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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 they 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 First 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. The airway is a bloody mess and BVM ventilation results in the 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 in 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 a sign of a 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, 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.


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