An Especially Difficult Airway

A long fall at a construction site is complicated by communication difficulties, challenging airway management and a difficult extrication

   The call sounded fairly benign: "Worker hurt at a construction site." But the initial responding engine reports that this is a high-rise building, and the injury is up high in the structure. Attack One arrives to find a building under construction. The initial crew reports a severely injured worker at about the 50th floor. Access can only occur by way of a crane elevator that ascends the outside of the building. The Attack One crew grabs as much trauma equipment as they can, loads it onto the stretcher and ascends to the upper portion. There they climb a makeshift ladder, cross several narrow catwalks and arrive with the first-in engine crew at the patient.

   This young man fell about six stories inside an elevator shaft that is under construction. He bounced across several pieces of protruding reinforcement bars, then landed on a concrete surface. Another worker also fell and is dead inside the construction area. His body has already been covered. Most of the construction workers speak little English, so there is some difficulty getting the history and procuring help. The worker is unconscious, with a number of facial injuries and an obvious closed fracture of the left femur.

   The crew applies high-flow oxygen as they note irregular breathing rate and volume, and pulls out the bag-valve mask to provide breathing assistance. There is obvious poor perfusion, delayed capillary refill and pale skin. This patient easily meets the criteria for a load-and-go transport, but moving him is going to take a great deal of time, and require the crews to carry him down several flights of construction flooring, across some narrow walkways, then load him in the construction elevator for a long descent to the ambulance. This is a process the crews estimate will take 25–30 minutes before they can begin vehicle transport.

   The paramedic recognizes the patient's airway is already unstable and will require management prior to movement. They are in a limited-access location, but it is the largest and best-lighted area they'll have until they get to the ambulance. She sets up to establish an airway immediately. Recognizing the man will be difficult due to the extensive facial trauma, she asks the crews to prepare an oral airway, a nasal airway, several endotracheal tubes and the rescue devices available for both failed endotracheal intubation and to capture an invasive airway in the patient's neck.

   The crews immobilize the patient on a backboard and have just finished preparing him for intubation when he vomits. They roll him to the side of the board, cleaning out the emesis and averting aspiration. A rapid attempt at oral intubation fails due to blood and injury to the hard palate. A nasopharyngeal tube will not pass through the nose. The patient's heart rate falls, he quits breathing completely, and his pulse almost disappears. The paramedic has prepared for needle cricothyroidotomy, but thinks the needle would be difficult to maintain during the tortuous exit through the construction site.

   Instead she prepares a rescue airway, which fits quickly through the injured face and is secured using a balloon at the end. The bagging technique will adequately ventilate and oxygenate the patient. The device is secured in place, and the ventilation bag utilized only at times when it will not accidentally tug on the airway. With the airway secured, an intravenous line is used to give a rapid liter bolus of saline, and the backboard is placed in a rescue basket for the trip to the ground.

   With each set of movements through the construction area, the tubes are rechecked. It is difficult communicating with the construction workers to establish each step of the trip, but a bilingual EMS worker has made his way to the top of the building, and he provides needed instruction for the various steps. When the crews arrive at the 50th floor, the crane elevator is ready. A small group of rescuers can fit on the platform, and the trip down takes about 10 minutes. During that interval, they complete a full assessment.

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