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Patient Care

An Especially Difficult Airway

   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.

   The patient's airway remains stable with the rescue airway in place, and he can be bagged and oxygenated. He is breathing slowly. The pulse oximeter can now measure an oxygen saturation. The patient begins to withdraw from painful stimuli. The crew notes a series of chest injuries. The femur fracture has been grossly realigned on the backboard. There are a number of lacerations. Another liter bolus of saline is given by the time the crew arrives at ground level.

   The man is stable on the trip to the hospital, and there is turned over to the trauma team in the emergency department. The crew shares his available history with the emergency staff, acknowledging that it's minimal due to the language barriers. The trauma team needs to use a surgical procedure on the neck to establish a definitive airway.

   The patient has multiple and severe injuries to the head, chest and abdomen, but emergency surgery goes well, and he is able to regain most function and return to work.

Case Discussion

   This case demonstrates the care of a complex trauma patient with an unstable airway and the need for intervention prior to movement. EMS providers must be skilled in using multiple forms of airways, from simple oral and nasal devices to advanced endotracheal tubes. Never in history have there been so many devices developed and marketed for out-of-hospital use. They include devices for visualizing the airway, ones for placing tubes in or near the larynx, ones for placement through the neck, and securing devices for maintaining tubes in the proper place.

   Providers and medical directors face many options for purchasing and placing these devices in service. After choices are made for basic airways, rescue devices must be purchased that meet the needs of the department and its providers. Rescue airways have an important place in EMS. Their selection is important, not for the airway that is ultimately selected but for the training in proper use and patient selection that must follow.

Initial Assessment

   A 22-year-old male critically injured in a long-distance fall at a construction site.

  • Airway: Unstable, compromised by head and chest injury.
  • Breathing: Irregular rate and volume requiring assistance.
  • Circulation: Poor perfusion, delayed capillary refill, pale skin.
  • Disability: GCS of 8. Moves extremities to painful stimuli.
  • Exposure of Other Major Problems: Obvious left femur fracture.


Time HR BP RR Pulse Ox.
1440 130 Can't obtain 6 No reading
1450 50 Carotid only 0 No reading
1504 100 80/palp. 12 92%


  • Allergies: Unknown.
  • Medications: Unknown.
  • Past Medical History: Unknown.
  • Last Intake: Ate around 11:30, per fellow workers.
  • Event: Fall in a high-rise construction accident. One worker dead, one critically injured.

Customer Service Opportunity

   The growing diversity of the American population is a challenge for all public-safety responders, and for the 9-1-1 answering points that must handle calls expediently. EMS providers must have layers of options available for use for the typical patients they serve, and backup options for languages that may not be common to their service population. The first line of translation may be bilingual family, friends and coworkers. Some technology solutions are now available as well. Translation lines may be available by phone, where phones are usable, but take some time to set up. Hospitals will typically have options for in-person or over-the-phone translation that can get questions answered later. EMS providers must be able to get basic information through nonverbal methods, if nothing else is available.


   Providers must be trained in the use of all forms of airways--oral, nasal and rescue--to face a range of needs, including adult and pediatric, trauma and medical.

   James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and a member of EMS World Magazine's editorial advisory board. E-mail

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