Parachutes and airways.

One of my colleagues in Alice Springs is a keen sky diver. When you're learning to sky dive, a lot of time is spent devoted to learning what to do when your chute doesn't open. This only happens approximately one in every 600 jumps. But if it happens when *you* jump, you need to know what to do.

Not many people die from sky diving, but all of the jumpers who have died in recent years died with 'RIP' or Reserve in Pack. The moral being, that if you things go haywire, you need to recognise the problem early, cut away the main chute and pull the reserve chute. There is no point in tugging and tugging on the main chute whilst you plummet to your death.

Unfortunately for Amanda, her chute failed to open on only her sixth jump. She pulled the cord a couple of times, checked her altitude and realised that she needed a chute open *now*. Going through the drill, she cut away the main chute, then pulled the reserve. The reserve parachutes are small and tricky to steer, especially for a novice. But she made it down and, in her own words, went to change her pants.

I think the same principle applies to airway management. People devote years to perfecting their 'difficult airway' algorithm, knowing the steps to go through in those rare cases where the tube just won't go down. But the principle is clear: if you've tried laryngoscopy a couple of times and failed, there is no point in just continuing laryngoscopy, convinced that you'll get it down 'next time'. Your patient is still in free fall! Instead, you need to throw away the laryngoscope and move on. And if that means doing a tracheotomy, then that's what you do. The fact that you're inexperienced doesn't matter if your patient is plummeting to their death. A patient who dies an airway death without a hole in their neck is like the skydiver who dies with his Reserve In Pack.

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