The Battle

A couple of months ago I posted at the end of ET Interruptions about the battle I would engage in the next time I had a patient with a witnessed cardiac arrest. The battle between getting a quick airway via an LMA or fulfilling my paramedic I am an intubator ego. Finally, after a long dry spell, the challenge presented. Here’s how it went down.

The call was for a man on the ground. The caller wasn’t certain why. I am pretty good at sniffing out a code from the dispatch, but this one sounded like a lift assist. I figured we would likely encounter an elderly man who had fallen and his neighbor couldn’t get him up. As we approached the scene, I saw the man was not inside his apartment but was actually in the parking lot by a car. There were two bystanders kneeling over him. Since it was a hot day, I said to my crew, “Take the gear off the stretcher. He’s outside. We’ll just get him on the stretcher, get him in the back and see what’s going on with him.”

I stepped out, while they went around to pull the stretcher. I could see one of the bystanders was holding a tube of glucose and squeezing it into the patient’s mouth. “He’s a diabetic,” the other bystander said. I could only see part of the patient, but the patient looked a little too still to be getting oral glucose. I shouted at the woman to stop. “He’s got to be able to protect his airway for you to do that. We can’t have him vomiting and aspirating.”

Just then a woman called down from a porch apartment. “He was just at the doctor. He’s hasn’t been feeling well lately. They gave him some new medicine. Do you hear me! Are you listening to me! He was just at the doctor! He got new medicine! New medicine! Are you listening to me!”

“Okay thanks” I said, thinking I’m a little busy here.

I was noticing then the patient was awfully still. His skin was warm and diaphoretic, but he did not seem to be moving one lick. he wasn’t just unresponsive. I wasn’t even certain if he was breathing. The stretcher was beside the patient now and in low position. I tried to sit him up and he was dead weight. Oh shit! This is a code.

I had my gear in the truck. It was drop him and work him in the 100 degree heat or lift him on to the stretcher, and get him in back, which is what we did, with some compressions thrown in on the way.

He was in a PEA in the 40’s. With one partner doing compressions (we shoved a short board under him) and the other reaching for the ambu-bag, I went — hooray for me –right for the LMA — a #5. I love to tube, but I promised myself, no interruptions in CPR, no dicking around, just toss in a quick LMA. Which I did. It went in easy. I got a continuous wave form with an ETCO2 of 15 that remained fairly constant for the next 10-15 minutes despite our interventions.

The man was short but obese. I tried for an IV in the hand with no luck so I went for the IO. He had elephant legs all the way down to the ankles which had tiny toes sticking out from underneath them. His shoulder was also huge. I ran my hand down the length of his tibia and finally felt some bone about midshaft. I shifted some of his fat and drilled right in. We don’t carry the bariatric needle so I was pleased to get the regular needle in. Some epi, some atropine, continuous compressions, but no change in result. I started to prepare the patient for packaging. When I went to secure the LMA, I noticed the LMA looked like it was sticking out a little far, so I gave it a push in and went to secure it and suddenly I started having some compliance problems. What I realized later, was giving it that shove had doubled the mask over, which I understand is a common problem. As soon as my partner said it was getting harder to bag, I, to my shame, felt the approach of a little bit of joy. Maybe I’ll just pop the LMA out and tube him for the ride in. I was thinking, the LMA worked great for the time I needed it to. We did our best – fifteen good minutes of CPR and drugs — the patient is unlikely not coming back. I did the right thing by putting the LMA in and now I still get my tube. Hot Dog! I did try to see if I could fix the LMA. I stuck the laryngoscope in and tried to move the tongue out of the way to see if that would fix the problem, but as I did the whole LMA popped back at me. I just took it out then, had my partner give a few bags while I prepared to intubate.

The patient of course had an enormous tongue. I tried to move it out of the way, and it slipped off the blade. I swept it over again with success this time, but then when I went to look for the chords, all I could see was blood in the airway, which puzzled me. I wondered if maybe I had been too rough with my first sweep or if maybe something else was going on with the patient’s arrest. I finally saw the bottom half of the chords and tried to pass the tube, but quickly pulled it out on seeing I had no wave form. The tube was covered with a very sticky blood. Screw this, I thought. I reached for a second LMA (a #4 this time) and popped it in. It worked great. ETCO2 back to 15.

We worked the patient all the way in, but couldn’t get the ETC02 above 15. The PEA continued throughout. With epi i could get it up to the 90’s but it would slow back to the 40’s then 30’s. The complexes had deep Q-waves, and made me think the patient likely had been having a massive MI all day until he finally just keeled over. They called him dead at the hospital. It wasn’t until the next day — Duh! — it finally dawned on me that the sticky red blood in the airway was just sticky red oral glucose.

What lessons did I learn? The good (get an airway that works quick and avoid any CPR interruptions) medic hasn’t completely defeated the bad (I gotta get my tube) medic but there is hope for me. After sitting idly in my box for a few years, I am learning more about the LMA with each use. After this call I reviewed the manual and picked up a few more tips on its use. I think I clearly would have been better off going for the #4 to start. The other point that I had missed entirely was lubricating the posterior side of the cuff prior to insertion. I now have a package of lubricating gel at the ready.

As for the battle between the LMA and the ET, stay tuned.

LMA Manual


  • Roger says:

    This is a great article. Over here in Mississippi were are only allowed to use dual-lumen combitubes as a rescue airway. I hope LMA’s come soon, I inserted plenty of those during my rotations. Getting an airway quick is always the best course of action. I am thinking of one tube attempt then combitube. Though I still have 20 more days until school is over

  • tom says:

    Does your service use King airways ? We have had great luck with them here in Virginia

  • Medic5 says:

    I’m still not 100% sold on the combitubes(never dealt with the LMA) they just don’t seem like as good of an airway based 100% off of my experiance with no actual concrete data to back my opinion. Then again I work for an agency who uses passive airflow thru a nonrebreather with an NPA/OPA for codes while we take care of everything else first then do an advanced airway, so my views on the matter may be a bit different then those of others.

  • medicscribe says:

    We don’t, but a service I oversee does and has had good luck with them, although like the LMA, they can buckle over on themselves.

  • Ian says:

    We use the KingLTs here. I haven’t had the opportunity to use one yet, but I hear from my colleagues that they are very easy to use.

    When I did my OR rotation I had the opportunity to put in a few LMAs and I always had difficulty with them folding back. The anesthetists typically combat that issue by running a finger along the hard palate and flipping the tip back into position. I never had much success with the LMAs. They just seem too finicky compared to the other available adjuncts.

  • Harrison says:

    We use combitubes here. They work great, you just shove it in and you have good placement most of the time.

    I did my medic clinicals for an agency that used the king tube and all I heard was how bad they were due to the fact that they rarely seat well, possible barotrauma due to balloon inflation and insertion procedure, the fact that you have to pull the tube back out of the airway (and I heard stories of how the tube was pulled out all the way by an EMT).

    For me, it’s either an ET tube or combitube. Keep it simple.

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