In emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).” I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.
Read MoreCircumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.
In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.
Read MoreLogistics are pretty much everything. A focus on logistics is what helps UPS deliver 500,000,000 during the holiday season. A focus on logistics is what helped the Allies win World War II. But logistics doesn’t just happen on the global, macroscopic scale. Logistics plays a role in every procedure we do in the ED and in the prehospital environment. If you only focus on learning the mechanics of physically performing a procedure, you are neglecting crucial steps that will help ensure your success. In this our latest podcast in the Air Care and Mobile Care Online Flight MD Orientation, Dr. Steuerwald and Dr Hill discuss some of the complicating factors for prehospital airways, focusing on both some of the logistical issues that come into play and some of the mechanical/physical considerations.
Read MoreFirst, pericardiocentesis should be considered a temporizing procedure. In the setting of trauma, you are hoping that the pericardiocentesis will clear a small amount of blood from the pericardial space and remove any tamponade the might be present. It is likely, however, because of the mechanism of injury, that blood will again rapidly accumulate leading to recurrent tamponade physiology. Ultimately (but not on Air Care — DON’T do a clamshell), these patients will need a pericardial window, exploration, and repair of whatever injury is causing the accumulation of blood.
Read MoreTXA… What can be said about TXA that hasn’t already been said. TXA is good for what ails you.
Nosebleed? No problem.
Menorrhagia? TXA can fix that.
Involved in a motor vehicle crash with multiple pelvic fractures, a busted up spleen, hemorrhaging internally? TXA has your back.
In this podcast, Dr. Hill, Dr. Steuerwald, and Dr. Gerecht sit down and talk through the indications for using TXA in the prehospital environment and briefly discuss some of the evidence for its use.
Read MoreYou need access? You need access right now? Drill, baby drill.
The EZ-IO is pretty ridiculously easy to use. The only real decision points in its use are what site to choose (humeral vs tibial) and what needle to use (pink, blue, or yellow). There are a couple of other nuances which we will cover below and in the embedded video.
Read MoreCritics out there may slight the use of ultrasound in the prehospital environment, saying it is just going to delay patient transfer and won’t add much to your decision making. However, when used properly, the ultrasound should never delay patient care and, when used in the correct patient population, it could help greatly in both decision making and treatment. Let’s first talk about when to use it. The logistics of this may be a bit tricky.
Read MoreWe talked about needle thoracostomy a while back and when we did, we talked about the propensity for the needle to fail. There are a lot of reasons why the needle could fail to relieve a tension pneumothorax (or to only temporarily relieve a tension pneumothorax). The needle may be too short to enter the thorax in the first place* or the catheter could kink, allowing reaccumulation of air in the thorax.
Read MoreMany historians argue that the first use of aeromedical evacuation was during the Siege of Paris in 1870, using hot air balloons (though there seems to be some question regarding the truth of this claim). We're still using balloons during air medical missions in 2014, albeit in a much different way.
The efficacy of IABPs has recently been called into question; see Cliff Reid's recent blog post at http://resus.me/double-balloon-pump-fail/ . Regardless, the decision to initiate IABP therapy isn't going to be ours. But the challenge of moving an extraordinarily sick patient receiving this therapy WILL be ours. We must be ready. How?
Read MoreIn our last podcast we covered the basics of the evaluation of the patient with blunt trauma. We switch gears a little bit this week and focus a little more on penetrating trauma. In this podcast, Dr. Hinckley and Dr. Chris Miller discuss several facets of the care of penetrating trauma patients including the initial approach and evaluation, detection of subtle presentations of shock, and triggers to initiate transfusion of blood products. In this accompanying blog post, I’d like to focus primarily on why we might want to withhold fluids on penetrating trauma patients.
Read MoreImmobilization of midshaft or distal femur fractures is thought to decrease pain for the patient during transport and to decrease the amount of bleeding and hemorrhage. Application of a traction splint, however, is a somewhat uncommon, and therefore potentially unfamiliar, procedure. A look at the literature on the use of traction splints in the prehospital environment shows that they are used uncommonly. And, when they are used, they are frequently placed incorrectly.
Read MoreThere has been much digital ink spilled over the topic of needle thoracostomy (check below for some additional reading) with most of the hub bub surrounding the proper location to place the needle. We’re not going to completely rehash that which has already been said, but instead focus on distilling the highlights and turning our attention to a video showing how to perform what is ultimately a potentially life saving procedure. We won’t go much into finger thoracostomy as we will cover that procedure in a future blog post. So I heard that you’re setting yourself up for failure if you choose the 2nd ICS MCL to decompress the chest?
Read MoreIn our most recent post in the Air Care & Mobile Care Online Flight Physician Orientation, we talked about pelvic binding devices. As we noted, there's generally a paucity of evidence for or against the use of a pelvic binding device in blunt trauma patients. There are no hard and fast indications for the use of these devices. Whenever there is a lack of evidence for a particular treatment, we find ourselves looking to experts in the field for their experience and practice patterns. To that end, I asked some of of the #HEMS #FOAMed community to weigh in on the question and tell us their practice pattern
Read MoreAs we mentioned in the podcast that accompanied our most recent post, an injury that is critical to identify in blunt trauma yet easy to miss or forget is pelvic fractures and pelvic trauma. Significant injuries occurring to the pelvic ring usually involved high mechanisms of injury such as high speed MVCs, motorcycle crashes, pedestrian struck, and falls from significant height. Pelvic fractures can be associated with a significant amount of bleeding, hypotension, and increased mortality. Mortality for all trauma patients with pelvic trauma ranges from 5-30%. If there is associated hypotension, mortality rises to 10-42%
Read MoreA quick and thorough evaluation of patients with traumatic injuries is extremely important. The ideal approach is regimented, practiced, expeditious, and flexible to the environment in which it is performed. Advanced Trauma Life Support (ATLS) courses do a great job of teaching the guiding principles to the approach to the trauma patient. However, while it is relatively simple to become facile with the exam of victims of trauma in the (relatively) controlled setting of the trauma bay, it can be especially challenging to examine the same patient in the field.
Read MoreSRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
