What comes after the Heimlich maneuver

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyones skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aarons Tracheostomy Page and it bills itself as "The Internets leading tracheostomy resource since 1996."

Heres an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers dont need an airway in a hurry and they dont bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwells outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?

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Hospitals Mess Up Medications in Surgery—a Lot

Yes, that was the inflammatory headline on Bloomberg Business News last week. It is great click-bait, but factually off base because the research it refers to was done at only one hospital.

Heres what the study found. During 277 operations with 3,671 medication administrations observed at the Massachusetts General Hospital, 193 (5.3%) involved a medication error or an adverse drug event. One or more errors or adverse drug events occurred in 124 (44.8%) of the procedures.

In all, 40 (20.7%) adverse drug events were not preventable—for instance, an allergic reaction to a drug that was not known about before. Of the remainder, “32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed adverse drug event and an additional 70 (45.8%) had the potential [emphasis added] for patient harm."

Sounds bad, but the Bloomberg article goes on to say "While all the errors observed in the study had the potential to cause harm, only three were considered [potentially] life-threatening, and no patients died because of the mistakes. In some cases, the harm lay in a change in vital signs or an elevated risk of infection."

The hospitals own press release, published on the science website EurekAlert, said this: "The most frequently observed errors were mistakes in labeling, incorrect dosage, neglecting to treat a problem indicated by the patients vital signs, and documentation errors."

Mistakes in labeling syringes, occurring 24.2% of the time, were the most common type of error despite the presence of a bar code-assisted labeling system. This begs the question, how valuable is a bar code system that only prevents problems 75% of the time?

A website called FierceHealthcare took it up a notch saying, "While the research was conducted on procedures that took place at MGH, it indicates that similar failures happen at hospitals around the country."

It indicates no such thing. The paper actually says "our findings may not be generalizable to nonteaching hospitals." Or as is the case with most papers from a single institution, the results may not be generalizable to any other hospital.

Finally, the lead author of the study poured more gasoline on the fire with this comment, "Patients don’t need to go into surgery thinking that they’re going to have lasting permanent harm every second operation."

The study found nothing to suggest that 50% of patients suffered "lasting permanent harm." In fact, it isnt clear that any patients suffered lasting permanent harm, and most (66.7%) of the medication errors and adverse drug events were only potentially harmful.

Google “medication errors” and click on “News” for links to several more hand-wringing reports about the MGH study.

Although the paper and its accompanying media blitz may have overstated the severity of the problem, too many potentially harmful errors are occurring in the operating room and anesthesiologists need to clean up their act.

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