Rural Medicine - Hairclip in the Airway
Vanessa Cardy MD, Mel Herbert MD, Stuart Swadron MD and Liza Kearl, MD
Take Home Points
- Language and cultural barriers may make it difficult to obtain a reliable history.
- It may be a difficult decision to keep the patient for a procedure versus transferring the patient.
- Delays associated with accessing care in rural medicine have the potential for bad outcome.
- It was a Monday in late November and busy in the emergency department. Cardy’s colleague was supervising a resident. A young patient was triaged with a cough. They were triaged as a level 4 priority. The vital signs were stable. The child was quiet and there were no other reported issues. It can be very challenging to get accurate histories in this location due to a variety of cultural and language barriers. Most of the patients speak Cree but the majority also speak English when they are of school age. It is common for patients to be reserved on initial interactions with strangers. The history may vary a lot.
- The resident picked up the chart about 45 minutes after the patient was triaged. The resident returned and said that that the child who was about one-and-a-half years old had been left alone in the bathroom with their older sister, who was 3 years old. After that, the mother noted that the child started to cough. The child had been well prior to this. There was no prior cough or upper respiratory infection symptoms. No fever. The vital signs were stable with good oxygen saturation. The resident described the child as looking fine.
- The attending physician went to see the patient and noticed that the child was very quiet and calm. There was no distress but the child was unusually quiet. The respiratory exam and rest of the exam was unremarkable.
- They got a chest x-ray and it looked grossly normal in the chest. Just as the attending was about to sign off on the x-ray, she looked up at the top of the x-ray and noticed a tiny, shiny spot. It was difficult to see. They ordered a soft tissue view of the neck. There was a hair clip that forms a V-shape when open and is bent when close. It appeared to be open around the vocal cords.
- They called the closest hospital which is 10 hours by car or 6 hours by plane. The hospital refused to accept the case as they did not have pediatric ICU. However, they did have an operating room and anesthesia and they do some pediatric surgeries. They told them not to attempt to try to remove it.
- They called the children’s hospital at McGill which is 16 hours by road and 8 hours by plane. The pediatric ER suggested attempting to remove the foreign body with Magill forceps and a laryngoscope. Cardy had no back-up. They called peds ENT for advice. The ENT told them to definitely not attempt to remove it themselves. They all recommended getting IV access, keeping the kid still and transferring to Montreal.
- You are in a resource limited area. Do you go for it or do you try to transfer the child? This is really dangerous. If it goes bad, do you have the skill to do what is next? In a child this age, it is not cricothyrotomy but jet ventilation. Do you have the resources to do jet ventilation? This will only give you a short amount of time. This is a big dilemma. Do you stay and play or go? If you stay and play and it goes badly, you will be criticized. If you put them in an airplane and fly them a long way to a tertiary hospital and they lose their airway on the way, you will be blamed.
- The patient was getting upset with everyone around her. She was whimpering when they approached her. They attempted an IV but she started to cry so they stopped. They used EMLA and distracted her and placed an IO. She didn’t flinch.
- The weather was bad and transport time was delayed. They decided to transport the child. The sending physician accompanies the patient with an unfamiliar transport nurse. Imagine how frightening this is. Should you do it in the ER where there is another doctor who can help?
- Another doctor in the village volunteered to go. They got in the plane and the flight went pretty smoothly. However, they had to land because the flight crew had exceeded the number of hours they could fly. They landed in the town with the hospital that had originally refused to accept the patient. They recontacted the hospital and pleaded with them to take the patient to the OR for removal. They refused again. They had to wait for three hours on a tarmac.
- They tried to keep the child upright which was difficult because she was exhausted and wanted to lie down. They went to the Children’s Hospital where the child was taken to the OR and the hairpin was removed by ENT in about 2 minutes.
- This raised several issues. The communication barrier prevented obtaining an adequate history to indicate higher acuity. The question of whether or not to attempt removal. This could help save costs and impact on the community of having two physicians unavailable. Cons included the possibility of making things worse.
- Liza Kearl is a pediatric emergency physician with many years of experience on the receiving end of pediatric transports
- She praised the team for recognizing this airway emergency in the first place and the need for imaging
- She was surprised that no complications developed despite the lengthy and difficult transport
- Kearl points out that you almost never have all of the pediatric subspecialists that you need outside of a pediatric tertiary care facility
- She adds that although the majority of physicians work with adults, most of us also have pediatric training; those in emergency medicine, surgery, and anesthesiology all have training in managing emergent pediatric conditions, including basic and advanced life support techniques.
- Although a team at a community hospital might not feel completely comfortable managing this patient, that unease must be balanced against the potential harms of more time and a potentially risky transfer to a pediatric facility.
BLS Choking Adult or Child Algorithm
BLS Choking Infant Algorithm
Michael B. - November 10, 2018 9:24 AM
It would of been great to have a description of the exact position of the hairclip in the posterior pharynx, what could be visualized on physical exam; did the child have stridor or a lot of secretions? And what the ENT specialist did to remove the FB. If it was so easily removed what was the exact procedure - was it sedation of the child with appropriate anesthesia that allowed extraction. I guess more details of the position of the hairclip in the posterior pharynx relative to the glottis/vocal cords.
Vanessa C. - January 17, 2019 10:43 AM
Thanks for the message. I tried to get a copy of the patient's Xray but our computerized Xray system was inaugurated the day after this case! I couldn't believe it that we had come so close to having a digital version of this film. Instead the film and the light box we used to use were in a box somewhere! I can tell you that the hairclip was in an open position, it appeared to be resting around the level of the cords with part pointing down and one part pointing across the airway. No stridor. Secretions were starting to become an issue nearer the end of the case.
With regards to how they removed the hairclip I believe it was a topical anaesthesia and then quick look/removal, but I wasn't in the room I fear.
Sorry it took me so long to reply, and thanks for your interest.