Medics add interventions easily. Prolonged field care is where those interventions start charging rent. Dave walks the unwind.
A cut endotracheal tube used as a cric can come out if the patient no longer needs it. Unhook the bag. Moving air through the tube, following commands, and a normal breathing pattern are good signs. Cuff down: if he cannot breathe around it, edema or a flap may be waiting, and pulling can lose the airway. Suction above the cuff first. Dress the site after. Do not pull the bookmark on a partial responder still in shock just to save narcotic. Uncomfortable and awake beats a lost airway.
Chest-tube logic is the same. Serous output and stable oxygen are a pull conversation. Blood, pus, or a leak plus climbing crepitus means the tube stays. Heimlich is enough for many. Suction, if used, is about 20 cm of water — a straw, not wall suction. No underwater seal is a sucking chest wound you created. A chest wall you cannot seal is bagged. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift the patient you were trying to save.
A cric can come out if the patient no longer needs it. Positive pressure off, breathing through the tube, follows commands, normal pattern, cuff down and air moving around the tube. Fail that last test and you may be looking at edema or a flap.
Suction before you drop the cuff. Dress after you pull. Whatever is sitting on the balloon goes into the lungs. Occlude the site for cough and speech. If he obstructs again, adjuncts first, then back in.
Do not trade the airway bookmark for narcotic savings in a partial responder. Shock patients who drop their GCS after you pull are a different problem than the isolated femur you over-sedated. Uncomfortable and awake beats lost airway.
Chest tube suction is 20 cm of water, not wall suction. Heimlich is enough for many. Serous and stable oxygen is a pull conversation. Blood, pus, or a kazoo plus climbing crepitus means the tube stays. No seal equals a sucking chest wound you created.
Some interventions you should not start if you cannot finish them. An unsealable chest wall is bagged, not endlessly patched. A continuous leak with crepitus is surgical. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift a patient you were trying to save.
Chapters
01:17 Adding interventions is easy. Unwinding them is the PFC problem.
02:17 The oversedated femur: ketamine, narcotic, snoring, cric
03:46 Same patient in a trauma bay — RSI, then do they still need the tube?
05:19 Yes, you can pull a cric — if the airway is not the problem you are about to recreate
06:29 Off the bag, follows commands, breathing pattern
07:10 Cuff down: can he breathe around it?
09:01 Suction above the cuff before you deflate
09:42 Ketamine no-man’s-land between analgesia and sedation
10:41 Fentanyl for the cuff, not another snow
14:05 If the airway is quiet, leave it until everything else is mitigated
14:16 Do not pull the bookmark in a partial responder
28:07 What is coming out — serous vs blood vs pus
28:30 Empyema tubes that stay for months
28:33 Air leak on a Heimlich: kazoo is fine, crepitus is not
29:02 SpO2, mental status, oxygen need before a pull
29:37 Heimlich vs three-bottle suction
30:51 Improvised single-bottle underwater seal
31:16 No seal, and you just made a sucking chest wound
33:34 Chest wall you cannot seal: positive pressure, or a cric
35:41 Finger thor converts tension to open. The tube is a valve and a measuring cup.
37:36 Continuous air leak and climbing crepitus — second tube, surgical problem
39:25 Sudden crepitus with an advanced airway: dislodged cric vs tracheobronchial injury
42:11 Fasciotomy: indication vs the wound you cannot dress
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