Airway & Respiratory, Columns

Can You Really Perform an Emergency Cricothyrotomy Using a Ballpoint Pen?

Issue 11 and Volume 41.

To the Point

Kisser U, Braun C, Huber A, et al. Bystander cricothyrotomy with ballpoint pen: A fresh cadaveric feasibility study. Emerg Med J. 2016;33(8):553–556.

This month’s article is in the mythbusters category of EMS research—when we should question even the most advanced procedures and popular beliefs. Like TV’s MacGyver, EMS providers are out-of-the box thinkers; we know from experience that we can often find a way out of any challenging situation. We also know, however, that popular media portrays lifesaving maneuvers which may not actually work in the real world.

Background: Cricothyrotomy is often touted as one of the most advanced and invasive lifesaving airway procedures. It’s relegated to a last resort used after every other airway maneuver has failed. In the world of TV and movies, however, cricothyrotomy is as simple as using a ballpoint pen to punch a hole.

This is the myth that Dr. Kisser and his co-authors sought to “bust.” Kudos to them for using peer-reviewed science to put popular fiction (pulp fiction?) under the microscope.

Methods: Three models of ballpoint pen were selected for the study. The first question the researchers asked was if the lumen of the pens was wide enough to allow for the airflow necessary to serve as a cannula. After testing airflow through each pen, researchers determined only two of the three pens were suitable. They then had 10 volunteers attempt cricothyrotomy in cadavers using one of the two pens.

Results: Only one of the 10 volunteers was successfully able to perform a cricothyrotomy using a ballpoint pen, but it took three attempts and a time greater than five minutes. Unlike TV minutes, which go by in a flash, this delay would be problematic in a resuscitation situation. The most common issue among the participants was they were unable to penetrate the trachea or the cricothyroid ligament. The authors concluded, “cricothyroidotomy just with a ballpoint pen is virtually impossible.”

Discussion: “Don’t try this at home” is the obvious conclusion here. Pulp fiction is just entertainment, not true in clinical practice. Seasoned EMS practitioners know how hard it is to make the decision to insert a sharp object into someone’s neck, let alone complete the procedure rapidly with someone who’s clearly not getting any air.

Conclusion: We secretly are left wishing this group had tried to bust a few other film-induced myths while in the lab. Maybe chest decompression with a ballpoint pen and realignment of severely broken bones? For now, we can rest assured that ballpoint pens should stay in our shirt pockets and on our run reports—not jammed into the necks of our patients.

Bottom Line

What we already know: Popular media portrayal of emergency procedures isn’t always accurate.

What this study adds: In the case of emergency cricothyrotomy, a ballpoint pen is not sufficient to establish a patent airway.

Sim vs. Didactic

Van Dillen C, Fitzpatrick D, Rowe J, et al. Effect of simulation training on prehospital provider competence and knowledge with needle cricothyrotomy. Acad Emerg Med. 2015;22(5):S245–S246.

On a related but more serious note, watch for a full article on an abstract presented by Van Dillen et al. at the Society for Academic Emergency Medicine. Working with Alachua County Fire Rescue, the researchers compared simulation vs. didactic training on knowledge and comfort of 92 paramedics performing pediatric cricothyrotomy. The group doing simulation was significantly more comfortable and knowledgeable, confirming the adage, “train like you are going to fight.”

EMS Today the JEMS Conference

Learn more from David Page at the EMS Today Conference & Exposition, Feb. 23–25, in Salt Lake City. EMSToday.com

UCLA prehospital care research forum

Visit www.pcrfpodcast.org for audio commentary.