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A Tale of Two Airways

0831-haskell

It was so frustrating. You'd get a call from a parent wanting simple advice, and you had to say, "I'm sorry, we're not allowed to give advice over the phone. But if you'd like to bring Johnny in to the emergency department, we'll have a doctor take a look at him."

We were telling this to the very same parents who would annoy staff when they actually brought Johnny in for that runny nose, or fever, or stomach ache or whatever. I always had to remind myself why we were prohibited from giving advice over the phone. To do this, I would recall the Mylanta run back in Lorain, Ohio.

The kid had a tummy ache, so Mom called the ED for some advice. The nurse told her to give the kid some Mylanta. Apparently, the mother went out and bought some Mylanta -- gelcaps instead of liquid. The nurse had just assumed the mother would know not give a gelcap to a young child, and it never occurred to her to specify. That's the thing about assumptions; by their very nature, we're rarely aware of them when we make them.

So, Mom buys the gelcaps and gives one to the kid. The kid chokes on it. We arrive to find a blue kid with a completely occluded airway. The thing about a gelcap is, it dissolves, sort of, and you can't grab it with your McGill forceps. The airway is so tiny that it doesn't take much gel to block it off. So, you can't pull it out, you can't suck it out, and you can't push by it. And because it coats the whole airway, neither needle nor surgical cric will do any good. It's the perfect airway occluder.

Thinking about that run always makes me think of another kid, years later, who came to us in the ED. The local EMS unit brought him in with an occluded airway. But this time, it wasn't a geltab. It was just a piece of food. The medic had spent the time from arrival on scene to arrival at hospital trying to remove the obstruction with a laryngoscope and forceps -- 10 or 15 minutes. The kid became pulseless in the rig. He had an IV, and they had given epinephrine. The obstruction was removed within two minutes of his arrival in the ED. I couldn't believe it. What happened to this medic's training? Common sense?

ABCs in kids is almost always airway, airway, airway. If there ain't no A, there ain't no B. What happened to all of that? What's the point of transporting without an airway? What's the point of the IV, the compressions and the meds without an airway? Did it not occur to the crew after the first 30 seconds of trying to remove this thing with forceps to try something else? Chest or abdominal thrusts? Back blows? Hang him by his ankles? Needle cric? Surgical airway? Try to push the tube past the obstruction? Something? Anything? Why is it that if first we don t succeed, we try the same thing that didn't first succeed, over and over again? How many times have you heard a medic, laryngoscope in hand, squinting into the oropharynx and chanting the mantra, "I've almost got it. I've almost got it ...."

Well, this time he didn't get it.

And I don t get it, either.

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