a band about two inches wide. Then wrap the band around the limb, two inches proximal to the bleed. Make one half-knot, like you’re beginning to tie your shoes. Then place your windlass over the knot and tie another half-knot over the windlass. Finally twist your windlass until bleeding stops. Use tape or another piece of material to prevent the windlass from unwinding.

References

1. Auerbach PS, Cushing TA, Harris NS. Auerbach’s Wilderness Medicine, 7th ed. Elsevier, 2017; pp. 1,052–3. 

2. Brown III CA, Sakles JC, Mick NW. The Walls Manual of Emergency Airway Management, 5th ed. LWW, 2017; p. 227. 

Gideon Zielinski is a freelance writer specializing in EMS and first aid content. He has seven years of experience in EMS, including 9-1-1 emergency calls, critical care transport, and community paramedicine, as well as lifeguard safety/water rescue. Reach him at gidzielinski@gmail.com.