We present a case of a 57-year-old man who fell while climbing a mountain in California and sustained severe facial trauma. Three firefighters and 2 emergency physicians witnessed the fall and resuscitated the patient. The patient ultimately required a surgical cricothyrotomy performed with a pocket knife and Platypus hydration pack. The physicians made a makeshift positive pressure airway device using the Platypus hydration pack. We believe this is the first case report describing an improvised cricothyrotomy performed in the wilderness using only hiking gear. This report also discusses indications for cricothyrotomy, the challenges of resuscitation in a low-resource environment, and special considerations in a high-altitude setting.

Cricothyrotomy is indicated in trauma patients who cannot oxygenate or ventilate on their own. Substitutes for airways in wilderness medicine settings are theoretically discussed in academic settings but are rarely used in real resuscitations. A 2013 case report describes a surgical cricothyrotomy on a rock climber in the wilderness using the blade of a multipurpose tool and prehospital equipment.Upon review of the literature, there were no published reports of an improvised cricothyrotomy in a wilderness setting using only hiking gear. This case report describes an improvised cricothyrotomy performed with a pocket knife and Platypus hydration pack by 2 emergency physicians on a climber with facial trauma who fell about 1500 feet. The authors of this article are the 2 emergency physicians who performed the cricothyrotomy and the flight nurse who continued the resuscitation.

Case Presentation

In the summer of 2015, a 57-year-old man fell on a steep slope on a mountain in California while climbing at an elevation of 12,500 feet at approximately 6:00 am . He tripped on his crampons, was unable to self-arrest with an ice axe, and tumbled about 1500 feet down a rocky and snowy slope. The patient eventually stopped falling when the slope became less steep. Two emergency physicians climbing with a team of 4 observed his fall and descended to care for him.

Three firefighters climbing with their own team reached the patient first and assessed him. They rolled the patient over on the snow where he was found, took off his helmet, and assessed his airway. They noted the patient to have a pulse and spontaneous respirations. No sources of bleeding or obvious limb deformities were found. They kept the patient’s C-spine in a neutral position and called for helicopter rescue.

Figure 1 Rescue scene at 11,000 feet. The physicians reached the patient 15 minutes later ( Figure 1 ). The patient had a pulse and irregular respirations. His face had diffuse contusions, superficial bleeding, and severe swelling. A pupillary examination was unable to be done due to the degree of facial trauma. The patient was making incomprehensible sounds and intermittently spontaneously moving his right upper extremity. He was unable to answer questions or follow commands.

Because of irregular and gurgling respirations, the patient was suspected to either have an unstable facial fracture or blood in his airway preventing adequate oxygenation and ventilation. Traumatic brain injury was also considered as a cause of irregular respirations. Due to concern for airway obstruction, the physicians decided to perform an improvised surgical cricothyrotomy on the patient although they only had hiking gear and a first aid kit.

Figure 2 Surgical cricothyrotomy with Platypus tubing. This picture shows the tube after it was connected to the airway equipment on the helicopter. The cricothyroid membrane was palpated on the patient. An initial vertical cricothyrotomy incision was performed with a pocket knife followed by deeper horizontal incisions. There was minimal blood loss. A finger covered with a hiking glove palpated inside the incision to confirm entry into the airway. A substitute endotracheal tube was made by removing tubing from the Platypus hydration pack and cutting the tubing to a smaller size. This was inserted into the patient’s airway. Respirations were felt coming into and out of the tube and misting was noted in the tube. The patient then had more regular respirations and equal chest rise and fall. Because he had spontaneous respirations, the rescuers did not blow directly into the tube. The tube was secured with suture from a self-made first aid kit carried by one of the physicians ( Figure 2 ).

A Fitbit exercise monitoring device worn by one of the physicians was placed on his right arm in an attempt to monitor his heart rate. Unfortunately, his extremities were too cool and his heart rate was not detected by the device. The patient was on the snow wearing several layers of clothing. The rescue team used their jackets and extra clothes to keep the patient warm and used a pair of pants to bind the patient’s pelvis in case of an unstable pelvic fracture. The entire rescue team then laid their bodies beside and gently on top of the patient to keep him warm given the concern for hypothermia. The temperature at the rescue scene was just below freezing. Helicopter rescue was reported to be on its way but there was no estimated time of arrival.

Figure 3 Positive airway pressure device made with Platypus hydration system. Thirty minutes after the cricothyrotomy was performed, the patient began having more irregular respirations. Increasing blood was noted within the tube. The physicians were concerned that there could be more blood within the airway, a hemothorax, or pulmonary contusions. There was need for a bag valve device to deliver positive pressure, so an improvised bag valve device was created out of the rest of the Platypus hydration pack and tubing. The improvised endotracheal tube was connected to the extra Platypus tubing and empty 2 L bladder of the hydration pack with duct tape. Then, another small incision was made in the opposite end of the bladder. Another piece of tubing cut from the hydration pack was inserted into this hole. This piece of tubing was held into the bladder with duct tape. The rescue team would blow into this second tube to inflate the bladder, pinch off this tube with pliers to prevent air backflow, and then push down on the inflated bladder to deliver a breath ( Figure 3 ). This worked effectively until a medical helicopter attempted to land at the scene about 1 hour after the patient’s fall. This medical helicopter staffed with a critical care flight nurse and critical care paramedic could not ultimately land because of the weather.

Approximately 45 minutes after the medical helicopter tried to land, another helicopter staffed with an advanced life support paramedic arrived. This helicopter did not land but dropped a rescue stretcher to the ground with ropes. The rescue team helped stabilize the patient’s C-spine with provided blocks and strapped the patient carefully onto the stretcher while the physicians watched his airway. As he was being strapped in, the patient lost a pulse and chest compressions were performed for 2 minutes. The patient regained a pulse and was pulled up into the helicopter using ropes. Advanced cardiac life support (ACLS) resuscitation was continued for a few minutes until this helicopter was able to land at 7000 feet to meet the medical helicopter with the critical care flight nurse.