"I'm out of ideas" Advanced Airway Seminar

Every time I try to dream up a clever title for a conference class I get stuck trying to not be too cute.  We all know the offenders who come up with something cute and clever as a class title, followed by a clinical description of the class.

Kind of like "Kids are suckers for a good joke - The Implications of Vaso Vagal Instructions using Humor on Children during Acute Asthma."  I still don't want to take the class but now I'm fascinated on how this is an hour long CE.


Not too long ago we had a call that could easily fill a 90 minute CE and we even accidentally named the seminar: "I'm out of ideas."


Called for the "possible heart attack," units are responding to a tough to reach location.  The last "possible heart attack" we were sent on was a man coughing so we're literally rolling into the unknown.  About 3 minutes into the response the first due rig asks dispatch "Can we determine if the nearby AED has been pulled (they're all alarmed) or if PD is on scene doing CPR?"

"Yes" is the only response.



PD, as always, is doing textbook CPR that puts the AHA video to shame.  They know our script and as we approach we hear one officer call out "15 minute down time, 1 shock delivered!"  Yes, you're jealous. No, you can't have them.

BVM, OPA and IV are almost  done in the background and an EPI is onboard as we prep for a tube.  I'm a big fan of keeping the BVM but considering the size of the patient and our trouble getting good chest rise we decide to go old school.

That would be the theme for the next 30 minutes.  Old School.

"Chords!  Passing!  End Tidal!" the medic calls out as if listing off his 3 favorite books, the blade snaps closed on the handle and is placed on the cold concrete as I begin to bag.


No sign of emesis, no stained clothing, evidence on mustache or chin...uh oh.  We have no sounds over the belly and zero compliance, confirmed with a big fat ZERO on the ETCO2. "Pull it and get the mask" I mention as the EMT draws the 10cc syringe out from the tube.

Mother. Of. God.

A solid 5 inches of rice, noodles and what appears to be either spinach or seaweed is clogging the tube and now filling the oropharynx.  Not in a wet, suctionable, as seen in Medic school fashion, but in an oddly dry, cakelike consistency.

"5 CALL!" is heard behind us as the local Ambulance arrives with a new hire student, ETT and camera scope in hand.

"Phew" I think.  This will be so much easier with a camera.

Wrong.  Remember our theme?  Old School.

The camera is constantly being obstructed by the food, the yank tip can't get the rice and noodle and the intern is wondering why we don't "just tube the bubbles?" Dude...that never works.

Suddenly the combined 75 years of experience begins to speak up,

"V-Vac!" Nope.

"Pull the yank tip off and just use the suction tubing!" Nope.

"Let's turn him to recovery and do some abdominal thrusts!" Oh yeah! Nope.

No matter of technology or mechanical maneuver was clearing the trachea.  19 year old me would have performed a surgical cric on him already but, alas, this is 2017 in California.  Besides, all we'd have is a new hole to clear.

"Options?" I ask the assembled crowd, CPR still in progress and a BVM standing by incase we get anything.  Before we knew what had happened 30 minutes had elapsed on the scene.  The BLS member keeping times on the Epi confirmed it.  Management of the scene was mine and time got away.  Dammit.

"We are leaving or we are done" and we began to load him up.  Quick thinking had the medic from the ambulance calling ahead to the nearby facility to warn them of this critical airway.

As we began the 5 minute walk from where he lay to as close as the ambulance could get we ran down the list of interventions attempted ending with...

"I'm out of ideas."

So was the ED.

Our preferred, dream intervention would have been an even bigger mess lying in the poorly lit garage.  We know that now from the absolute chaos the ED created.


It is important to remember that many of our interventions can take place enroute and others can not. Half of what we tried would have been impossible in the back of a rig and the other half just as useless but the major take away from this call was time.  Do what we can't do later now and do what we can do now, later.  While the old days of intubating with the long spine board on my knees in the back of the rig is over, we can't forget that, sometimes, that's what needs to be done.

You have a scope on your blade?  Do you know how to use it?  Do you know when it has exceeded its few limitations?

Do you know when to quit?

Do you have anymore ideas?  Because, if not, I'm calling it.