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We must note that these two procedures could have different Disclaimer
indications within the medics’ aid bag. The iGel was preferred Opinions or assertions contained herein are the private views
by medics despite little experience, and while there was no sig- of the authors and are not to be construed as official or as
nificant difference with first-pass success, we should highlight reflecting the views of the Department of the Air Force, the
that this equivalent finding was in the setting of medics hav- Department of the Army, or the Department of Defense.
ing trained on the cricothyrotomy previously versus almost no
training on the iGel. This suggests that the iGel may be easier Disclosures
to learn. Given previous findings by these authors with simi- We have no conflicts of interest to disclose.
lar outcomes comparing patients receiving a cricothyrotomy
versus an SGA, this suggests that for patients with no clear Ethics
indication for a cricothyrotomy (e.g., massive facial trauma), The US Army Institute of Surgical Research regulatory office
the iGel may be a better option – faster and similar first-pass reviewed protocol H-19-013 and determined it criteria for ex-
success rates with limited-to-no training. Moreover, given the emption from IRB oversight. Our study met all institutional
6
complexity of performing a cricothyrotomy, this may be an requirements.
opportunity to consider whether all medics must be trained in
the cricothyrotomy given the limited initial training and even Author Contributions
more limited sustainment training. Given that we did not pro- SGS is the principal investigator and was involved in all aspects
vide them training as a part of this study, it is plausible that of this study. MDA and RAD were involved in grant applica-
with iGel-specific training, it would have been superior in all tion, protocol development, data interpretation, and critical
aspects. revisions of the manuscript. NU is the research coordinator
on the study and was responsible for protocol management,
Aside from the shortcomings associated with mannequin mod- data collection, data aggregation, and manuscript revisions.
els, we must highlight other limitations in our study. First, the RF, IH, MJ, and DEK were involved in data collection, data
medics did not receive training on the iGel prior to enroll- interpretation, and critical revisions of the manuscript. All au-
ment other than the brief orientation video, nor did we pro- thors contributed substantially to the study and accept respon-
vide them refresher training on the cricothyrotomy. It is very sibility for its publication.
likely that with just-in-time training right before the enroll-
ment, their cannulation success proportions would be higher. References
Second, while the participants preferred the iGel in the survey, 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
with proper training, it is possible that even more would prefer (2001–2011): implications for the future of combat casualty care.
the iGel as they were using the device without any training and J Trauma Acute Care Surg. 2012;73(6 suppl 5):S431–7.
their inexperience likely affected their preferences. Moreover, 2. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway
procedures performed in trauma patients by ground forces in
we do not know how using the device before the survey for the Afghanistan. J Trauma Acute Care Surg. 2018;85(1S suppl 2):
device testing may have changed their opinions. Third, the iGel S154–S60.
versus the cricothyrotomy may have differing indications for 3. Schauer SG, Naylor JF, Maddry JK, et al. Prehospital airway
use on the battlefield, which limits the ability to make compar- management in Iraq and Afghanistan: a descriptive analysis.
isons based on these results directly into clinical care. Fourth, South Med J. 2018;111(12):707-13.
our study only enrolled conventional forces medics and thus it 4. Otten EJ, Montgomery HR, Butler FK, Jr. Extraglottic airways in
tactical combat casualty care: TCCC guidelines change 17-01 28
may have limited applicability to the Special Operations med- August 2017. J Spec Oper Med.17(4):19–28.
ics. Moreover, while we enrolled medics from a training instal- 5. National Association of Emergency Medical Technicians. Tac-
lation, many had deployment experience and were thus able tical Combat Casualty Care guidelines for medical providers.
to provide combat relevance to the data we captured. Last, we https://www.naemt.org/education/naemt-tccc/tccc-mp-guidelines
conducted this study in a student population not assigned to -and-curriculum. Accessed 5 October 2020.
combat arms units and in a well-controlled (e.g., temperature, 6. Schauer SG, Naylor JF, Chow AL, et al. Survival of casualties
ambient noise, etc.), well-lit environment, which does not di- undergoing prehospital supraglottic airway placement versus cri-
cothyrotomy. J Spec Oper Med. 2019;19(2):91–4.
rectly mimic the operational environment in which we seek 7. Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and
to apply our results. It is unclear how such changes in setting Afghanistan. J Spec Oper Med. 2012;12(1):17–23.
would affect the results or their report preferences. 8. Schauer SG, April MD, Cunningham CW, et al. Prehospital cri-
cothyrotomy kits used in combat. J Spec Oper Med. 2017;17(3):
18–20.
Conclusions 9. Mabry RL, Nichols MC, Shiner DC, et al.. A comparison of two
open surgical cricothyroidotomy techniques by military medics
In our study of active duty Army combat medics, we found no using a cadaver model. Ann Emerg Med. 2014;63(1):1–5.
difference with regard to first-pass success or overall success- 10. Schauer SG, JR DF, J LR, et al. A randomized cross-over study
ful placement between the iGel and cricothyrotomy. Time-to- comparing surgical cricothyrotomy techniques by combat medics
placement was significantly lower with the iGel. Participants using a synthetic cadaver model. Am J Emerg Med. 2018;36(4):
reported preferring the iGel versus the cricothyrotomy on 651–6.
survey. Further research is needed as limitations in our study 11. Research Randomizer. 30 December 2019. http://www.randomizer
.org/. Accessed 5 October 2020.
highlighted many shortcomings in airway research involving 12. Schauer SG, Kester NM, Fernandez JD, et al. A randomized,
combat medics. cross-over, pilot study comparing the standard cricothyrotomy to
a novel trochar-based cricothyrotomy device. Am J Emerg Med.
Funding 2018;36(9):1706–8.
Our study was supported through the Defense Health Program 13. Schauer SG, April MD, Naylor JF, et al. A descriptive analysis of
6.7 (DP_67.2_17_I_17_J9_1635). We received no commercial data from the Department of Defense Joint Trauma System Pre-
funding or support for this study. hospital Trauma Registry. US Army Med Dep J. 2017(3–17):92–7.

72 | JSOM Volume 20, Edition 4 / Winter 2020