A Tale of Two Crics


This post isn’t going to teach you the skills of performing a surgical cricothyrotomy. There are already some incredible resources out there. What I aim to do is highlight the differences between two surgical crics that I performed and what it taught me about the mental landscape of performing the cric. 


We’ll start with the two generalized and anonymous cases focusing more on Human Factors than on medicine. For this post, the medicine is taking a back seat. 


The Fist Cric-- The Oliver Twist

I was fresh out of my agency’s Field Training Program, feared but respected, known locally as “The Program”. I had been a medic well under six months and my partner hadn’t been a medic much longer. While I had great expectations for myself, I was still very green behind the ears. 

As an agency, we had just released a new Cardiac Arrest package, which among many deviations from ACLS, moved BVM and intubation to the six-minute mark for any cardiac arrest that was not presumed primary respiratory etiology. 


This all leads up to the scene; Unresponsive Party at the dialysis center, the perfect storm for premature closure and hard times for the new medic. We immediately get to work and before you know it some epi, calcium, and bicarb are in; we’re feeling like heroes. Dutifully, at six-minutes I begin to manage the airway. I hand a BVM to the EMT firefighter and begin to set up for an intubation. I get a good Grade IIb view, with a big ole’ epiglottis in the way of the cords but clearly identifiable arytenoid cartilage. I pass the tube, watch it pass anterior to the arytenoids and all of a sudden stop. Big left twist, nothing. I pull out, grab my trusty bougie and go for a second try. This time the bougie holds up. “Wow, I didn’t know I was this bad at intubation” was the self-talk as I grabbed the iGel and dropped it in buttery smooth like.


The scalpel-finger-bougie cric itself went well although resuscitative efforts were ultimately terminated in the field. 

The exact sound of an iGel NOT WORKING


Case 2: Improvement

 This case is much simpler. Arrive on-scene to a 20s F in a bathtub, covered in blood. Isolated GSW midline at the angle of the neck. No exit wound. She’s breathing and has a weak femoral pulse at 150s, unable to auscultate a blood pressure. Airway is a bloody mess and BVM ventilation results in air blowing out of the new hole in the neck. Suction can’t keep up with the hard palate bleeding but it doesn’t matter because the mandible is broken in two, the airway landmarks are mutilated and she’s now become apneic. A surgical cric is performed with success, although the patient does not survive the resulting TBI. 





Lessons Learned:


These cases serve to illustrate one of the most common pieces of “wisdom” you hear about performing a surgical cric: that the hardest part is making the decision. We set people up for failure by telling them that the cric is a “once in a career” procedure because it prevents providers from being a “loaded mousetrap”.It takes a lot of time to overcome the diagnostic momentum in order to “pull the trigger’on performing a cric IF you tell yourself you will probably never do one. In fact, a paramedic should be in a constant “surgical cric” OODA loop whenever managing an airway, and be ready to perform one as soon as the CICO is recognized. 


This is important though.   As the first case highlights, if you are not constantly asking yourself whether or not the situation you are in is in fact a CICO situation, you will have a delay to recognition. 


The goal in emergency medicine is to be able to run your OODA-loop

faster than your patient can decompensate


In real terms:  Due to the 6-minute delay in beginning airway maneuvers, it was likely 10-12 minutes before the failed airway was recognized, with the obvious implications that it has on survivability. In the second case, time from patient contact to surgical cric was well under 4-minutes--and this included the time to extricate the patient and begin transport to the regional trauma center. And remember, the patient still had spontaneous ventilatory effort for probably three of those minutes. 


I think the question that is worthy of digging into is why the second case felt so much smoother, so much more in control, and why the decision was made more quickly and assuredly. 


The obvious answer is that the case was much more obvious. When we think of the surgical cric case, we think of the traumatic airway. There’s more to it than just that.


As I mentioned earlier, the first case was the perfect storm for the cognitive trap of premature closure. You’d be hard pressed to find a medic who, when finding a patient down on the floor of dialysis with a story along the lines of “She’s a new patient here, we don’t know when her last dialysis was. We were getting stuff ready and came back to her like this” wouldn’t immediately leap to the Hyper-K+ arrest. This isn’t necessarily a bad thing either. This will allow for much more expedient treatment of the ongoing life threat. One of my favorite sayings though, in part because of this call, is “abandon bad ideas early”. I learned that not only is it okay, but it is the sign of the good medic to abandon their bad ideas. The wrong move is to allow the diagnostic and treatment momentum to keep pushing you in the wrong direction. 

The mental tool that I use to overcome this is a simple one. As soon as I feel that I have landed on a diagnosis that I am going to treat, I start treating it (whether that be Hyper-K+ arrest, or asthma, or any other diagnosis). Then, I try to prove myself wrong. I ask myself “what else could this be” over and over as I try to prove my initial diagnosis correct by proving everything else wrong. Obviously this is not to advocate for hasty treatment after a shoddy assessment. In fact, quite the opposite. Do that good assessment, but treat what you see. Then prove your eyes wrong. 


The idea of the “set mousetrap” is one that you should hold for multiple situations. Mike Lauria talks about the “emergency reflex action drill (ERAD)” and “recognition primed decision making”. The mousetrap is both of these ideas wrapped up in one simple model. You “set” the trap with recognition primed decision making: the CICO situation, or inability to visualize cords, or massive extremity hemorrhage. The ERAD is what happens when the mousetrap is sprung: the Cric, or the optimization, or the tourniquet. It is worth forming these for yourself and writing them down, practicing, and codifying them until they don’t require active thought. Defend your mental bandwidth on critical calls--this is one way of doing that.


Reading this blog so you can be the mousetrap, not the mouse


Finally, by having done a cric before and “breaking the seal”, I knew what to expect, had the confidence that my assessment of the CICO situation was appropriate. I also had that mental “mousetrap” (what Scott Weingart refers to as CriCon) set and ready to go. My goal with this is to help teach from my failures so that you don’t NEED a second cric in order to be ready to go. I hope this helps you prime yourself so that you are ready to recognize a CICO, and perform the procedure. You’ll nail it at it. It’s easy if you practice.


 Godspeed out there.




"Set Me Up": On Partner Duties

I want to preface this by saying that I work in a double-paramedic system, which helps make this possible, though there is no hard reason why this does not work in a high-functioning Medic/Basic system with well trained EMTs. I also recognize that this is not appropriate for all patients, there are plenty of sick  patients who benefit from initial stabilization and treatment on-scene; this is for the rest of the cases. 

In my system, we have a set, codified division of labor between the “attending paramedic”, who handles direct patient care, and the “driving paramedic”, who does big-picture scene management, interviews bystanders, and family members, and generally helps facilitate the attending medic’s ability to perform high-quality medicine. The new-hire paramedic’s ability to do these partner functions well is taught and tested on in our field training program. 

One of the more unique things that falls under “partner duties” is “setting up” the attending. What this entails is as soon as the attending determines it’s “time to go”, the driving medic high-tails it to the back of the ambulance with the goal of having everything the attending will need for the rest of the call setup and ready. 

The attending asking their partner to “set me up” can happen at any point in a call. It can happen from down the block as you’re pulling up on a nasty shooting or it can be after being on-scene for 15 minutes resuscitating a patient. If you have a really dialed partner (most of mine are) by the time you look over your shoulder to ask them to set you up, you can just make their silhouette in the doorway. 

As a driving medic,  you develop your “doorway” general impression. Based off of sometimes only seeing a patient for a second or two, how they are interacting with providers on-scene, their skin signs, their work of breathing, etc., you now have to form a general impression, have a sense of how this call is going to develop over the next 10-20 minutes and prepare your partner for that. This is harder than it looks, but is low stakes. Don’t think about something your partner ends up needing? Not a big deal, be better next time. Over-prepare your partner? Pull out an airway roll for a patient who’s awake and talking by the time the wheels click in? No big deal at all. This general impression “practice” absolutely pays dividends for anticipating where a call will be going the next time you’re attending. This in turn helps improve delegation skills, which are after all, a reflection of your ability to be  minutes ahead in your head of where the call is now.

So what does this actually look like? I’ll talk through a scenario. 

The first will be the run-of-the-mill STEMI alert. You and your partner get on-scene, rapidly recognize the need for an EKG, and identify as STEMI. As soon as you and your partner agree, you as the driving medic would head toward the ambulance, leaving your partner with the fire department to work on extrication.

Once there, you will make sure all the lights are on in the back, turn on AC or heat depending on what’s needed, make sure the electric oxygen button is pressed. You then spike two lines (or whatever your setup for bilateral lines is), have a nasal cannula hanging from the christmas tree should their SpO2 be <92-94%. You’ll also pull out the fentanyl with a few syringes to draw it up. If the patient looked like they were hurting and you have time you might even draw up the fentanyl and label the syringe.

You’ll also have the nitro out. As soon as the wheels click in, you’ll go to work ensuring electrodes survived the transport, shoot another EKG, ensure defib pads are in place if not already. While your partner is making a phone-call and depending on distance to the ED you might even rope off an arm and start an IV for your partner. Then it’s time to get up front and drive. 

Having everything set-up and ready to go makes the call feel that it “flows” a lot better. Indeed, having things laid out, ready, and setup makes it easier to get into and stay in a “flow state” which is the point of peak cognitive performance and a place we should strive to be in with sick patients. 

How can you apply this to your system? Because of how much reliance it takes on a partner, when we are training paramedic students we insist that they specify what they want: “Hey can you set me up with two lines and airway stuff?” This is totally something that could work with an EMT or even a paramedic partner. Test your own general impression and tell your partner what you want set up as soon as you recognize that the patient is sick. I think you’ll find it’s a great exercise to improve your “doorway impression”, helps to make the stress of a sick patient feel more manageable, as well as reduce your scene times for the few patients that need a trauma surgeon RIGHT NOW. 

I think the patients for whom this is most useful for in most systems is sick trauma patients. My system has an expectation that trauma which is an emergent return will have a scene time of <9 minutes in blunt trauma and <6 minutes in penetrating trauma. These times are easy to make, but a large part of being able to do this well is having your partner set you up. In the sickest penetrating trauma scenes i’ve run, my partner doesn’t even see the patient, they set me up as I make patient contact, roll the wheels to a firefighter. We get the patient on the bed and by the time the wheels click the ambulance is in gear rumbling to the trauma center with everything I’ll need for the short transport setup. 

I hope this has been helpful, and has some pieces that you can incorporate into your practice to help make your scenes run more smoothly, with more control, and you get to spend more time in the flow state giving high quality clinical care to the sickest of sick patients!



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