Ume책 Institute of Design | MFA Advanced Product Design | Paramedics Project | 2015
EMERGENCY CRICOTHYROTOMY IN THE PRE-HOSPITAL CONTEXT Project Report | Ahsen G체lsen
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PROJECT STAKEHOLDERS
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Abstract Emergency cricothyrotomy is a medical procedure that is used in order to establish an airway in certain life-threatening cases, such as airway obstruction by a foreign body, angioedema, or massive facial trauma. Although there are several techniques described to perform cricothyrotomy, surgical cricothyrotomy and needle cricothyrotomy are the two main techniques used today. Surgical cricothyrotomy provides effective ventilation; however, the procedure requires a high level of skill and experience which makes it hard to perform for paramedics and nurses when considered the rarity of the cases requiring cricothyrotomy and the extreme conditions in a pre-hospital context. On the other hand, needle cricothyrotomy is preferable by the paramedics since it is easy to perform and not invasive, although it does not provide an effective ventilation. Laerdal Cric provides confidence for pre-hospital health professionals to choose surgical cricothyrotomy instead of less effective procedures. It is a signle-use tool that combines the advantages of two procedures in a designed form optimized for pre-hospital context by minimizing the necessary skill and experience required to perform an otherwise complicated procedure.
Table of contents Abstract Introduction Background Who is the paramedic? Stakeholder : V채sterbottens L채ns Landsting Stakeholder : Laerdal Medical
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9 11 13 15
Initial Research Field trip Field trip | Ethnography Field trip analysis VPS diagrams Problems and solutions workshop Developing quick concepts Role-play exercise Design opportunities
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Research on Focus Area Understanding airway management Emergency cricothyrotomy Needle cricothyrotomy Surgical cricothyrotomy 4 Step rapid cricothyrotomy Wire guided cricothyrotomy Landmarks and cricothyroid membrane Market research
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Research Conclusions Overview Key problems Problem definition Goals and wishes
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Creative Process Overview Experimenting on providing depth information Sketches and mockups Traction+Incision Position Initial concept Defining anatomical requirements Refining the concept CAD development Model making Final Design Proposal Key features Depth control Tube with introducer Use scenario Sterilization and packaging Palpation Incision Intubation Retraction Ventilation Presentation and Reflections Final presentation Local media coverage Reflections Reflections on project process Reflections on final result References Schedule
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Introduct覺on
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Background The Paramedic Project was the term project of Advanced Product Design Programme’s first year students in 2015. It was a 10 weeks project in which Umeå University, Västerbottens Läns Landsting ambulance station and Laerdal Medical worked in collaboration. In the scope of this 10 weeks, the aim was to deal with the problems and solutions for a specific user group,
paramedics, by applying the methods of People Centred Design (PCD) or Human Centred Design (HCD). The project has started with an in-depth ethnographic research, group workshops to cluster the design opportunities and followed by individual work on a specific area.
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Who is The Paramedic? A paramedic is a healthcare professional, predominantly in the pre-hospital and out-of-hospital environment, and working mainly as part of emergency medical services (EMS), such as on an ambulance. The paramedic role is closely related to other healthcare positions, especially the emergency medical technician role, with paramedics often being a higher grade role, with more responsibility. The scope of the role varies widely
across the world, having originally developed as a paraprofession in the United States during the 1970s. Since this time, in countries such as the United Kingdom, the paramedic role has developed into an autonomous health profession, with individual licence to practice, whilst in other countries (including the United States) the paramedic remains an agent working on behalf of a doctor to provide the pre-hospital health care. The Paramedics Project | Term Project 2015
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Tvistev채gen 2, 907 36 Ume책, SWEDEN
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Stakeholder : Västerbottens Läns Landsting Ambulance Station One of the stakeholders included in this term project is Västerbottens Läns Landsting ambulance station. We worked closely during user research phase of the project. The paramedics, nurses and drivers working there has contributed the project both by sharing their experiences and giving us opportunity to follow them during their work shifts. 80 employees are working at the ambulance station in Umeå. 50 of these are employed full-time, 30 work part-time. There are two groups of paramedics, the first one (70%) are trained nurses with or without a
40-week specialist training in trauma medicine, like anaesthesia and intensive care. The second group of paramedics (30%) are assistant nurses (Undersköterska in Swedish) who have additional training in paramedic medical care of either 7, 10, 20 or 40 weeks duration. Other more administrative positions at the station includes a manager, a deputy manager, a vehicle responsible working half-time and a clerk working 20%, responsible for the journal system. In total 29 women are employed at the station. The Paramedics Project | Term Project 2015
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Tanke Svilands gate 30, 4002 Stavanger, NORWAY
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Stakeholder : Laerdal Medical Laerdal is a company that specialized on medical equipment and medical training products based in Stavanger, Norway. Laerdal started its journey as manufacturer of wooden and rubber toys. With the experience on plastic manufacturing techniques and the motivation coming from the story of a survival that the son of companies’ CEO has experienced thanks to the CPR on scene, the company turned its face to the medical
sector. This historical background has never lost its importance in companies’ vision is that even today Laerdal’s best-known product is a training mannequin popularly named ‘CPR Annie’. With the same sense, motto of the company is ‘helping save lives’ which sounds ,in my opinion, very ambitious but at the same time modest with the emphasis that they put in ‘helping’ side of their jobs. The Paramedics Project | Term Project 2015
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In覺t覺al Research
Field Trip - Day 1 On the first day of the project, we visited V채sterbottens ambulance station as a group of 12 students and programme director Thomas Degn. During this first visit, we got an introduction to V채sterbottens ambulance station, how the paramedics work and the tools they use during their work shifts.
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28 CALL-OUTS In the following visits to the station we got the chance to join ambulance teams in 28 cases in total and got first-hand experience on-site. If you want to see more about our field research, please have a look at this
Field Trip | Ethnography - Day 2 & 3 The visits was made to the ambulance station in smaller groups in the following days. These visits was more field ethnography oriented. Visiting in smaller groups enabled us to get involved in the daily routine of the ambulance station. The small chats that we had during the day helped us to get to know them better as well as the interviews conducted. In addition to this, we joined first aid demonstrations and got more in-depth information about the tools, devices and techniques which they use during the day.
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BACK TO SCHOOL After completing our visits in the field, we came back to school to dive into a creative process based on analyzing the information collected. We went through the process listed below. Field trip analysis VSP Diagrams Problem solution workshop Quick concept exercise Role Plays
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Title
Field Trip Analysis As a group of 4 students, we summarized the information gathered during the field research and analyzed it in a way that concluded our insights and observations. At the end of the field research analysis, each group presented the outcomes of this process.
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Visual Social Persona Diagrams A Visual Social Persona (V.S.P.) is the visualization of a hypothetical user’s day with the details from both work and private life to get a better understanding of the user group. It helped us to see the details that we are not able to see in the big picture.
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Title
Problem & Solutions Workshop After the VSP diagram, we tried to figure out problems and possible solutions. As the amount of information that we had during the previous days was quite a lot, we tried to cluster and prioritize the problems, solutions and design opportunities collaboratively by voting on each of them.
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Title
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Title
Developing Quick Concepts We developed 12 concepts in 6 hours. They were based on the most interesting areas chosen by the class.
Role-play exercise We explored four of these concepts in-depth with the roleplay exercises that enable us to see these possible solutions in the scenario and real context.
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Design Opportunity Areas Info flow | Communication Layout of the ambulance Stabilization (in the ambulance environment) Supporting Paramedics Self-protection for paramedics Multitasking Optimizing the equipment for ABCDE & Triage Weather and context conditions Preventing hypothermia Lifting and carrying support Transition of the patients The Paramedics Project | Term Project 2015
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Research on Focus Area
Understanding Airway Management Airway management is a set of medical procedures performed in order to prevent airway obstruction and thus ensuring an open pathway to a the patient’s lungs. As even short time hypoxia can end up causing vital brain damage, it is very important for paramedics to have the right skills and knowledge required to perform effective airway management. We can also understand its importance just by looking at the its place in the ABCDE (airway,breathing, circulation, disability and exposure) procedure. With this motivation I have dived into a research about the airway management tools, devices and techniques. Two nurses from the Västerbottens ambulance station also shared their experiences on airway management procedures. I came to the conclusion that performing emergency cricothyrotomy is one of the most skill demanding, risky, stressful but lifesaving interventions that they perform as a part of airway management procedures.
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“Surgical airway operations are not that common. I think it was only two cases requırıng thıs in the last 5 years.” Kristofer Östenson,19.10.2015 (Paramedic)
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Emergency Cricothyrotomy The procedure was first described in 1805 by Félix Vicq-d’Azyr a French surgeon and anatomist. In order to define cricothyrotomy, the first thing can be done by looking at its direct meaning. In the medical terminology, ‘‘-otomy’’ means basically a hole. Cricothyroid membrane is the soft tissue between two cartilage(see the left corner). Thus, a cricothyrotomy is the surgical placement of a hole in the cricothyroid membrane.
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Two medical doctors M. Gregory Katos and David Goldenberg who are specialized on anesthesiology and surgery from Penn State College of Medicine, describes emergency cricothyrotomy as a lifesaving procedure in the scenarios where other means of ensuring definitive airway has failed to prevent disastrous consequences arising from hypoxic injury or death(2007). It is also one of the most important intervention skills for the
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paramedics. In the pre-hospital emergency literature, the cases which requires cricothyrotomy are called “cannot ventilate, cannot intubate” situations. They are required to say this out-loud when they take the decision to go for cricothyrotomy in order to inform other paramedics or nurses in the scene.
“cannot intubate, cannot ventilate” If the patient is not able to breathe effectively, definitive airway methods are used to ventilate the patient. The term ‘definitive airway’ covers both intubation and cricothyrotomy. Thus, the first and most important step of the cricothyrotomy is trying to reach an effective ventilation by intubating the patient. The picture on the left shows a rapid sequence intubation. However in the article titled ‘Surgical Cricothyrotomies in Prehospital Care’, Scott R. Snyder, Sean M. Kivlehan & Kevin T. Collopy brings another perspective to the topic.
Contrary to popular belief, a cricothyrotomy does not need to be a last-ditch effort. Instead, think of it as just another strategy for establishing a definitive airway. In fact, there are times, such as respiratory arrest in anaphylaxis or upper airway obstruction, when cricothyrotomy could be the first choice in airway management.(Collopy,Kivlehan&Synder, 2014)
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Needle Cricothyrotomy Needle cricothyrotomy is seen as a one of the most convenient way of cricothyrotomy by paramedics and nurses. The the main reason for this may be that they are already experienced in the use of over-the-needle catheters, which is used to establish vascular access almost every day. However, needle cricothyrotomy is still considered as the most ineffective cricothyrotomy method because it does not allow the elimination of CO2. Accumulated CO2 and high pressurized oxygen causes the rise of CO2 saturation in the blood which could result in life-threatening brain injuries.
‘‘In choosing to perform needle cricothyrotomy, we are making a conscious decision to oxygenate rather than ventilate.’’(Collopy, Kivlehan & Synder, 2014)
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Stabilize the skin and trachea with your non-dominant hand between your thumb and middle finger, leaving the index finger free to palpate the landmarks
With the 10 mL syringe attached to your needle, insert the needle through the skin and cricothyroid membrane caudally at a 45째 angle
While inserting the needle, aspirate with the syringe. Bubbles will appear in the syringe once you have penetrated the tracheal lumen.
Advance the catheter over the needle
Remove the needle
Connect the oxygen supply Images retrieved from: https://www.youtube.com/watch?v=dvWy9NXiZZI
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Open Cricothyrotomy Contrary to the needle cricothyrotomy, open cricothyrotomy procedure allows a true ventilation which must also support the elimination of CO2 in addition to O2 supply. With the two traverse incision made on the skin and cricothyroid membrane, tubes bigger in diameter can be placed to the airway. Once successfully accomplished, the efficiency rate is higher than the needle cricothyrotomy. However; this procedures advantages also brings some disadvantages. As the high complexity level because of the steps added to the process and the long incisions, the risk of complications such as damaging blood vessels and surrounding tissues are higher with this method.
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Stabilize the trachea with your non-dominant hand between your thumb and middle finger, leaving the index finger free to palpate the landmarks
Stab 2–3 cm vertical incision over the skin, subcutaneous tissue and cricothyroid membrane | stabilise with index finger
Stabilize by using index finger of non-dominant hand and visualize cricothyroid membrane
2–3 cm vertical incision over the skin, subcutaneus tissue and cricothyroid membran
While stabilizing with tracheal hook and widen the hole horizontally with trousseau dilator
Place the tracheostomy tube between two legs of trousseau dilator
Rotate together after placing the tube
Advance the tracheostomy tube
Remove the guide and inflate the cuff Images retrieved from: https://www.youtube.com/watch?v=dvWy9NXiZZI
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4 Step Rapid Cricothyrotomy 4 step rapid cricothyrotomy is a simplified open cricothyrotomy procedure in which lower compelation times can be reached. The equipments required for this cricothyrotomy technique are #20 scalpel, high radius trecheal hook and tracheostomy tube. Because the operator’s body position and hand movements (steps 3 and 4) are similar to those in orotracheal intubation, there is a feeling of familiarity that enhances retention of the procedure. The steps are illustrated and 4 cases using this technique are reported. Since the hands at each step are stabilized on the patient and no special equipment is needed, this technique also may be ideal for the out-of-hospital environment (Brofeldt, Panacek & Richards, 1996).
Palpation
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Stab incision
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Inferior traction
Tube insertion
Wire-guided Cricothyrotomy Wire-guided cricothyrotomy is another cricothyrotomy technique that provides better control during the procedure. In this technique, a wire is placed to the trechea through a needle which later guides the tube for the right placement. According to the research published in The Journal of Emergency Medicine in 2000, 14 of 15 physicians stated that they preferred the wire-guided to the standard technique. The data suggest that this wire-guided cricothyrotomy technique is as accurate and timely to use as the standard technique and is preferred by the physician operators. In addition, the technique results in a smaller incision on human cadaver models (Chan, Vilke, Bramwell, Davis, Hamilton & Rosen, 2000).
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Landmarks & Cricothyroid Membrane Cricothyroid Membrane is basically the most suitable part to penetrate into the airway during cricothyroidotomy. It is placed between the thyroid cartilage (Adam’s ape) and the cricoid cartilage. Manoj Mittal, Associate Professor of Clinical Pediatrics in University of Pennsylvania School of Medicine, states that catheters up to 13-gauge can be safely used on a patient with a fully developed airway in which average vertical width of the cricothyroid membrane is 13.7 mm and 28 mm in the transverse dimension in the paper titled ‘Needle cricothyroidotomy with percutaneous transtracheal ventilation’ (2015). As the size of this part is considerably smaller in the children, surgical cricothyroidotomy is not used for children under the age of 12. Inability to identify landmarks is one of the biggest challenges for the health professionals in this kind of interventions. It becomes more and more difficult on patients with obesity or anatomical abnormality.
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Even if there were no procedure defining the use of ultrasound in the emergency cricothyroidotomies until 2012, the results of the research titled Ultrasound-guided, Bougie-assisted Cricothyroidotomy: a description of a novel technique in cadaveric models, ultrasound guided cricothyroidotomy is rapid, with a median time to completion of 26.2 seconds, and has considerably lower failure rate with 20 of 21 cadavers undergoing successful cricothyroidotomy. (Curtis, Ahern, Dawson & Mallin, 2012)
Retrieved from http://aucklandhems.com/2012/12/05/ultrasound-assisted-surgical-airway/
Although the ultrasound guided cricothyroidotomy procedure is evaluated in 2012 for the first time, Melike G端lsen who is a nurse working in Ege University Research Hospital, stated that ultrasound imaging is commonly used in the hospital emergency services in order to identfy landmarks. The Paramedics Project | Term Project 2015
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Tactical Kit
Control Key
https://www.cookmedical.com/products/cc_tccsbuni_webds/
http://www.rescue-essentials.com/surgical-airway-kit-hard-case/
http://www.pulmodyne.com/#!control-cric/cbua
Cric
PCK portex
As the webpage has removed because of US army secrEcy, further information cannot be reached about this product.
http://www.medikalblog.net/trakeostomi-acil-seti/
Melker Kit
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Quicktrach http://www.teleflex.com/en/usa/productAreas/anesthesia/
Sterilization wipes
Trecheal hook Torseu dilator
Scalpel
Market Research Evaluation The products that are available on the market can be categorized into two main groups: kits and specialised tools designed just for the cricothyrotomy procedure. The main approach of the kits, such as Melker Kit and Tactical Kit, is to provide the traditional equipment in a single package rather than touching upon the way that the procedure is done. On the other hand, Control Key, designed for the rapid four step technique; and Cric, designed for the traditional technique, are making it easier to handle the dilator or tracheal hook by integrating those into a single body together with the scalpel. Apart from these, we see two other remarkable products on the market which can be
considered as needle cricothyrotomy tools with larger diameter cannulas: PCK Portex and Quicktrack. While PCK Potex includes a smart spring mechanism for the depth control, Quicktrack comes in with a preloaded syringe to speed up the process. To conclude, although all of these products available on the market include key features to make cricothyrotomy process easy and safe; they rather sacrifice from the required tube diameter or they just provide traditional tools in a single body. Taking this into the consideration, there is still a room for a product in the market that could provide a more comprehensive solution.
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Research Conclus覺ons
Overview Since there are several techniques described for cricothyrotomy, I have tried to map out advantages and disadvantages of these techniques in order to understand the procedure better and have a clear problem definition. As this was more functional approach and not enough to set a clear project goal, I have blended the outcomes of this literature research with the insights from the user research to have a clear picture at the end.
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Emergency scene is not a surgery room. However today emergency cricothyrotomy methods are still identical to the ones in surgery rooms.
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https://www.youtube.com/watch?v=yfyQP4wNbcA
The video footage is attributed to Dr. Peter Rhee who is a trauma surgeon from USA.
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It is highly important to visualize the trachea if you are not able to feel it with the scalpel. On the other hand, trying to visualize trachea could end up loosing the incision, especially if you are not an experienced surgeon. In the pictures on the right, we see the fingers ends up in trachea to find a lost incision. This scenario can lead to several incisions which mean high risk of complication, time loss, and stress.
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A needle is a daily instrument for paramedics.
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A scalpel is a surgical equipment.
In an emergency situation, I would prefer to go with needle cricothyrotomy because surgical cricotodomy is complex, requires skill and practice and includes high risk of complication.
Although open cricothyrotomy is more effective than the needle cr覺cothyrotomy, it is not preferred by the paramedics.
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Problem Definition
I have seen a number of successful airway placement is more important “emergency “ Accurate tracheotomies where the than rapid airway placement when considering patient ended up brain dead. This is bad. the efficiency of the process. ” ”
SPEED
X ACCURACY
Balancing these two is highly depended to skill and experience level which is hard to maintain for emergency health professionals even if once gained, because of the sparseness of the cases requiring cricothyrotomy.
Difficulty to identify land marks Need for more than one person Stabilization Control over the depth of incision Added steps resulting in added time Dynamics of emergency scene Unfamiliarity to the procedure Risk for major vessel injury Losing the incision during traction area Multiple tools decreasing the concentration and control during the process Inadequate vision because of blood and inadequate lighting Stress caused by severity of the situation Accidental perforation of the esophagus Skill maintenance Need for fast decision making
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Goals and Wishes
provıdıng confıdence to pre-hospıtal health professıonals to perform crıcothyrotomy by mınımızıng the skıll and experıence level requıred and reducıng the complexıty of the process Goals Minimizing the skill and experience level required for a successful cricothyrotomy Reducing the complexity of the process Providing better control of the operation Supporting also CO2 elimination in addition to oxygenation Being suitable for the pre-hospital emergency scene context and environment Providing better control of the operation Increasing accuracy without extending the time Compatibility with the current O2 supplies Facilitating sterilization of the operation area
Wishes Helping paramedics with the stress management caused by the severity of the situation Preventing hyperoxia during the ventilation process
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Creat覺ve Process
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Overview Considering the advantages of needle cricothyrotomy such as being easy to perform and low risk of complication, which are usually the reason for paramedics to prefer needle cricothyrotomy over the surgical one. I looked deeper into the characteristics of needle cricothyrotomy and it’s advantages and tried to explore ways to incorporate these characteristics into a surgical solution with mockups, experimentations and sketches during the creative process.
+
how can we incorporate surgical cricothyrotomy with the advantages of needle cricothyrotomy?
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advancing the needle + aspirating
deconstruction
advance and aspirate in one move
Experimenting on Depth Control One of the main problems of surgical cricothyrotomy is not having control over the depth which most of the time results in several incisions, time loss and complications. On the other hand, depth can be easily controlled in needle cricothyrotomy by simply using a syringe. Since the syringe is aspirated while the needle advance through the trachea, the bubbles are observed in the water when it reaches to the trachea thanks to the positive pressure in the lungs. This method is also used in tension pneumothorax cases, high pressurized state of lungs, in
order to reach the correct depth and evacuate excessive pressure. As it is a very manual and common way of finding landmarks in the body, paramedics, masters of the needle, feel very comfortable with it. For this reason I have looked more deep into how the physics works in there, and made some experimentations on it. At the end, I came up with the idea of reconstructing this system in a way that it could work in one motion, and does not necessarily require a syringe body.
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Sketches and Mock-ups
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Incision + Traction
Finding the right position
As the cannula is advanced over the needle in the needle cricothyrotomy, the operation becomes quite easy. On the other hand, in the surgical cricothyrotomy, most of the problems occurs during the transition between incision and traction. Similar to the needle cricothyrotomy approach, advancing the dilator, or tracheal hook, over the scalpel could actually bring the incision and traction steps closer.
Choosing the position relative to patient is being described at the beginning of most the training manuals and videos. It is defined according to the dominant hand because it is very vital to have a good control of the tool with the dominant hand while palpating with the non dominant hand. As It could affect the use scenario of the product, I have tried out possible configurations and operation sequences for the possible solutions.
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Initial Concept
water chamber | depth information
tracheal hook control
scalpel control
tube holder
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The scalpel hook connected to water chamber and scalpel hook in inactive position
The scalpel that provides depth information penetrates through the skin and trachea
The hook goes over the scalpel to catch the wall of the trachea in a safe way.
Then it becomes safe to enlarge incision by traction and advance the tube.
Initial Concept Evaluation The initial concept was based on guiding the tracheal hook through scalpel that provides the depth information and a preloaded tracheal tube. The aim was to eliminate the problems related to transition between incision and traction as well as making the sequence of actions more coherent. The concept was weak on the intubation and sterilization scenario. With
the feedback that I got from Laerdal Medical, I took a decision of making it into a single use product as it is nearly a surgical tool in a pre-hospital context. With this decision, final design had to be cost and material effective. Relatively, it also had to reflect that it is a single use product with its form and design language. The Paramedics Project | Term Project 2015
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Defining Anatomical Constraints Looking more into the anatomical restrictions and dimensional requirements, I have created guidelines to follow for the final design proposal. To be compatible with the ventilation systems, the opening of the tube has to be 15 mm in outside diameter since all the ventilation bags are standardized in size of the connection valve. As the depth of the trachea wall varies a lot because of the anatomical differences, anatomical distortions related to trauma, weight and sex; the scalpel must be able to reach 6 to 25 mm excluding the distance that must be taken after the outer wall of the trachea. In order to provide effective ventilation, the diameter of the tube must be as large as possible. At this point, the width of cricothyroid membrane restricts the size. For a safe cricothyrotomy, it is suggested to use a catheter the inner diameter of which is 7 mm.
Trachea
Scalpel-Hook
25
10
Tube
Depth
23
15
7
9
6-25
Cric Membrane
Concept Refinement Moving forward from the initial concept, using the tracheal tube as a dilator tool; and placing the tube over the scalpel could simplify the process a lot more. However; the challenge here was to make an optimization on the size of the scalpel, the tube, and the dilator so that they would actually meet with the anatomical requirements. By making small alterations with a heat gun on different sized tubes, I built quick mock-ups. Since it was hard to work on small details on mock-ups, this process was a bit back and forth between the CAD and physical material. Instead of using a circular catheter, using a slightly elliptical catheter was making it easier to dilate the incision over a scalpel; and it was meeting the anatomy of the cricoid membrane better.
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CAD Development I started the CAD work at an early stage to test out mechanical principles. It also helped me a lot with working in small details which are difficult to build and try out with mockups.
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almost there...
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Model Making
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F覺nal Des覺gn Proposal
LAERDAL CRIC Emergency Cricothyrotomy Tool Laerdal Cric is a single-use cricothyrotomy tool that combines the advantages of needle and surgical cricothyrotomy in a designed form optimized for a pre-hospital context. It minimizes the necessary skill and experience required to perform an otherwise complicated procedure.
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Key Features
Depth control With the regular scalpels, it is not easy to understand the depth of the incision which most of the time result in several incisions and complications. In the needle cricothyrotomy, the needle can be easily penetrated to right depth by using a water filled syringe(see page 68). As the plunger is pulled back while advancing the needle, the bubbles are observed in the barrel thanks to the positive pressure in the airways. Taking inspiration from this physical principle, Laerdal Cric accommodates a depth control mechanism in order to make more controlled and precise incision. As the specialized 9 mm scalpel-needle is connected to the pre-loaded water chamber; the incision and aspiration can be done in one action. The idea behind the design of this scalpel-needle was also that paramedics do not feel comfortable with using a scalpel because it is a surgical instrument. On the other hand, syringes are their daily instrument. Taking this into consideration, the aim was also to keep the syringe metaphor not only in function but also in the overall form language so that the paramedics would feel emotionally more familiar to the product.
Tube with introducer The introducer head of the tube functions as a dilator so that the tube can be placed over the scalpel. By combining the incision and intubation steps, it is aimed to minimize the problems arising form loosing the incision between two steps. the tube is guided by the scalpel like in the wire guided cricothyrotomy. The elliptical form of the tube makes the dilation easier, while it fits better to the anatomy of cricoid membrane.
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strap attachment
introducer
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USE SCENARIO | sterilization The product and sterilization wipe are packaged together. When it is striped of from the top, the sterilization wipe is reached before the product itself, which decreases the risk of contamination of the tool while sterilizing the operation area. The protective cap is sealed to the package. When product taken off the package, it is ready to be used leaving the cap in the package.
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USE SCENARIO | palpation The paramedic defines the landmarks with the non-dominant hand while positioning the product accordingly. As the product is one-hand operated in the incision step, the non-dominant is hand kept in the palpating position to stabilize the trachea, which provides better control.
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USE SCENARIO | incision Since the button stays locked in the tools passive mode, this button can only be moved forward when pressed.By pressing and sliding, the paramedic advances the scalpel-needle and the catheter together through trachea while stabilizing the trachea with the non-dominant hand.
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USE SCENARIO | intubation Once the right depth has been reached, the bubbles are observed in the water chamber thanks to the positive air pressure in the airway. Then the paramedic stops advancing the scalpel and advances the tube with the non-dominant hand.
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USE SCENARIO | retraction The paramedic takes out the cric tool while supporting the tube with non-dominant hand.
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USE SCENARIO | ventilation Once the airway is secured, paramedic can provide positive pressure ventilation to the patient with a standard manual resuscitator.
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Presentat覺on & Reflect覺ons
Final Presentation The final presentation was held at the Ume책 Institute of Design on 24th of January 2016. Representatives from the Laerdal Medical and the V채sterbottens L채ns Landsting ambulance station gave feedback on the concepts that we had developed during this 10 week project.
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Local Media Coverage
The local press was also present at the final presentation. The headline in the local newspaper Folkbladet said “Smart inventions for the ambulance service”.
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Reflections
Reflections on Project Process Having two collaborating partners one from the field and one from the industry, Laeral Medical and V채sterbottens L채ns Landsting, was a great opportunity for me to work on a medical project. Although working on an individual medical project was quite challenging for me; and I had some up and downs during the process, the execution worked quite well. Firstly, It took me more time than I planned to move from the research phase to the ideation phase because the research phase was not just about understanding the different techniques of cricothyrotomy, but also digesting them and seeing the advantages and disadvantages of them from a design perspective. Going deep into understanding these medical procedures, give me a feeling of being locked into a box borders of which has already been described by medical doctors. Although this challenged me at the beginning and resulted in time loss, it turned into an advantage once I was able to set my boundaries with the information and insights gained from research phase.
Secondly, It was also hard to follow up with the ideation and concept presentations because of the process that I followed. What is expected from designers is usually coming up with an overall concept at the beginning and then going into detailing. As I could not move forward in the project before deciding on certain details, the process for me was more inside out. I came up with the overall concept by building upon the details that decided earlier. Even if following this kind of method caused some difficulties with debriefing the company about the process, I think it was a good method to approach this kind of topic which highly depends on anatomical restrictions. To conclude, although I was scared on diving into a quite challenging and invasive medical topic like cricothyrotomy at the beginning, I have learned a lot from this challenge during the process.
Reflections on Final Result As it is a project on a nearly surgical procedure, it is hard to evaluate the results and truly know if I have reached the goals and wishes that I set at the beginning of the project. This was also causing me an uncertainty during the whole process. However at the end, the project got positive feedback from both the paramedics and Laerdal Medical. Especially hearing good comments of Jonas Alex, who is a paramedic
specialized on emergency cricothyrotomy, and seeing him using the product in the same way as I have intended to be used at the final presentation took away my concerns about reliability of the concept. To take the concept one step further, I think that there is still work to be done with the safety issues and semantics.
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References
Brofeldt, B. T., Panacek, E. A., & Richards, J. R. (1996). An Easy Cricothyrotomy Approach: The Rapid Four-step Technique. Academic Emergency Medicine, 3(11), 1060-1063. Callopy, K., & Kivlehan, M., & Snyder, R. (2014). Surgical Cricothyrotomies in Prehospital Care.
Retrieved from http://www.emsworld.com/article/12024704/surgical-cricothyrotomies-in-prehospital-care Chan, T., Vilke, G., Bramwell, K., Davis, D., Hamilton, R., & Rosen, P. (2000). Comparison of Wire-Guided Cricothyrotomy Versus Standard Surgical Cricothyrotomy Technique. Annals of Emergency Medicine, 36(1), 83-84. Curtis, K., Ahern, M., Dawson, M., & Mallin, M. (2012). Ultrasound-guided, Bougie-assisted Cricothyroidotomy:
A Description of a Novel Technique in Cadaveric Models. Academic Emergency Medicine.
Griggs, W. ( 2015). blog. Cricothyrotomy vs.tracheostomy?. Retrieved from http://www.trauma.org/index.php/community/list/ Katos, M., & Goldenberg, D. (2007). Emergency cricothyrotomy. Operative Techniques in Otolaryngology-Head and Neck Surgery,
para2. DOI: http://dx.doi.org/10.1016/j.otot.2007.05.002
Mittal, M. (2015). Needle cricothyroidotomy with percutaneous transtracheal ventilation. Retrieved November 23, 2015, from http://www.uptodate.com/contents/needle-cricothyroidotomy- with-percutaneous-transtracheal-ventilation
If you want to see and learn more about emergency cricothyrotomy, you can reach the collection of video material reviewed during the project from the web address below. https://www.youtube.com/playlist?list=PLMBL7-nMtEsbV82mPsQxqcs7rL8a2XZhC
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Schedule
1
W45
2-6 Nov
W46
2-6 Nov
W47
2-6 Nov
W48
2-6 Nov
W49
2-6 Nov
W50
2-6 Nov
W51
2-6 Nov
W1
2-6 Nov
W2
2-6 Nov
W3
2-6 Nov
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