What would Weingart do?

aka Trauma Tribulation 033a

For this Trauma Tribulation, we are opening up the floor to all our wannabe Trauma-Queens, and we’re gonna put it to the people…

“What would you do?”

Have a look through the case, think about your response and let us know in the comments section what you would do.

Once we have enough responses, Scott Weingart of EMCrit.org will tell us what he would do. And despite much shame, and gaffaws of “You did WHAT???”, we will tell you what may or may not have actually happened.

Lets go!

One day, in a hospital quite far from here, you are locuming as an ED registrar in a small provincial hospital, in the middle of an Antipodean island. It’s been a good day, and you are certainly not earning your money.

You are 11 hours into a 12 hour shift and you have seen 6 patients. With a smug smile, you remember why you gave up the daily grind to locum your life away.

The orderly turns to you, whilst mopping a pool of blood off the floor, and says, “Nothing ever really happens around here.” You pause to wonder about the pool of blood, and how it got there without your knowledge or consent. Shaking off the surreality, you turn to the nurse in charge and say cheekily, “You know what we need now? A trauma!”

She laughs.

Then the Bat-Phone rings.

“This is MICA 34. We are 15 minutes away with a 16 year-old male. Multiple stab wounds to the back. He is currently Status 2. Vitals: PR 120, BP 130, Sats 96% on Hudson mask oxygen.”

The orderly throws you a glance. You think you hate him. “Cool,” you say a little nervously, “finally some action.” The charge nurse sends you a sideways look, which almost seems like a glare. Ignoring it, you decide to plan for the trauma.

“Right!” you say to the charge nurse, “How do we get some backup?”


“Are there any other doctors in the hospital?”. “No…” she says.

“Oooohhh – Kaaaayyy,” you say slowly. “…and we don’t have any on-call”, she continues.

“Surely there is a surgeon on call? And where is the nearest trauma centre?”


Hmmm… your heart rate quickens…

You know the nearest large hospital is 90 minutes away – probably too far for a Category 2 Trauma. You try to quickly familiarize yourself with the trauma bay, which also triples as the cardiac bay and the plastering room.  Your trauma team consists of you, your charge nurse, another staff nurse, the radiographer and the blood mopping orderly. There is no CT scanner, but you have access to basic bloods and 2 units of O negative RBCs.

Oh, brother! Beads of sweat form on your brow. Before you have time to worry about anything else, the ambulance rocks up.


Here is your patient. Click to enlarge each photo.

The questions for you are… (and please ignore that thing sticking out of his right chest which may or may not be an ICC)

(1) What things immediately concern you?

(2) What are your immediate priorities?

and most importantly

(3) Do you pull the knife???

Comments please…

Find out what Weingart would do, and what may or may not have hypothetically happened here.

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  1. says

    Sounds like a typical day for a rural doctor…

    Well, let’s take this down piece by piece

    first up, group huddle and plan. we’ve got limited staff and equipment. Mobilise retrieval service only -- he’s going to need to be transferred out, so they need to be aware and canhelp us out via telemed -- share decision-making. Mobilise lab staff if available (many rural Oz settings will just have an iStat). No surgeon, but often GP’s with anaesthetic and EMST (ATLS) skills. Use them. He’s shocked by definition and we’ve only got two units PRCs. In some parts of rural Oz we’ll still use walking donors…

    OK, let’s assume he’s arrived. Standard ATLS aproach

    -- airway
    -- breathing
    -circulation etc

    Airway -- high flow O2. Intubation might be an issue with that hardware sticking out of his back, so anticipate difficulty in positioning him. RSI kit and drugs ready, kit dump ready to go…http://ki-docs.com/resources/ for illustrationsof a standard RSI kit dump. If he needs an ETT he’s going to need early finger thoracostomy…

    I am more worried about breathing and circulation -- that knife might have gone anywhere -- great vessels, heart, spleen, liver, spine, PTX or HTX. Quick look-listen-feel to exclude tPTX and portable USS to look at lung sliding, effusion, FAST etc. needle decompression with long needle (he’s 16, skinny, should be easy) if suspect tPTX, otehrwise formal ICC 32Fr…but probably time to drop in a drip first

    IV access -- two large bores. Rapid-infuser catheter (7Fr0 if I;m real worried, but caution with fluid resus as may worsen bleed and make him cold/coagulopathic. Probably titrate fluids to radial pulse, or aim for MAP 70.

    I;d be leaving the knife in -- and be talking to retrieval about HOW we are going to move him!

    • says

      Thanks Tim,

      Great thoughts.

      There are no other staff (no GP anaesthetists, etc), no ultrasound available -- no FAST.
      A CXR shows a moderate pneumothorax, and the knife outside the shadow of the SVC/IVC.

      You stick a right ICC in -- it’s swinging, no blood.

      You have talked to retrieval -- they are going to get back to you. You have limited anaesthetic skills -- you certainly could’t intubate someone on his side.


        • Gerard Fennessy (@doctorgerard) says

          Sorry Tim, I didn’t mean to suggest YOU couldn’t intubate him on his side (or for that matter have limited intubation skills) -- I meant “you” in the scenario. 😉 Sorry for any offence.

          And thats a good question about the intubation. Does he need it?

  2. Dave says

    Here’s my 2 cents worth

    Initial assessment/treatment -- My initial concern is for cardiac, lung, great vessel injury, and as Tim said spleen/liver/diaphragm also. He needs to go to theatre ASAP but of course that’s difficult in Rural practice. HR, RR, BP, Sats and mentation important to determine how shocked he is. Clinical exam incl abdo and Bedside USS to assess for pneumo, haemothorax, pericardial effusion and abdo free fluid. Simultaneously this guy needs good access (big bore lines or if he’s shut down then IO to start off with). You could make a case to treat this using CABC as opposed to ABC as A is less likely to be an issue unless he’s just about to arrest. Limit fluids until it’s necessary then use the blood you have aiming for MAP = 65 or radial pulse. Oxygen as required for sats >94%.

    It’s important to recognise that this guy is going to theatre or he’ll arrest and you’ll need to bring theatre to him in the form of a thoracotomy. You need backup in the form of a retrieval team +/- any docs in town who might be able to help. Leave the knife in if at all possible. If he’s agitated/combative consider small doses of ketamine as analgesia/sedation (ie 25mg aliquots) but know if he’s in extremis this may well drop his BP and/or precipitate a significant decompensation.

    He buys an early LT chest drain in my book (32 to 40Fr) and you could consider a Rt sided tube also depending on clinical findings as you don’t know where the knife has gone . If you get a lot of blood out of his chest and are limited in how much you have available then you could consider autotransfusion if able to in the heat of the moment again aiming for MAP 65 or radial pulse. Art line might help guide this but is probably further down the list of things to do here.

    More pressing is planning what to do if this guy decompensates during the above or before the retrieval team arrives. It would be important to communicate with your team about the issues here -- if he arrests you open his chest. I’d get whatever equipment is around to help with this brought to prepare for this eventuality. Position is difficult here as the knife is still in. I think I would leave the knife in and have him on his Rt side for intubation and thoracotomy. I’d be interested to hear others opinion regarding this as you could make the case that if he’s arrested you should just pull the knife and intubate then open him up on his back. I don’t know the correct answer to this. The arrest is most likely to be either from exanguination or pericardial tamponade so I would give at that point whatever blood/fluid you have available.

    If he’s not actively about to die I’d do all of the above including the chest drain/s, art line and prepare for intubation and thoracotomy if required then watch him like a hawk for deterioration while the retrieval team is en route.

    • says

      Hi Dave,

      Good thoughts as well. No other Docs available, no USS. Certainly no theatre (no surgeon).

      Getting the retrieval team ASAP (even just for advice) is a great start -- the paramedics can stay until they arrive. I am not sure about intubating him on his side -- how many ER docs have had a chance to do that? Like you said -- if he arrests, probably better just to pull the knife, turn him supine, intubate and deal with it.

      You get a chest drain, it has no blood in it (The CXR shows moderate PTX, but looks like the knife is not near the IVC/SVC).

  3. says

    Well, what Dave says…except probably NOT the art line in rural setting as we often can’t transduce…that said, if time allows I’d place one and hep lock it -- danger in rural setting is it being unrecognised as art line (we don’t have kit to transduce and someone may inadvertently hook up an infusion to it)

    As for autotransfusion -- in a rural setting? Well, if the abdomen or chest is open, can take blood and sieve thro gauze into an inverted sterile plastic container with bottom cut off, then flow thro more gauze into an IV line…but seriously, who can autotransfuse in rural Aus?

    It all changes if he decompensates…and Dave’s approach is a good one -- two thoracostomies, trauma shears between the two holes, Gigli thro sternum and clamshell the bugger open…

    I’d intubate im on R side or even VL on side -- done this recently in an entrapment using KingVision and worked a treat

    I forgot to mention lactate measurement

    • Seth Trueger @mdaware says

      The good news is that autotransfusion is easy — the gear is quite simple. The concept is basically: dump blood in bag. Give blood to patient.

      There are some concerns about how useful the blood is: http://www.ncbi.nlm.nih.gov/pubmed/22137140

      Lower hct, and minimal coagulation! But perfect is the enemy of good, and if nothing else is available, then it seems better than crystalloid for the traumatic bleeder.

  4. says

    Agree with all that. Though admit I don’t think I could tube him that easy on his side…

    Definitely clamshell if he codes though Most injuries would be difficult to access from the front

    And I would defo leave the knife in…

  5. caseyparker207 says

    Agree with Tim -- standard operating procedure in some Oz towns

    Only logistic / strategy I can add would be to fly the surgeon to the patient, I would not put this guy in a plane, train or automobile…. Imaging might help localise the injury if he is stable, but I would not insist if he remained tachy / shocked
    The thing that will save him if he crashes is somebody getting in there and tying / plugging / etc -- all the massive transfusion in the world will not help if he goes south.
    Best bet is to avoid cold / acid / excessive crystalloid -- i.e. do no harm.
    Put in Chest drain(s) so you have a clue what is happening in there and relieve any “B” problems

    Intubating in lateral position is not too bad -- I had a boss in Anaesth school who made us do it on elective lateral cases so we felt pretty comfortable with it. It really isn’t too hard on the normal-looking necked patients.

    • says

      Thanks Casey,

      The retrieval team can be there in 60 minutes. Can’t get a surgeon.

      The CXR shows knife in hemithorax, moderate PTX, doesn’t appear to be near the SVC/IVC.

      You stick an ICC in -- no blood.

  6. Rob Bryant says

    Agree with all of the above,
    Knife stays put
    PA (because he is prone) and lateral CXR could give some clue to potential injuries re: blade length, and current position, including injuries from the other stab wounds.
    Not exactly the GOMER Samuel Shem was referring to in House of God, but he still needs face time with a surgeon in a tertiary care facility.
    Intubate, chest tube, transfer

    • says

      Thanks Rob,

      What do people think about trying to intubate him on his side? How many ER docs have done this in their lives?

      If you were going to tube (elective vs emergent), would it be better just to pull the knife and intubate normally?

      I’m not sure…


  7. says

    Casey’s boss was sensible. As rural docs we get a year of anaesthesia training, then get let loose on the public . ED docs get 6/12 and ongoing skills maintenance on the floor

    Big bugbear of mine has been the way such training is delivered. We dont need to specialist anaesthetists, versed in the nuances of neuro- or cardiac anaesthesia.

    We DO need to be able to safely intubate, both the elective fasted case but also the unfasted, combatative, hanging-on-to-BP by fingernails type patient as in this scenario

    So…having a boss who ‘gets’ the likely skills set is useful, as is ongoing training. logistics over strategy. We dont get much chance to do this in day-to-day practice, which is why FOAMed is so valuable.

    DuCanto talks a bit about training on Minh Le Cngs blog recently. Elective lists with a sensible specialist supervising in training are a great exercise. If you havent already, try these…

    -- intubate in L lateral with std blade
    -- intubate sitting up
    -- run through DAS algorithms with all staff once a month
    -- practice a massive transfusion scenario
    -- simulate a monitor failure mid-anaesthetic … How will you proceed? (Happened to me twice this year, thanks Health Dept for supplying crap kit with no spare). Good for my grey hairs

  8. says

    1st priority would be make sure he isn’t carrying a blade or hand cannon.

    I’m sure he was just popping out for a pint of milk when he was stabbed in the back several times like most stabees, but he might be an unsavoury character.

    I’d leave him prone, palpate everywhere for surg emph, USS chest and abdo ( remembering everything upsidedown), bilateral chest drains, neuro exam before any RSI, decent analgesia, Antibiotics, think about tetanus. Get trauma/ CT surgeon in same room ASAP -(from own experience in UK, quicker to move pt). Ask transfer team to bring O-neg.

    As soon as his numbers start rapidly heading south and I “know” he’s gonna arrest soon… This is when I’d give modest dose ketamine, pull out blade, flip him over and join the thoracostomies via the sternum. No point in waiting till he actually arrests

    • says

      Hi Ciaran,

      Thanks for your thoughts.

      I believe this “gentleman” was just walking around, minding his own business, when the knife fell into his back -- 4 times. It happens surprisingly often, dontchya know…

      I like your comments about the numbers going south -- because at this stage his numbers aren’t too bad.

      How many ER docs would be comfortable doing thoracostomies by themselves? Are bilateral chest tubes sufficient?


  9. Duncan says

    Bilateral chest drains.

    Permissive hypotension, blood only ideally but crystalloid if run out.

    Leave his airway up to him. LMA if loses it, intubate if/when safe further down the track.

    If clinical / sonographic tamponade -> drain.

    If arrests or deteriorating towards without other reversibles (all mentioned above) -> clamshell.

    Early priorities are rounding up local skillmix if present, regional retrieval service (fly in specialists v fly out patient), getting blood from wherever.

    Supportive cares (ABs, analgesia, ADT, dressings.)

    Knife -- leaving in might ‘plug hole’ but also may move and cause further injury. Pulling out might exsanguinate but prevent further injury. I’m tempted to pull it as moving lung against sharp blade might be problematic, but if he is stable then maybe not. If CXR shows deflated lung clear from knife blade then pull it.

    • says

      Hi Duncan.

      Thanks for your comments.

      Pull the knife -- a lone voice in the LITFL wilderness.

      The CXR does show moderate PTX, and the blade appears to be away from the IVC/SVC/RA.

      Would the retrieval team (helicopter, ER physician, paramedics) transport him prone or in a difficult intubation position? Would they prefer to transfer him supine, sans knife??


      • Duncan says

        In that case I would say that the risks of leaving the knife in are higher than taking it out, although ideally I’d like ‘authorisation’ from the regional cardiothoracic consultant (not reg).

        I’d transfer him unintubated if he didn’t need it. Retrievalist can agree or disagree dependent on their own assessment but if he has no airway problem and can ventilate OK then the only risk is cardiovascular collapse (LMA in a hurry as above and open the bonnet).

        If it’s well away from major vessels, risk is to intercostals, which can be dealt with with a finger / swab / catheter balloon in a hurry. Any other injury is already established.

        Pull the knife.

  10. says

    Is it appropriate to consider emergency thoracotomy in a peripheral hospital without a surgeon (of any kind, never mind a trauma/ CT surgeon) on site…?
    I don’t think so.
    If this man arrests in such a setting, it is all over IMO -- not worth the risk to staff to proceed with a worthless emergency thoracotomy when there is no one to pass the ball to.

    • Duncan says

      Man up Nickson! ;o)

      Practitioner dependent. You don’t necessarily know what injuries you are dealing with until you get in there.

      If he has an unrecognised tension pneumothorax, decompression alone may fix him.
      If this guy has an isolated stab wound to a great vessel, a finger / swab may fix him.
      If he has an isolated cardiac laceration, pericardiotomy +/- finger / swab may fix him (not suggested from this scenario).

      He doesn’t need closed. He doesn’t need definitive treatment. He can be transported with positive pressure ventilation and an open chest on sedation.

      I think it boils down to the individual practitioner. If you think that the risk of harm is higher (e.g. any suspicion of blood borne disease) or that the return is lower (e.g. prolonged downtime, comorbidities) then the balance shifts. Your expectation of success may also depend on your previous experience -- someone who has been involved in previous thoracotomies v someone who has read about them. A 16yo is relatively unlikely to carry infectious hazards and the return is potentially greater.

      I think your description of a thoracotomy as ‘worthless’ is a bit telling -- based on what?

      • says

        Has there ever been a successful case of emergency thoracotomy performed in a peripheral hospital 90 minutes away from a surgeon?
        Gerard -- does this ED even have a thoracotomy kit?


        • says

          Look, I agree…90 mins away from cardiothoracics and a clamshell…he doesnt have much chance

          That said, I thought the procedure was fairly straightforward…bilateral finger thoracostomies then trauma shears to cut between

          Got a SA-trained rural doc with me. He’s done ‘a few’ pericardial repairs.

          But getting back to reality, his airway is intact, we’d practice permissive hypotension and, based on imaging so far, would transfer him lateral. LMA if he codes or, as others suggest, pull, flip, tube.

          So, WWWD?

          And what did YOU do?

        • says

          I think if you asked for a thoracotomy set at this hospital, you would be lucky if they handed you a scalpel blade, a dressing pack and asked “What size gloves, Doctor?”.

          Should we be even entertaining the idea of thoracotomy?

          I wonder if there are any retrieval physicians around who would care to comment? What advice would you be giving the doctor? Would you pull the knife? Would you transport him prone? Would you want to flip him over? Would you ask for a surgeon to come with you on the retrieval?

        • Duncan says

          Given that:
          -- (from trauma.org) ‘The first successful ‘prehospital’ thoracotomy and cardiac repair was carried out by Hill on a kitchen table in Montgomery, Alabama in 1902.’
          -- we can have successful prehospital thoracotomies (http://www.ncbi.nlm.nih.gov/pubmed/21131854)

          I wouldn’t have any particular concern about doing this in a peripheral hospital. This guy intuitively should be in the lower mortality group if he arrests / is periarrest in from of you -- neurologically intact with no underlying morbidity likely (though that all depends on the reversibility of his injuries when you get in the chest).

          Interestingly from a quick literature search there was a subgroup of 14 patients seen by HEMS in the early 90s who had recorded GCS of less than 3. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502735/). Notably most of this group also had blunt injury, but I will take this as a practice point that I will no longer consider ED thoracotomy on patients with a GCS of 1 or 2.

          • says

            Ha ha. Classic article -- that is definitely one for the R&R files. (It was written by cardiothroacics -- they’re not brain surgeons you know!)

            I guess the point here is that you only have an ER -- a very basic ER. No OT, no other docs, no anaesthetist, a couple of nurses, no equipment -- I think it would be extraordinarily difficult to do under those circumstances.

            Who does the CPR? Who manages the airway? When or where do you stop?

          • Duncan says

            In the event of needing thoracotomy (which, in any event, is unlikely despite it becoming a focus for discussion):
            -- no indication for CPR
            -- airway with LMA, BVM on 100% or oxylog 1000 on 12x500 with no air mix (I’m presuming that’s the kind of thing we’re dealing with here?)
            -- open the chest, if something can be fixed -- fix it. Else call it. If both pleura are open, pericardium is open, and there is no controllable source of haemorrhage from an intercostal / cardiac chamber / great vessel, then there’s nothing else to add.

            Anaesthetic -- vecuronium. Add adrenaline at 10 if ROSC for multimodal anaesthesia. Ketamine as a late consideration.

  11. james cuthbertson says

    Chris -- I agree. Also some posts seem to suggest a prearrest thoracotomy “if deteriorates” -- I am not convinced that this is a great plan, especially since Gerard’s subsequent posts indicate that an OT is a long way away.

    If he arrested, I think pericardiocentesis is as far as I would go. If that got him back, and it was possible to arrange with local resources then I’d try the USMC option of high volume whole blood from sentinent blood banks.

    As far as his airway and the knife -- I’d be loathe to remove it initially but with CXR & ICC findings I would consider cutting most of the handle off and padding with gauze to go supine (or cut a hole in the mattress?). This may cause problems for transport but at least allows me optimum positioning for airway Mx -- I could then pull it with retrieval team onsite to help/guide etc. Ultimately I think I’d be guided by phone advice from a surgeon for that though.

  12. Minh Le Cong says

    hi folks
    some comments from a retrievalist who works in a region where stabbings are not uncommon.

    yes we have transported patients with knives in situ but on the back is very tricky. all it takes is to lose the positioning and that knife can get rammed in further. So they either get anaesthetised prior to transport to ensure they do not move and we can position them as we like.
    Or you remove the knife..and given the CXR findings I would remove it.
    Of course he needs a chest drain and something to close over the wound.
    You can transport someone on their stomach if you choose to and if its a short flight

    I would only do thoracotomy in penetrating traumatic arrested patient who lost signs of life in front of me. You can do it without an OT or formal surgeon. A colleague of mine has talked a remote doctor over the phone to do one in a penetrating trauma arrest. patient died but procedure performed satisfactorily.

    I have done one in a remote clinic in a 140Kg + bloke stabbed in chest who arrested. on entering chest, sudden release of air and rapid ROSC. made a full recovery. My instruments were a scalpel and several pairs of hands. lucky no cardiac injury just the pneumo. I saw him in remote clinic a month later with a fully healed chest scar.

    for the right indication, it is worth the risk.

    London HEMS teach a simple prehospital thoracotomy protocol : scalpel, forceps, trauma shears gloves.
    But here is the thing. Chris is right. its a high risk procedure and the only useful indication in my view is patient arrest with history of penetrating chest trauma. You can try for blunt trauma arrest but the odds are not in your favour. london HEMS series shows about 18% leave hospital survival rate for the penetrating traumatic arrest patient.

    Cliff Reid has been promoting the concept of teaching resuscitative surgical skills to prehospital docs and I support this viewpoint. Sometimes you just cant wait for a formal surgeon to arrive . you need to have those surgical skills. I view it like surgical airway. its surgery to resuscitate.

    • Luke Lawton says

      I’m coming a little late to this discussion (after some time away from Medicine over Christmas!) but as an emergency and retrieval physician I have to say I tend to agree with Minh and Chris.

      Sorry Duncan.

      From the perspective of the person in the aircraft coming out to get this man, my thoughts are:
      1) The knife needs to go prior to transport. Ideally when the backup (ie the retrieval team) is present and the chest tube is already in. There’s no way I could guarantee that the knife position will not shift in transit, and from the information given it’s currently not in contact with anything other than the lung (xray images and tube thoracostomy findings). Getting in a vibrating AW -- 139 or Beechcraft super Kingair might change this.
      2) If the patient arrests I am not sure that there is any point to thoracotomy in this setting.
      3) I would only delay to secure the airway in the event that the patient was unlikely to maintain it by himself or he posed a significant risk to the safety of the aircraft (agitated, intoxicated, obtunded because of morphine etc). Otherwise in the interests of rapid transfer to definitive care I would take him doing his own breathing.

      I am intrigued by this talk of autotransfusion. Does anyone have any experience of this in Australia?

  13. says

    Well you folks will hear my reply based only on the original case shortly. Gerard has supplied all sorts of juicy tidbits in these comments that I didn’t hear until now, so some thoughts.
    Retrieval in your neck of the woods is very different than in the States. You folks get trained docs with a bevy of interventions at their disposal, so I would leave the knife in situ. What do I gain by yanking it in a stable patient. If need be, pull it if the patient decompensates in the air. If Minh tells me he wants the airway controlled before the pt flies, then let’s do that in the ED as a team. Lateral intubation is not hard you just turn your body to match the patient’s orientation. Minh will probably show up with video which makes it even easier. If you fail your first pass and the pt’s sat is not being maintained, pull the blade, put him on his back, reoxygenate and intubate normally.

    If you folks did decide to pull the knife, put the chest tube in first, just as they did.

    Thoractomy will be something of a shitshow in this case. You would definitely want to do it as the BP is going way south but before arrest. Clamshell is not doing you any favors, this is a posterior wound and your visibility is going to be poor with the patient supine. Probably better off going in with the pt propped up on some sheets extend the L incision toward posterior and pray it is an intercostal that you can put pressure on with some sponges at both ends of the cut vessel, while your nurse pour in whatever blood and products this center has and hope the BP recovers. If it does, then some poor soul is going to sit there holding pressure until you can fly in a surgeon.

    If it is not an intercostal, then it is lung. If you know how to find the inferior pulmonary ligament and cut it, then you can clamp the hilum or do a pulmonary twist. Both of these maneuvers are hard and the pt will prob die before definitive management can get there,

    Every ED doc should know how to perform a thoracotomy with the sole goal of opening pericardium and putting a finger on a hole. This can be life saving anywhere regardless of the time for surgeons to arrive and is well within the skillset of the specialty. If you can’t do this, come to SMACC2013 and I will take you through it.

  14. Minh Le Cong says

    As Scott says, lateral intubation is not impossible and with practice is not overly difficult. You can start practising in mannikins and then if you have a willing anaesthetist can try it on elective lists as Tim alluded to . One of my anaesthetic teachers used to make us intubate from the side of the patient and lateral position for a challenge…in case we had to. Now if you trained with the Fastrach ILMA..or any ILMA, tubing from lateral position is not too hard. You drop in the Fastrach, ventilate and then blindly intubate. recently for skills training, I stuck a mannikin onto a rack of shelves, with little space between mannikin face and shelf. Challenge was to intubate. With Fastrach, it was straightforward tube. I have used a CMAC in a lateral intubation and it was fine, but so is DL as long as you train for it.

  15. says

    Regarding intubation on his side -- the vast majority of EPs would not have ever done this. Many anaesthetists may not have either.

    Don’t pull the knife….I repeat, don’t pull the knife

    So if you really need to tube (and I would try to hold off if possible until the troops arrive), why not fashion a hole on the bed or put another bed/trolley alongside so that when you turn him onto his back, the knife will stick down into the gap and not be pushed further into him. Just a thought