Keychain Emergency Airway Device (Video)

Health professionals who know how to perform cricothyroidotomy to obtain an emergency airway in someone who is obstructing can appreciate a nifty keychain device called LifeStat.

LifeStat can be carried around and immediately utilized to perform emergency cricothyroidotomy in any setting.

Watch a video here to see how it works.

It can be purchase from Shippert Medical for $145 here.

Reference:
Utilization of the LifeStat emergency airway device. Ann Otol Rhinol Laryngol. 2008 Jan;117(1):1-4.

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Man Chokes to Death During Air Flight... Preventable?

Image courtesy of digitalart / FreeDigitalPhotos.net

News media reported on Sept 5, 2011 about Robert Rippingale who choked to death during a flight from Singapore to New Zealand. He was with his girlfriend who noted he was shaking and turning blue after eating an in-flight meal. A doctor and two nurses attempted to save him though unsuccessfully.

The article reports that CPR was performed to try and save the man, but the obvious question is whether a Heimlich maneuver was done. Obviously, as long as an obstruction is present, doing CPR is bound to fail.

Assuming a Heimlich maneuver was performed and failed to remove the airway obstruction... what could have been done to save this man's life?

Let's assume best case scenario of having an experienced ENT surgeon was on board.

The surgeon could try to relieve the obstruction manually by looking down the throat using a laryngoscope and using instruments to remove the food obstruction from the airway.

If that fails, an emergency cricothyroidotomy would have saved this man's life. This emergency life-saving procedure is in essence making a hole in the neck directly into the airway. It is slightly different from a tracheostomy in terms of where anatomically this hole is made, but the end-result is the same.

Question is, EVEN if you had an experienced ENT on board, would an airplane even have a laryngoscope as well as instruments to remove a food impaction? Would an emergency cricothyroidotomy even be possible due to prohibition of sharp objects in airplanes? After all, you still need a knife of some sort to make the incision and to dissect down to the airway. Without a sharp instrument, this step would be impossible even if you have someone who knows what to do.

According to Appendix A to Part 121 of Title 14 of the Code of Federal Regulations (14 CFR 121), the specific requirements for US carriers regarding first aid and emergency aid kits are as follows:

For 0-50 seats, one kit is required; 51-150 seats, two kits are required; 151-250 seats require three; and more than 250 seats require 4 kits.

These kits must include, at a minimum:

• 16 Adhesive bandage compresses, 1-inch
• 20 Antiseptic swabs
• 10 Ammonia inhalants
• 8 Bandage compresses, 4-inch
• 5 Triangular bandage compresses, 40-inch
• 1 Arm splint, noninflatable
• 1 Leg splint, noninflatable
• 4 Roller bandage, 4-inch
• 2 Adhesive tape, 1-inch standard roll
• 1 Bandage scissors

Also, at least one approved medical kit must be on board that includes at a minimum:

• 1 Sphygmonanometer
• 1 Stethoscope
• 3 Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent.
• Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent).
• CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent.
• 1 IV Admin Set: Tubing w/ 2 Y connectors
• 2 Alcohol sponges
• 1 Adhesive tape, 1-inch standard roll adhesive.
• 1 pair Tape scissors
• 1 Tourniquet
• 1 Saline solution, 500 cc
• 1 pair Protective nonpermeable gloves or equivalent
• 6 Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications).
• 4 Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications).
• 4 Analgesic, non-narcotic, tablets, 325 mg
• 4 Antihistamine tablets, 25 mg
• 2 Antihistamine injectable, 50 mg, (single dose ampule or equivalent).
• 2 Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent).
• 4 Aspirin tablets, 325 mg
• 1 Bronchodilator, inhaled (metered dose inhaler or equivalent).
• 1 Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent).
• 2 Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent).
• 2 Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent).
• 2 Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent).
• 10 Nitroglycerin tablets, 0.4 mg
• 1 Basic instructions for use of the drugs in the kit.

It seems that there are airways of different sizes available, but no laryngoscope or other instruments to remove airway foreign objects.

Nowhere is a scalpel or knife listed either. You have needles and syringes which theoretically can be used to "poke" into the airway. However, though an 18 gauge needle might work for a chipmunk's airway, it is not sufficient for a full-grown man. It would be like breathing through a straw, but 50 times smaller and even more difficult to breath thru.

So it appears that in the event of an airway obstruction during an air-flight for which Heimlich fails, you can have the world's best surgeon present, and the man still would have died.

Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough "fabric" and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on.

Read the news article here.

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2 Years Old Child Dies After Tonsillectomy

In Wichita, Kansas, jury has begun deliberation regarding the death of a 2 years old boy in 2006 the day after tonsillectomy surgery. Read the story here.

Based on the limited information provided, the relevant facts I have gleaned from the story are as follows:

• Child was appropriately admitted to the hospital after surgery
• There is some question regarding what was going on with his oxygen levels and other vital signs during hospitalization
• Autopsy revealed pneumonia confined to a small part of one lung
• Hydrocodone was prescribed for pain
• Lack of accurate communication between nursing and the surgeon
• Unclear patient/family factors
• Child had history of breathing problems (probably asthma)

Overall, it seems that this child's death was the result of many errors that piled upon each other. Any single error certainly wouldn't have resulted in death.

Reading between the lines, I conjecture the following might have occurred, giving as much benefit of the doubt to all parties involved, though I may be totally wrong:

1) Tonsillectomy surgery was uneventful and routine.
2) During extubation, coughing may have occurred with some aspiration of secretions (extubation... cough, cough, cough... strong inhalation with secretions resulting in aspiration)
3) Child was admitted after surgery due to age.
4) Child was overly sedated with hydrocodone and as such, not able to easily cough up secretions. Rather, probably slept more often than not.
5) Vital signs were probably on the low normal side. If truly abnormal, something should have been done immediately (nebulizer treatments, a chest x-ray, etc).
6) Lungs were listened to and potentially clear on auscultation given pneumonia was localized to only a small part of one lung. This exam was probably performed only once or twice. Given the child was sleeping, nursing may have decided (family may also have requested) that he be left alone so he can sleep rather than be disturbed and examined which would have caused him to start crying.
7) Patient was recommended for discharge the next day based on available information.
8) At home, child still overly sedated given hydrocodone administration by parents to treat pain resulting in inadequate lung ventilation thereby not allowing for aspirated secretions to be coughed up and out.
9) Death

A few areas of concern on my part...

It is possible in the parent's misguided resolve to ensure their child will not be in pain, that they may have given hydrocodone even if the child was not complaining of pain. It would be important to know what his hydrocodone narcotic level was in his bloodstream. In any event, this only reiterates that hydrocodone should not have been prescribed in a child this age. Rather plain tylenol or at most tylenol with codiene would have been more appropriate and certainly less sedating.

The story also reported the child had a history of breathing problems, most likely asthma. This fact just exacerbated the overall situation. In a healthy child, the lungs would have been much hardier and less prone to compromise.

Second, a pneumonia that has been present for many days is unlikely if localized to only a small part of one lung (one would expect a large area to be affected). Furthermore, if the pneumonia was as severe as they say BEFORE surgery, high fevers would have been present in which case, surgery would have been cancelled regardless of cause due to concern for febrile seizures induced by anesthesia.

In summary, what likely happened was an unrecognized aspiration event in a child with a history of asthma followed by over-sedation with narcotics which led to this unfortunate demise.

But... that's just my guess based on incomplete information.

Read the story here.

ADDENDUM 7/30/11: Jury ruled in favor of the defendants absolving of any malpractice in this case. Of note, a comment about the case by one of the jurors stated "I was one of the jurors on this case, and it was very hard to come up with a verdict. The reality of the situation is that there was not an acceptable cause of death and there was not enough evidence proving that Wesley and Dr. Kubina more likely than not caused the death."

Read more here

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A Crime For Doctors to Ask About Guns?

When I saw this report on ABC about a Florida politician wanting to make it a crime if a physician asks about guns in the home or else face 5 years in jail and up to $5 million fine, I could not believe it.

Who cares that more children die of accidents than of diseases.

It is standard practice for pediatricians to provide guidance on a variety of unintentional injury-prevention counseling for infants, preschool-aged children, school-aged children, and adolescents as well as their parents. These include:

• Traffic safety
• Burn prevention
• Fall prevention
• Choking prevention
• Drowning prevention/water safety
• Safe sleep environment
• Cardiopulmonary resuscitation
• Poison prevention
• Firearm safety
• Sports safety

According to the American Academy of Pediatrics, gunshot wounds account for one in 25 admissions to pediatric trauma centers in the United States. Furthermore, a gun in the home is 43 times more likely to be used to kill a friend or family member than a burglar or other criminal.

As the trite but true saying goes, an ounce of prevention is worth a pound of cure.

And in this day where healthcare costs are spiraling, how precious and common-sense it is to ask and provide guidance on firearm safety and security at a cost of one physician visit rather than a child accidentally getting shot and using up hundreds of thousands of dollars worth of surgeries, hospitalizations, studies, physician visits, etc.

Read the ABC report here.

Why as an ENT am I even bothered about this? It's because I often have to ask similar but what some people may consider very private questions akin to asking about guns (ie, oral sex).

Reference:
Office-based counseling for unintentional injury prevention. Pediatrics 2007 Jan;119(1):202-6.

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Twins Die after Tonsillectomy and Adenoidectomy

Twin Ohio boys, 3 years old, both died on April 19, 2006 after both kids underwent tonsillectomy & adenoidectomy (T&A) less than 48 hour earlier. Both children were discharged home on the same day of surgery. Read the story here.

On Aug 6, 2010, A malpractice suit was found against the otolaryngologist who performed the surgery, based on the assertion that if the surgeon "kept the children in the hospital overnight - something within his power and a standard practice for children under 3 and for those with a history of breathing trouble - their low oxygen levels could have been detected. Maybe they could have been saved..."

Tonsillectomy and adenoidectomy (T&A) is a very common surgery done on children for a variety of problems. However, this surgery does carry risks, especially as it relates to airway swelling that almost always occur to some degree after surgery, especially uvular swelling (see picture).

Due to this swelling and risk of airway problems, most (but not all) otolaryngologists are reluctant to perform this surgery on very young children (less than age 2 for adenoids and less than 4 years old for tonsil removal) unless absolutely essential. And when performed on such young children, most (but not all), otolaryngologists will admit into the hospital for overnight observation.

I personally take the extra step of warning parents of very young children undergoing T&A that given this airway risk, it is not unreasonable to not only be admitted overnight after surgery, but to also have the surgery done in a facility that has an ICU just in case airway loss occurs. Otherwise, if done in a community hospital without pediatric ICU capabilities, an airway loss event would require emergency intubation followed by helicopter life-flight transportation to a hospital that does have one.

By the age of 4 for tonsillectomy and 2 for adenoidectomy, the airway risk for most children becomes negligible and it is safe to discharge home same day of surgery unless other medical problems/concerns are present.

Why at those particular ages is it fine? It is mainly because the child would be much bigger with a correspondingly larger airway that can accomodate the swelling. Furthermore, a child who is older can communicate what they are feeling better which leads to the other risk that is present in very young children.

The other risk involved is over-administration of narcotics which are prescribed after surgery. When the child is too young to communicate their feelings, any signs of discomfort could be erroneously misinterpreted as pain by the parents. And with suspicion of pain, parents often will give prescription narcotics. If too much is given when the child is not truly in pain, the narcotics can suppress breathing resulting in respiratory arrest.

Read the full story here.

References:
Surgical management of obstructive sleep apnea in infants and young toddlers. Otolaryngol Head Neck Surg. 2009 Jun;140(6):912-6. Epub 2009 Mar 9.

Ambulatory pediatric otolaryngologic procedures in the United States: characteristics and perioperative safety. Laryngoscope. 2010 Apr;120(4):821-5.

Postoperative respiratory complications of adenotonsillectomy for obstructive sleep apnea syndrome in older children: prevalence, risk factors, and impact on clinical outcome. J Otolaryngol Head Neck Surg. 2009 Feb;38(1):49-58.

Avoiding airway obstruction after pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2009 Jun;73(6):803-6. Epub 2009 Mar 14.

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Teenager Dies From Tonsillitis

A teenager in the United Kingdom died from an unfortunate missed diagnosis of tonsillitis. Apparently, her primary care doctor thought she had swine flu and was prescribed tamiflu... an anti-viral medication.

For bacterial tonsillitis, treatment is with anti-bacterial antibiotics like amoxicillin, penicillin, etc.

The tonsil infection spread into her blood, seeded her lungs, and eventually caused multi-organ failure and death.

Read the full story here.

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12 Year Old Child Dies After Tonsillectomy

There was a recent report of a 12 year old child who died after a routine tonsillectomy in Florida on Aug 15, 2010. Details on the exact circumstances of what caused her death has not been released and autopsy is pending.

However, this story does illustrate that even though tonsillectomy is one of the most common surgery performed in the United States and is considered routine, NO surgery is without risk.

Medical literature places the mortality rate from tonsillectomy between one in 15,000 and one in 35,000 procedures (0.03% - 0.06%), mostly from anesthesia complications, airway loss, and blood loss. Keep in mind, about 600,000 tonsillectomies are performed in the United States per year... which means about 30 deaths occur per year from this surgery.

As such, tonsillectomy should ONLY be performed if they are truly causing a significant health problem such as obstructive sleep apnea or recurrent tonsillar infections and NOT just because "they are big."

Read the story here.

Read more about tonsillectomy surgery here.

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Epiglottitis Killed President George Washington?

I came across a great blog post by Michael Hebert regarding a book review of Joseph Ellis' biography His Excellency: George Washington.

Apparently, at the age of 67, President George Washington died in 1799. I quote from the blog post the following account:

"One morning in mid-December 1799, Washington went out, as it was his daily habit, on horseback from his home to inspect his Mount Vernon property. That particular day the weather was very cold and there was an ice storm. It is said that Washington spent five hours out in freezing rain, then returned home and dined with guests in his wet clothes because he did not want to keep them waiting. The next day he complained of a sore throat and was hoarse, but otherwise appeared well. The following night he awakened Martha to tell her that he felt a severe pain in his throat, and was having trouble breathing.

The next day his personal physician, Dr. James Craik, was summoned. Craik diagnosed the condition as life threatening, and hastily assembled a team of doctors for aggressive treatment. They bled him of five pints of blood, burned his neck, and gave him calomel, a mercury compound used as a purgative but which probably did little more than induce mercury poisoning. Finally, after several days of this torture, Washington displayed the judgment that made him a great president and told them to stop. According to Ellis: “Eventually Washington ordered his doctors to cease their barbarisms and let him go in peace. ‘Doctor,’ he muttered, ‘I die hard, but I am not afraid to go” (p.269). He expired a few hours later."

According to the biographer, Pres. George Washington died of a serious childhood infection called epiglottitis which is an infection of the soft tissue flap (epiglottis) guarding the entrance of the voicebox. It is for which the Hib vaccine given to all kids now makes this type of infection a rarity (in fact, in my entire 10 year career so far as an ENT, I've seen only 3 cases so far).

However, I do agree with the blog article that epiglottitis is unlikely to be the actual cause for Pres. George Washington's sore throat and eventual death. Given his ripe age of 67, he would have developed natural immunity to the germ (Haemophilus influenzae type B) that causes epiglottitis and as such, it would be highly unusual (but not impossible) cause of infection and death. As the blogger stated, a more likely cause of the sore throat that eventually lead to his death is a peritonsillar abscess, a far more common cause of sore throats that could lead to death if not treated. Indeed, I see about 3-4 peritonsillar abscesses in my clinic per month during the winter season. It is also not unusual for a person to go from normal to developing a peritonsillar abscess within 1-2 days.

Ludwig's angina is the other possible culprit the blog post addressed which I also find unlikely. Ludwig's angina in essence is an infection of the submandibular salivary gland and would have presented with a huge swelling under the tongue and under the jawline (see picture to right)... two symptoms I would think that would have been documented in George Washington's history.

In any case, it is entirely possible that his physicians may have contributed to his death... blood-letting of 3.75 liters... Gosh... a human adult has about 5 liters of blood. As far as I'm concerned... that's medical malpractice and one could argue first degree murder. Add mercury poisoning as well.

You can purchase the biography of George Washington here.

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Coffee Decreases Risk of Head & Neck Cancer

Researchers at University of Utah found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Coffee contains over 1,000 different chemical compounds, including cancer-fighting antioxidants, and it’s those antioxidants that may provide a “plausible explanation” for reducing the cancer risk.

However, patients should not take this study as an excuse to increase their coffee intake specifically to counteract known cancer-causing behaviors including smoking, drinking alcohol, and chewing tobacco.

Read a CNN report on this here.

Reference:
Coffee and Tea Intake and Risk of Head and Neck Cancer: Pooled Analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev, June 22, 2010; 1055-9965.

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Taking Tylenol and Ibuprofen Also Has A Potential Risk of DEATH!

The New York Times in July 6, 2009 published an interesting article regarding the potentially fatal risk of taking tylenol and ibuprofen. The story titled "Reasons Not to Panic Over a Painkiller" states that tylenol (due to liver damage) kills about 400 people and hospitalizes about 42,000 every year in the United States. Ibuprofen is even worse. More than 100,000 Americans are hospitalized each year with complications associated with ibuprofen and an additional 15,000 to 20,000 die from ulcers and internal bleeding linked to their use.

Tylenol and ibuprofen is also linked to hearing loss with regular use. [more info]

The reason I am mentioning these facts with such a ubiquitous medication like tylenol and ibuprofen is because many patients have a distorted sense of what is risky and what is not. I had one parent who refused to give her child zyrtec or benadryl for severe allergies as she did not want to "add poison to her child's body." Though such sentiment is usually laudable (and in some cases, even encouraged by me), in these particular cases, it's odd to say the least, mainly because she was giving her child repeated doses of motrin and tylenol for symptom relief. As far as I know, zyrtec and benadryl has not killed anyone. Tylenol and motrin have... many times.

Or get this... the average woman puts on herself 515 chemicals on her body everyday through self-inflicted use of body and facial moisturizers, perfumes, deodorants and various other make-up products. Click here to read more on this.

There are many other such examples, but it is always nice to have in perspective that even supposedly "safe" medications really aren't safe if taken improperly.

Read the NYT story here to read more about the risks of tylenol and ibuprofen.

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