Category Archives: Macgyvering

So maybe you can use that for a wilderness airway

We’re going to have to talk about the improvised wilderness airway. Caveat: this post is not exactly evidence based. It’s literally an anecdote. But an amazingly good and peer-reviewed anecdote at that. And there is a smattering of evidence thrown in at the end. Typical wilderness airway tool

The case report starts like this: Three firefighters were climbing as part of a team in California when they saw a man falling ~1500ft down a rocky slope. They descended to offer help, and when they got there they removed his helmet, checked ABCs, and maintained his C-spine. Neurologically he was unresponsive. Two emergency doctors with a separate climbing team arrived 15 minutes later. By this time his respirations were irregular and they noted significant facial trauma. Due to gurgling respirations, they decided to perform a cricothyrotomy.

All the physicians had for supplies were climbing equipment and a small first aid kid. They used a pocket knife to make the incision (vertical first, then horizontal), and tubing from a hydration pack as a makeshift ETT. Suture from the first aid kit was used to secure the tube. Since respirations were spontaneous, they did not perform positive pressure ventilations initually.

His pelvis was bound with a pair of pants, and extra clothes were used to prevent hypothermia. After 30 minutes though, his respirations became irregular again. Blood was noted in the tube, so the team decided to create a makeshift positive pressure bag using the rest of the hydration pack. One of the team would blow into hydration bladder to inflate it, and close it off using pliers as a valve of sorts. They would then deliver breaths by squeezing the bladder, similar to commercial products. They used this for another 30 minutes successfully.

Helicopter transport eventually was able to evacuate the man, and it turns out that a 6.5 ETT adapter fit into the makeshift tube easily. A bougie did confirm airway placement, and etCO2 readings were monitored. Unfortunately the patient went into V fib, got ROSC, then went into it again shortly after. The patient never regained pulses after that, and was pronounced dead prior to landing at the hospital.

The most important point of this case report isn’t the cool factor of Macgyvering other equipment into functional airway tools. It’s making the hard decision to perform the cric in the first place. Making that call, even in a low resource setting, is critical. Sadly this patient didn’t survive the injury, but it wasn’t due to lack of an airway. The fact that these physicians were able to also devise and then produce something that gives some form of PEEP is icing on the cake. However, it would be nice if someone took this device and measured what kind of pressures they could obtain with it.

And remember, if you’re going to perform a makeshift cricothyrotomy as your wilderness airway, make sure to use something of proper diameter. Ballpoint pens have too much resistance, but sports bottle and hydration bladder straws will work in a pinch.

Improvised Cricothyrotomy on a Mountain Using Hiking Gear
http://www.wemjournal.org/article/S1080-6032(16)30208-3/abstract

Is there anything a SAM splint can’t do?

Deciding what to carry in your medical kit on an expedition is hard. You don’t want to leave anything out, but you can’t carry an entire hospital on your back. I mean, the wheels on the slit lamp really suck at crossing rough terrain. So you have to decide what goes and what doesn’t. Thus the reason for much of the improvisation inherent in wilderness medicine. An item that only does one job had better be the only item that can do that job, or it is extra weight.

C collars are one of those items. Now, ignoring the fact that many of them aren’t good at their job to begin with, they really aren’t good for much else. Sure, you could maybe improvise a pressure dressing out of it, but what else are you going to do? And while some of them do lay flat, they’re still pretty long and take up space that could be used for something else.

Enter the SAM splint®*. Waterproof, moldable, and able to be cut to size, it can be used pretty much anywhere on the body. And everyone has seen the picture of one being used to immobilize the cervical spine. But does it work well in that role?

Improvised C Collar in Auckland

These authors put it to the test against a Philadelphia collar using 13 EM resident “volunteers”. I’m sure they were paid well for their time. Using a goniometer they measured maximal extension, rotation, and lateral flexion. They found that no statistically significant difference in any one measurement, but looking at the results the SAM does appear to allow slightly more rotation and extension, while doing a better job of limiting lateral flexion. This likely is due to the bulkiness of the SAM laterally.

While the method of measuring falls short of a radiographic gold standards, and the number of subjects is low (but powered to an 11° difference per the authors), it looks like the SAM splint, in fact, is just as good as a Philly collar at immobilizing the C spine. I am OK with it in an awake patient, but would add more reinforcement to an unconscious patient.

Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Cervical Collar
http://www.ncbi.nlm.nih.gov/pubmed/19594206

*I’m using SAM splint to cover all the moldable splints out there, similar to how Xerox is used to cover all photocopiers. I do not receive any money from SAM Medical Products® for using their name here. You are welcome to use other splints, but this article only used the SAM.