Ep. 24 - Airway Management in Austere Environments with Dr. Nicholas Weinberg - Wilderness Medicine Updates

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Patrick Fink MD (00:13):
Hello and welcome back to Wilderness
Medicine Updates the show forproviders at the edges.
I'm your host, Dr.
Patrick Fink.
Today we're gonna talk aboutairway management in austere
situations, and we're gonna usea real life case.
I'm pleased to have Dr.
Nicholas Weinberg join us todayto discuss a case that he
published in the WildernessMedicine Journal.

(00:34):
Look in the show notes for alink to that and some pictures
related to the case.
I'm excited to bring thismaterial to you because I feel
like these situations of highacuity patients where you're
making consequential decisionswith advanced interventions are
not all that common inwilderness medicine.
Search and rescue, we just havea low volume of similar cases,

(00:58):
and so it's useful to be able tolearn from one another.
To hear about someone's thoughtprocess, why they made certain
decisions, even if maybe youdon't agree with them in all
points.
Not saying that, that's how Ifeel about Dr.
Weinberg.
Dr.
Weinberg is an emergencyphysician at Dartmouth Medical
Center and an assistantprofessor at Dartmouth's Geisel

(01:18):
School of Medicine.
He serves as the assistantdirector of Dartmouth's
Wilderness Medicine Fellowship,and he has practiced expedition
and wilderness medicine aroundthe world.
Notably, Dr.
Weinberg just returned from apatrol on the National Park
Service high altitude patrol onDenali, and he is known for his
extensive experience in Mountainand Wilderness Rescue Medicine.

(01:41):
Without further ado, I want tobring you straight into my
conversation with Dr.
Weinberg.
I hope you enjoy.
Why don't, why don't we juststart with how do you tell
people what you do and, andwhere does wilderness medicine
fit into your career?

Nick Weinberg (01:55):
So I am an emergency physician, at
Dartmouth Hitchcock MedicalCenter, and I'm at the medical
school at Dartmouth an assistantprofessor, and I'm an assistant
director of our wildernessmedicine fellowship here.
And also I, I am involved inultrasound as well.
I did an ultrasound fellowship.
So I kind of wear two hats here.

(02:17):
And I, before medical school Iwas a

medical appointments.

a mountain guide ski patroller, ski instructor,
offshore sailor bum dirt bagtraveler.
And then I went kind of back to,I went to medical school after I
was in a climbing accident manyyears ago with a friend of mine
and.
I evacuated him with some basicwoofer training, and had this

(02:43):
epiphany that I wanted to dowilderness medicine.
I went to a conference inSteamboat many years ago,

So.

most of the folks there were emergency medicine
physicians that worked part-timein the ER and did lots of other
cool stuff.
So they said, yeah, it's great.
You can do emergency medicineand work part-time in the ER and
then do wilderness medicinestuff.
in your other time.
So that was kind of my goalgoing back.

(03:11):
And then I worked I went tomedical school in Vermont,
university of Vermont.
And then I worked in thecommunity hospital in the
Adirondacks and upstate New Yorkfor a few years and which
allowed me to do a lot ofwilderness medicine stuff.
I worked in Nepal for the HiHimalayan Rescue Association.
I did patrols on Denali.

(03:31):
I worked on a, a ship that sailsaround the world a square rigor
as the physician crossing theIndian Ocean for four months.
So I did a bunch of stuff likethat

So I did a bunch of stuff like that and
then

academics,

to get back, back

fellowship, in Boston at Mass

into Austin and.

up in New Hampshire at Dartmouth.
Yeah, that's kind of abbreviatedversion of my story.

Great.
Well, I was really happy to seethe two cases that you published
in Wilderness and EnvironmentalMedicine.
'cause I think these kinds ofcases are useful for learning
purposes, but the frequency ofthese high acuity cases is
relatively low in any given.
Rescue outfit or or SAR group.
So it's hard to chase them downand get'em out there in a HIPAA

(04:16):
compliant format.
And so when I saw this papercome across my desk, I was like,
I gotta find this guy.
So

Yeah,

let's start with, with.

and it was kind of an unusual paper to publish
and we were kind of threadingthe line of, you know, HIPAA
compliance and, you know, Ithink we, we were compliant.
And, and actually the fallingclimber you know, she reached
out to me.
I can tell you this is aninteresting part of the story
actually and gave me permissionto publish this and to help

(04:45):
other people learn from thisexperience.
So,

That's awesome.
Well, let me just start with thefirst paragraph of this case and
then I'll have you lead us in.

sure.

In the White Mountains of New Hampshire, a
rock climber and her thirtiesand her partner scrambled
Unroped through Class fivetechnical terrain.
To reach a crag, the climberslipped and fell approximately
12 meters or 40 feet.
Down a loose gully onto a steepexposed ledge.
A nearby pair of climbers,including an emergency
physician, heard the fallfollowed by calls for

(05:18):
assistance.
The EP had technical climbingexperience and training in
mountain rescue.
He scrambled up the ledge toaccess the victim.
Meanwhile, his partner used acell phone to call for medical
assistance and organized a teamof nearby climbers to perform a
litter rescue.
So let's just get it out there,right up front.
You are the emergency physicianin this case, right?

I am.
Yeah.

Can you walk us through the moment when you
first arrived on this scene?
What, what did you see?
What was going through your mindas you approached this woman?

Yeah.
So

Yeah, so

at

you know, I was climbing at this.

climbing area in New Hampshire.
And I heard this loud thud soundthat if you have ever heard the

Never heard

falling, it's the sound that you never forget.
And I immediately.
Knew that it was a bad event andthat someone had fallen pretty
far just from the sound of it.
But then I didn't hear anynoises

didn't hear any noise.

was just a tree that fell in the woods.
Sometimes you hear a random treefall and then like a minute
later we heard calls for helpand then knew that someone was
pretty badly injured.
So you know.
Being a physician experiencedand trained in mountain rescue,
I wanted to assist.

(06:36):
and so I climbed up to thisledge that the, that she, this
patient was on and kind of foundher there.
So she had fallen and wasbasically kind of down headfirst
on this ledge.
and she was breathing, but, butreally wasn't

But

her

really wasn't

Which was pretty dramatic.
I mean, we

pretty dramatic.
I mean, we learn a lot

in emergency medicine, and it's pretty rare
that to have someone

Rare.

no airway reflex and she really didn't have any
airway reflex.
So it, it was kind of like basicfirst aid stuff that you're
taught in wilderness first aidcourses.
And you know, I did a, a jawthrust.
and opened her airway and herpartner was with

And her partner with

shaken up.
Not really very functional.
So we kind of calmed him down

her,

him.
And then I realized that she wasgonna require a technical rescue
'cause it was on this exposedledge up on a steep hillside.
so, I figure I made the decisionto

I made the decision

Her there.
After we had kind of talked herpartner down and kind of calmed
him down a bit and then taughthim how to do a jaw thrust and
he was able to do thateffectively, so I felt that my
skills would be better

be better.

kind of running this rescue and getting the
right resources that we wouldneed for this particular rescue.

What did it take to get to that ledge?
How, what kind of terrain wasbetween you and there?

was kind of some, some moderate scrambling, maybe
kind of 5, 5, 5, 6 climbingterrain.
I don't know if you're aclimber, but,

Mm-hmm.
Yeah.

so I mean if, if, know, it was a little bit
exposed,

was a little bit exposed, but

An experienced climber it wasn't.
I I was comfortable kind ofsoloing

mm-hmm.

Yeah.

And were there any concerns about either your
security or the patient'ssecurity on the ledge, like

The ledge

proximity to the edge potential for an
additional

she was on this kind of

Yeah.

ramp where it was not an ideal place to kind of
package her and kind of initiatecare, and so I wanted to, the
first thing I wanna do is moveher down to this lower ledge.
A few feet down where there wasmore space to work work with,
and it was less exposed.

(09:09):
'cause I obviously didn't wantsomeone else, you know, to
create additional victims.
So, so we,

And did you do that during your.

so we, we a, a bunch of us basically beamed her
down to this other ledge.
Yeah.

Okay, so you then descend off of the ledge to
start coordinating rescue forher?

Yeah.
So then,

Yeah.

the, the partner kind of, well, we left him kind
of holding her in a jaw thrustposition immobilizing her.
And then my climbing partner whodidn't have any medical
experience.

Any medical

organized a rescue, a, a team of litter
carriers, essentially, of otherclimbers.
And also called for nine one oneon his cell phone.
And then I scrambled down, toeventually down to a parking
area where I met the.
EMS crew that was first on sceneand I, I used to work in a

(10:08):
community

I used to work

in, near this

near

and I

area.

paramedic who was on, who was a, also a climber.
So it was very convenient and Ibasically told him story and
that that explained that thiswoman probably needed, you know,
to be intubated and needed RSImeds.
So he, we basically packed upall of their RSI

Up

and brought it up to this ledge.
So it's a pretty unique scenariowhere we were

where we were

from the

far enough from the road that.

and lowers, but close enough that you know that
that street paramedics, well itis a rural area, but, but the
paramedics could make it upthere.

Mm-hmm.

that's what made it kind of an

How, how long do you think it was between did
it take to leave the patient,get the paramedic, come back?

Probably.
45 minutes, maybe 30 to

Okay.

Yeah,

Yeah.
And when you returned to thatledge with the paramedic, did
you appreciate any change in hercondition at that point?

wasn't, was about the same.
Really still

Mm-hmm.

her airway.
Her very low GCS basicallyunresponsive to even painful
stimuli.

Yeah, so I, I think for the emergency
physicians listening, that tellsa, a pretty stark story.
But for, for those maybe withless medical training, what was
going through your mind aboutthe nature of her injuries and
what you might be facing?

Yeah, I mean the, so she

Yeah,

and the way

tell.

landed up kind of upside down headfirst.
I was very concerned aboutC-spine injuries, which she
ended up having.
Several cervical spine fracturesunstable fractures.
And she ended up being neural,neurologically intact in terms
of c-spine injury, but she hadseveral unstable c-spine
fractures.
And then she ended up havingsubdural, subarachnoid

(12:03):
hemorrhages and intraparenchymalbleeds as well.
So yeah, my biggest concern was,

My biggest concern.

immobilization.
You know,

Mm-hmm.

she, we were able, we kind of controlled her
airway by just a jaw thrust andthat was working.

Yeah.
I guess with that sustained,altered mental status, it's
telling you that she has apretty significant head injury.

Yeah.

I, I imagine that if I had been in your
place, I would've had someconcern that she could herniate,
she could deteriorate.
You know, you might be comingback to an even worse situation
or someone who's died while youwere gone.

Yeah.
That definitely.
But fortunately, she, shemaintained degree of stability
even though she was obviouslyvery sick.
Yeah.
So.

So it sounds like as you were returning, you
were thinking through how youwanted to manage her airway.
What factored into your decisionto pursue rapid sequence
intubation versus an LMA,sticking in an oral airway and
continuing bag valve masking?

Yeah.
I mean, I, I

Yeah, I mean.

in most wilderness situations you're not
gonna have RSI available.
And it's, it's not gonna be anoption.
You know, you'll have maybe an,an oral airway but since,

But

since it was kind of a unique case in that it was
remote but not remote enough

not remote.

you know, a LS crew from being on scene
essentially.
So we had a lot more resourcesthan you might have in a lot of
other scenarios.
We had the experience and skilllevel to do RSI and I knew that
paramedic, I trusted him.
He knew me, we'd workedtogether.
So, and I knew that it was gonnabe technical carry out with some

(13:58):
lowers and that, you know, anLMA wouldn't be ideal since you
really needed an airway.
Were able to do RSI and we had asuction device.
We had meds, RSI meds andsedation meds, and we had oxygen
as well.

Mm-hmm.

And we had, we had backups,

All had backup

So it, it seemed like a reasonable choice given
the situation.

given how abed and out of it she was.

Yeah.

And the potential for blood or, or
vomitus in the airway, did youconsider not paralyzing her?

Yeah, that, that was my

Yeah.

concern was that she would have blood or
secretions in the airway andthat we would be out here with a
mechanical suction device andnot able to intubate her.
And there were secretions andblood in her airway, but we were
able to quickly suction it outand it ended up being a
non-issue.
But yeah, that, that could havebeen, you know, a, a point where

(14:57):
things could have turned for theworse into different
circumstances for sure.

Yeah.
When I imagine myself in yourshoes, I'm, I'm feeling
apprehension about paralyzingthis patient because of the.
You know, obviously suboptimalpatient positioning.
You know, this patient is not ona gurney up at your sternal
height where you're gonna beable to get a great angle into
the larynx.
And yeah, I, I got a littlepuckered just thinking about it.

yeah.
I don't, I, I guess, I don'tknow.
Yeah.
The other thing was paramedicsare used to intubating people on
the floor lying down, you know,so.
So he, my, my, the, mycolleague, the paramedic who was
there, was very comfortabledoing this.
And, and I, I wanted him tointubate since, you know, he,
they don't get too intubated asoften as we do, so, and I was

(15:48):
there as kind of a backup, so Ikind of walked him through it.
But yeah, it's,

But yeah.

you know, it, it worked.
The, the other thing was she wasotherwise young and healthy and,
you know.
Didn't, I didn't think she wouldbe a difficult airway, and she
wasn't so based on her anatomyand age.

Thinking your way down the airway algorithm,
did you have things to perform?
A Cracko thyroid otomy if youneeded to?

I don't We did.
I don't, I don't know if theparamedics have a, had a CRI
kit.
They might, but I, I honestlycan't remember.
They, they might've.

Okay, so then you've got this patient
intubated despite the fact thatshe had blood in her airway and
manual suction, which almostnever seems to work.

Work actually.

the,

Situation.

that's, that's great.
That's like the first time I'veever heard of that.
Every, every time It is like oneof those squeeze ones

Yeah.

where you have to like

It

it.
Yeah.
It never

I've ever used one of those in a real scenario,
and it worked surprisingly

you.
You got your one that like,never, ever, ever have worked
for me.

I, I

regardless, so you've got the tube in.

all, they're all these like cheap fans you can
get on Amazon.
I want, like, I, they must havelike battery powered suction
devices now.
That could be very powerful.
Anyway.
Something to think about.

That's often like a, a terrible YouTube ad.
It is like this device will blowup the internet and it's like
some tiny little vacuum cleanerlike that.
Maybe that's all you need.

Yeah.
Well, I mean, stuck wheneverI'm, you know, setting up for an
intubation with the residentsI'm, and suction is all, is the
most important thing in my mind,you know, making sure it's there
and

Yeah.

Yeah.

If you can't see, then

Yeah.

that makes everything nearly impossible.
So how did you secure theendotracheal tube?

We had tape and just, yeah.
The, the paramedics had kind ofall their, kind of let them do
their thing.
I was there kind of

mm-hmm.

them and of, yeah, being the point person,

Okay,

I let them the small stuff like sharing the
tube the way they do it.
Yeah.

so then you eventually get her packaged into
a litter.
She needs at least like onetechnical lower off this ledge.

Yeah.

did you continue to ventilate her during
that process?

Yeah.
So we, I mean, we

Yeah.

attendance that were bagging her while she was
being lowered.
So which worked it wasn't, itwas steep, but it wasn't a
vertical lower, I would say itwas maybe.
50 degrees, 50 to 60 degreesRocky

So did you have multiple attendants on the
litter then?
Okay.
Yeah, that's that's helpful.

yeah.

Okay.
And then you, you mentioned someof her injuries, so she had
unstable cervical spineinjuries, multiple varieties of
intracranial hemorrhage.

Yeah.

How did she end up doing clinically?

She, she also had a BAS skull fracture.
It was mostly kind of from the Cspine up where her injuries, but
they were very severe.
And so she, so eventually wecarried her down and transferred
her to Dart, which is the nameof our Air medical service at
Dartmouth.
and they landed in nearby fieldand flew her to Dartmouth to our

(19:07):
hospital, and she was evaluatedas a trauma patient, admitted to
the surgical ICU, and she had a

And she had it very complicated.

She was in a pento barb because of increased
ICP.
She was on like continuous EEGmonitoring.
She was cranked and pegged.
and basically, so this isactually a good story.
I remember one of my residentswas rotating in the ICU and I
would talk to'em about hergetting updates.
And I, I guess the teams werecontinually trying to convince

(19:39):
the family to withdraw care.
Because her

Oh.

was that poor.
And eventually she got, she wentback to where she got
transferred back to her homestate and was cranked and pegged
in a, a nursing facility forseveral months.
And I kind of assumed that wasit.
And she would be in thispersistent vegetative state, et

(20:03):
cetera.
and her one day when I wasworking in the ed, her mother
came to me like found me in theER and was very grateful'cause
she thought I had, you know,saved her daughter's life, et
cetera.
Anyway, so I, I, I stayed intouch with her mother.
anyway, about six months afterthis, I kind of had forgotten

(20:25):
about her.
I got a text from her, from thepatient basically saying.
Explaining what had happened toher and thanking me for saving
her life.
And I said, wow, this, this textis fairly coherent.
Like there was one little typo,I think.
so and so she ended up having anamazing recovery and, and was

(20:47):
functional and she sent me apicture of her, like playing
guitar.
And I, last I heard she waswriting a, a book or a memoir
about her experience.
So a happy ending to the story.
Yeah.
Which is which on

Yeah.
It's all,

I think.

yeah, everything about this case is,
is remarkable.
And I don't think it washyperbole to say that having
someone with your combination ofskillsets on the scene was
incredibly fortunate for her.

yeah.
Yeah.
I, I guess

Yeah.

Yeah.

Well, it's always nice to have someone say
thank you.
That doesn't happen all day,every day.

that often in the er.

Great.
Well, I, I'd like to, I think wehave time to move on to the
second case if you're open tothat

Yeah.

the, the two cases together do raise the
question like, are you aterrible black cloud?
On every expedition you go on.

I don't think so actually.
'cause I, I, just got back froma month on Denali doing rescue
work and this was my thirdseason up there.
And it was actually very lightin terms of SARS and, and stuff.
There was a lot of frostbite'cause it was very cold, but
there were not a lot of

Mm-hmm.

Bad falls.
So I, I think I used to be moreof a black CRA cloud, but now I
don't know.
It's, it's

You've, you've punched that card.

Yeah.
Yeah.
Although I have, I have hadquite a bit, quite a few
accidents once I was climbing inthe Gunks, which is a climbing
area in New York state kind of asimilar episode where a climber
fell right next to us.
A 40 foot lead fall and was all,was basically hanging upside

(22:32):
down, unresponsive, notprotecting his airway.
And I, I, we, we kind ofevacuated him as well.
He ended up getting intubatedand flown and had severe head
injuries as well.
So, I don't know, maybe I am ablack cloud.
Maybe you don't wanna beclimbing next to me, I guess is
the moral of the story.

Or maybe you do.
It's hard.
It's hard to say.

I think the more

All right, well let.

you know, a

And

of people ask

you know a lot of people,

like how to get interested in wilderness
medicine.
And I think, you know, Iironically,

you know, I ironically, I, I.

that day and I was supposed to be at some
conference.
A wilderness medicine conferenceand I went, decided to go
climbing instead.
And then that event ended uphappening kind of
serendipitously.
And so I, I think what I tellpeople is like, if the more you
get outside and do things, themore you will end up in

(23:26):
situations where you have tooffer care or rescue people.
So the, I guess my, my adviceto, to young people interested
in wilderness medicine is to.
Just get out and recreate andspend a lot of time doing things
'cause you'll end up gettingpulled into rescues.
And I think as, as

I think.

physician, people, just, whether you want
to or not, they will look up toyou and you will end up kind of
being the leader in theserescues often.
So, which is kind of cool.

Yeah, it is.
I mean, it's a, it's a verypertinent skillset in that we're
used to being, you know, kind ofthe leader of the team and
assuming the, the risk and thedecision making, which are the
two elements that people aremost willing to just hand off
in, in one of those rescuesituations.

Yeah.
Well, I, I think we'recomfortable.
We're, we're so UI think we takefor granted actually how much
risk we manage on a day-to-daybasis in the ed,

Mm-hmm.

So in these situations.
A lot of other people areincapacitated, but for us, you
know, this, we just have onepatient, you know, compared to
what a busy day in the ed, youcan have 40 patients that you
are responsible for.
So, I mean, us, these, the,like, that scenario is, is not,
actually not that challengingfor what we're trained to do,

(24:39):
you know?

Right.
The challenge is just thelimited tool set, which on the
flip side is also dramaticallysimplifies the decision making.

Yeah, and that's, that's I

Yeah.

we decided to write this paper was because,
you know, you, you have limitedresources and basically you do
the best with what you can.
And in some ways it's lessstressful because you have
options to choose less potentialpathways.
You kind of just, just doing thebest you can.
It's, it's a different

when you're,

care and I think that was kind of the one of the
main reasons I wanted to writethe papers because it is a
different standard of care andjust it out there that it's okay
to function at a differentstandard of care from what we're
used to in the ed.

mm-hmm.

I don't know

Well, let me introduce this second case and,
and we can work through it andsee the contrast.
During a snowstorm, a guideescorted a middle-aged tracker
on horseback from the village ofBuche at 4,940 meters or 16,000
feet to the Himalayan RescueAssociation Clinic in Che.
Am I saying that right?

got it.
Perfect.

Che Che Nepal.
The Trekker had a Glasgow comascore of nine and was Tachypnic.
Her guide told the two emergencyphysicians at the clinic that
the trekker likely had highaltitude cerebral edema.
She had spent the previous dayin her room at a lodge with a
headache.
She had no reported respiratorysymptoms.
She had no known significantpast medical history and had

(26:06):
been at altitude before withoutproblems.
Where I wanna start with thisone is I think folks should look
at the paper in the show notesand see the picture of the room
that you're working in.
Can you set the stage for uswhat this clinic looks like?

Yeah, sure.
So the Himalayan RescueAssociation is a nonprofit
that's based in Catman du Nepal.
And their initial clinic was inthis region, which is the Kubu
region, which is the EverestValley.
Which is a very popular, it'sthe most popular area in Nepal
for trekking and obviously forclimbers as well.

(26:40):
And it was first developed inthe seventies because they were
seeing a lot of unnecessarymorbidity and mortality in that
region, mainly from altitude,illness that could have been
prevented.
And so the, this was developed,the first clinic was in Farge,

(27:01):
which is at 14,000 feet roughly.
And it's a small clinic in a,it's a small stone basically
with some solar electricity.
And that's about it.
And it's basic in terms ofresources.

Pretty basic.

there's some oxygen tanks, there's a monitor,
oxygen concentrators.
an EKG machine, there's noimaging, there's

No imaging, limited medication,

supplies

basically whatever supplies,

the years.
And they also have anotherclinic

they also have another clinic.

region on the Anaperna Circuit Trek.
There's a pass that people goover that's 17,000 feet and a
lot of Reers get altitudeillness there.
So the main reason there is toprevent altitude, illness, and
reers there.
and they take volunteerphysicians for about.
Four months, three to fourmonths in the fall and spring
seasons.

(27:55):
So I did

Okay.

there and it, it happens to

Yeah, the, the.

probably the best place in the world to see and
treat altitude illness.
If you're interested, I'll put aplugin for the HRA.
Yeah, it's a fun time too.

The, the picture really looks like you're
in a kind of crummy room of ahostel, and there's two, two
beds and there's a monitor andwhat looks like a climber's
oxygen tank sitting on the bed.
And you guys are both wearinglike knitted caps, like it's not
heated and it's cold in there.

Yeah, it's, it's very

Yeah.

and that was towards the end of the season
in, I think it was November.
It, it gets quite cold up there.
And I was in the middle of thenight actually.
I was basically running a codein my long underwear, which was
kind of funny.
And only time I've run a code inmy long underwear.
But we were, there's this, thisgiant bell school bell that they
have out, it's front of the doorand people ring it.

(28:51):
And so we were sleeping in themiddle of the night and someone
rang the bell and then we, Iopened the door and there's this
woman that looked like she wasliterally dying and she was, and
she was on horseback.
And then as soon as we walkedher over to a bed, she syncopize
and basically went into a PAarrest.

Yeah.
So what were you thinking atthat moment in terms of what
might be going on with her?
Don't, don't ruin the punchlinequite yet as to what is actually
going on, but.

So, well,

So.

the, the, the Nepali guide that was with her
basically said, oh, she.
She has, she has hate and has,you know, that's what, that was
his diagnosis.
and you know, basic, most thingsat altitude are altitude related
until proven otherwise.
So kind of everything else inthe diagnosis of exclusion.

(29:42):
So most of the time, whateverthese people come in with, it's
usually related to the altitudeand when they go down, when they
descend.
Whatever symptoms they hadseemed to go away.
It's kind of like a dialysispatient where whatever symptoms
they come in with seem to getbetter when they get dialyzed.
You know similar with altitude,illness, they get better when
they go down.
So, you know, our, our firstassumption was this is, you

(30:03):
know, you had, has, or somethinglike that, or hape and has is
the most likely cause.
And her, her oxygen saturationwas unmeasurable, so we kind of
assumed it was hape and haze andthey can often be.
commitment together.
The only thing is she had clearlung sounds, which was a big
clue what she ended up having.

Mm-hmm.

Yeah.

Yeah.
How did, how did your initialsuspicions guide your initial
interventions?

So we, we just kind of empirically treated her
for hape and hace, so we put heron oxygen and we gave her I am
dexamethasone.
didn't give her Nifedipine.
Then we basically bagged her.
She didn't, she, she did regainpulses, but she didn't really
perk up that much.

(30:52):
And one thing about ha, which ishow to pulmonary edema is they
often, and this is often a boardexam question, they often get
rapidly better with oxygen.
And that can be useddiagnostically too.
Unlike someone with pneumoniathat is still gonna stay pretty
sick and hypoxic people withhate because it's this
inappropriate pulmonaryvasoconstriction.

(31:14):
As soon as you put them onoxygen, they get rapidly better,
and that didn't happen to her.
So that raised our suspicionthat there was something else
going on.

Talk to me about how, so she, you do CPR
for a bit, you get pulses back,which is sort of remarkable in
and of itself in someone who'sgot PEA and maybe just hypoxic
versus intracranial cause of herarrest.
She then doesn't have greatinitial respiratory effort.
How were you thinking aboutmanaging her airway, both over

(31:44):
the, you know, the next hour ortwo, and then looking forward
through her potentialevacuation?

Yeah, well,

Yeah.

thing, one other clue to the diagnosis is that
she syncopize with exertion.
And then once we kind of stoppedexerting her, she did slowly get
better and then regained kind ofweak pulses.
And she, she did slowly improvein terms of her, her mental
status.
but she still remained basicallyabcu all the whole night.

(32:12):
And then the next morning shewas a lot more awake and alert.
being on oxygen all night.
so, you know, we still thoughtthere was probably a component
of, of tape involved, whichthere may have been.

And what tools did you have to manage her
airway, and how did you opt forone over the other?

Yeah.
So I mean, we had oxygen tanks,oxygen concentrators, masks.
There was an assortment ofendotracheal tubes that had been
brought and left there.
There had been someanesthesiologists who had worked
there.
There was a couple LMAs, A BVM,there's no, no ventilator.
And, and just kind of ahodgepodge.

(32:52):
I, I don't, I don't know if, if,if you do expedition medicine
you end up using kind of ahodgepodge of stuff like that.
Sailboat.
I worked on that tall ship.
It was random stuff that peoplefrom all over the world had
brought different doctors overthe years.
So that's also kind of fun, islike you kind of what you have.
But there was, there was astorm.

(33:14):
We knew we weren't gonna be ableto fly her out for at least 24
hours.
So the thought of intubating herand then just bagging her for to
48 hours before we could fly herout just didn't seem that
appealing.
And she was very sick, but waskind of somewhat stable at this
sick level.

(33:34):
So we, we kind of made thedecision to just watch and wait.
And again, you know, we were theonly, she was

You know.

in, if you were in a busy er, you would, would
just intubate her and move on.
Right?
And they, she'd go upstairs tothe nicu.
but we had the option to kind ofmonitor her closely.
so, we made the decision not tointubate her.
And, you know, both the point

You.

was that both of these patients, if you presented
them to any.
Standard emergency department ina developed country would get
promptly intubated.
And we could have managed themdifferently based on, based on
the context.

Right.
So you, you didn't feel like youwanted to be up all night
bagging this patient orpotentially through the
following day, even maybeemploying the guide or whomever
else to, to bag

and also we didn't have

and.

like we, I don't think we had any RSI meds.
We didn't have sedation meds.
You kind of, I mean intubatingsomeone is a commitment.
Once you intubate them, you'recommitting to, you know,
maintaining them as sedated,which with the other patient,
the climber, we could do that.
And I knew that we were gonnaget her down to a helicopter who
could, you know, get her to aTER care care center.

(34:48):
So,

Mm-hmm.

yeah.

So by the following morning, she's a
little bit more alert.
Was she able to give you anyadditional history that helped
you better understand what hadhappened?

the, the, the following afternoon, I would say
by the following afternoon shecould actually talk to us and
she said, yeah, she didn't havehi a headache at all.
And that basically she'd been inher, in her tent for a couple
days, and then became reallyshort of breath.

So she ends up being flown by a helicopter to a
hospital in Cat Mandu.
And what did they find there?

So they, they worked her up and they ended up
scanning her chest with a CT andfound that she had bilateral
massive pulmonary emboli andshe.

she had any history of clots?
Do you know?

Yeah.
And she flew back to Austria andended up doing well, is what I
heard.

It's another case that seems so improbable
because cardiac arrest in thesetting of massive pulmonary
embolism doesn't usually turnout well, let alone in this
austere setting.

Yeah.
Yeah, well, I, and, and I thinkthe fact that, that she kind of
syncopize and arrested withambulation, that's kind of a big
clue in retrospect.
You know, I, I always have theresidents kind of ambulate
people if you're thinking abouta PE because they often get more
symptomatic with ambulation.
And she got very symptomatic,obviously, she went into a

(36:17):
arrest, so you know that.
But, but so she, she

Yeah, so.

enough that, you know, she, she made it through
and and got better overnight.

So you do a nice job in this, in this paper,
there's a great table that Iwould refer our readers or
listeners to.
Talking about the differentairway interventions, everything
from a recovery position upthrough endotracheal intubation,
and a crike.
And looking at the advantagesand disadvantages of, of both of
those, of, of, of each of thoseinterventions.

(36:51):
What strikes me is it'sprimarily an issue of once you
commit to the airway, what doyou have to do to maintain it?

Yeah.

that seems like kind of a, a critical point in
both of these cases.

Yeah.
And that's something that Idon't think we have to really
worry about in, in the ed, in inour, our home environments
because there's always gonna bea respiratory therapist who
appears and kind of manageseverything, gets the vent set
up, and then get eventuallytransferred to the ICU.

(37:26):
in these wilderness settings youdon't have that.
So you really have to kind ofthink.
Carefully about, you know, whatthe, the, the ramifications of
your, of your actions, I think,and how you're gonna manage this
patient after you intubate them.
So, yeah.

you had a, a senior resident who's graduating
and they're saying, Dr.
Weinberg, I'm spending my nextyear up in, up in the Himalaya,
or I'm, I'm doing multiplepatrols on Denali.
How would you brief them or, orgive them a mental framework for
how to take them ER skills andapply them to that setting?

Hmm.
Where do I begin?
Yeah, I think I, I think one ofthe main reasons we

I think one of

was to

the.

teach people to be flexible and to maybe about
things and not just followblindly, you know.
But I often get, have residents,junior residents, that are so
eager to intubate becausesomeone's altered.
And, know, again, like I said,that that

You know, again, like I said, that.

and convenient in the hospital, but, but in a
wilderness setting, it may notbe the best decision.
And I, if basically I, I wantedto write this

Basically I wanted to write the papers so
that

situations, they, could kind of set a standard of
care that where there is nostandard of care actually, and,
and know, that standard of careis, is kind

standard.

is, fluid and can vary.
But depending on where you areand what situ, you know, what
situ situation you're in andwhat resources you have.
So I guess the, the biggest Iwould teach people is to be
flexible and not, not jump down.
To, you know, jump intofollowing an algorithm.

What was the setting of your community
hospital that you worked in?
Was that critical access?

I've worked in a few different,

I worked few different.

critical access hospitals.
I worked in a busy communityhospital in upstate New York,
with very sick patientpopulation without access to a
lot of access to primary care.
And so that I kind of, and thenI also worked in a small
community critical accesshospital in, in New Hampshire as
well.

(39:47):
And I think of those helpedprepare me a little bit for, you
know, os year settings where youdon't have as many resources you
have in a busy academic center.

Yeah, I hear you talking about all the
resources you have at Dartmouthand, and I was thinking to
myself about our practice sitein Madris, Oregon, which is a
critical access hospital, thatit's pretty, pretty small,
pretty under-resourced overall,and I was thinking about the
fact that.
Yeah, we have four hospitals inthe region and, and Madris is

(40:19):
one of them, and it's a, it'ssingle coverage.
On the MD side, we have an a PPduring, during the daytime, but
pretty limited number of nursesand lower experience with high
acuity patients overall, but apretty sick patient population
with patients from the WarmSprings Indian Reservation and
we're along a a highwaycorridor.

(40:40):
And that, that kind of site, Ithink is a great stepping stone
after a residency in an academiccenter where you have all of the
resources.
Because as soon as you're thrustinto that situation, you realize
how much you had farmed outmentally to, to the respiratory
therapist, to the

Right.

experienced trauma nursing staff, and all of
a sudden you need to know how toset up the arterial line,
pressure bag or run the vent orwhat have you.

Yeah, I,

Yeah,

a, I

I,

I gave a grand rounds a few

I gave a.

on, on wilderness medicine just'cause so many
people would come up to measking me how to get into it.
And I have a couple slides onthat topic where.
Basically you're the nurse,you're the tech, you're the EKG
tech you know, you're therespiratory therapist.
So it it, it's useful to justpractice doing, get comfortable

(41:34):
doing all these other thingsthat you don't usually do as a
physician if you are gonna be inremote areas, especially in a,
in a clinic like that, in Nepalwhere you do have some resources
you have to, you're expected toplace IVs and.
Put the EKG leads on that sortof thing.
So it's all stuff that you canlearn pretty easily, but it can

(41:56):
be pe people can be caught offguard if they're not prepared
for that.

Definitely it's, you could, you could
easily become task saturated inthose things if you were
unfamiliar and, and learningthem in real time.
Task saturated, even if yousuddenly realize you have to do
direct laryngoscopy, you don'thave your video scope and you
haven't done that since youranesthesia rotation in.

Yeah, totally.

Well, Dr.
Weinberg, I appreciate youtalking through these two cases
with us.
I'm gonna have the.
Airway management paper in theshow notes for people to have
access to.
And I'd encourage them to readit even after listening to this
because I think the analysis andsome of the literature review
on, for example supraglotticAirways in comparison to
intubation in the pre-hospitalenvironment is really useful.

(42:42):
And it's a very concisewell-structured summary of that.
If folks want to hear more fromyou or connect with you.
Where are you?
Are you on social media?
Do you have other things that wecan point to?

I, I'm not really on social media actually.
I'm happy to you, you can givemy email out.
I'm happy to like field emailsfrom people.
Yeah, but I, I, I don't have a,a blog or a webpage.

Okay.
We'll, we'll put your academicemail in the show notes if folks
wanna reach out with questions

happy.

and.

happy to give people advice if, you know, if
they want to get interested in,in wilderness medicine and don't
know kind of where to go, tojump into it.
I'm happy to, to give advice.
Awesome.

Awesome.
Well, I really appreciate yourtime.
The listeners of this show arevery appreciative and courteous,
at least in the interactionsI've had with them.
So hopefully you'll get somenice thank yous from them as
well, and I'd love to have youback on some time maybe to talk
about the.
The climbing accident that, thatbrought you into medicine.

Yeah, I did.
Definitely.
I'm happy to, happy to chatanytime.
It was really fun chatting withyou.

That's it for this episode of Wilderness
Medicine Updates.
I hope you enjoy thatconversation with Dr.
Weinberg and that you're able totake away some learnings or at
least some mental simulation ofa couple interesting cases.
I do encourage you to look atthe paper, which is in the show
notes and makes a good read asit does break down the pros and
cons of different airwaymanagement techniques in austere

(44:14):
situations.
And I think it's worth thinkingabout, in the situations where
you commonly operate, what toolsdo you have available to you and
what are you actually capable ofdoing?
And for how long?
Because that is gonna drive thecare that you can deliver to a
patient and the decisions youmake about how you manage them.
I, in my education for our skipatrollers, for example, like to

(44:37):
harp on the fact that really itis that basic life support care.
That can actually make adifference for patients.
And so just like Dr.
Weinberg said, probably thebiggest thing that he did for
the patient in that first casewas to do a jaw thrust open the
airway, a very simple maneuverthat he can teach a climbing
partner on a cliff side, butthat in and of itself is a

(44:59):
lifesaving maneuver.
Those basic, basic tools are thethings that we can fall back on
time and time again.
And then if you're in the rightplace at the right time, like
Dr.
Weinberg was, can deliver someof that advanced care from the
emergency department to thecliff side.
I wanna give a couple shout outsI've been hearing from Bruce
Petty and Hako Sak.

(45:21):
Thanks for reaching out.
I appreciate the communication.
You guys are awesome.
I hope that you enjoyed thepodcast, and if you did, please
give it a five star rating.
On iTunes, on Spotify, thathelps us get out to more people.
This passion project that I hopedelivers benefit, the more
people it can reach, the better.

(45:41):
So tell your friend, yourcolleague, a doc, a nurse, a
paramedic.
Tell your mom, I think your mommight like this podcast.
Until next time, you can connectwith us on social media.
Now, there is an Instagram,there's a blue sky.
The information's in the shownotes as well, or you can find
it on the Buzzsprout page.

(46:02):
James Hanson is our mediamanager and he does an awesome
job in his free time.
So thanks to you, James.
Until next time, I'm your host,Patrick Fink.
Stay fit, stay focused, and havefun.

All Episodes

Ep. 24 - Airway Management in Austere Environments with Dr. Nicholas Weinberg

Episode Transcript

Popular Podcasts

New Heights with Jason & Travis Kelce

Dateline NBC

On Purpose with Jay Shetty

.css-15opob5{left:0;position:absolute;top:0.8rem;} All Episodes

.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Ep. 24 - Airway Management in Austere Environments with Dr. Nicholas Weinberg