Decision is a Sharp Knife

Decision is a Sharp Knife

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 More

Needle Cricothyrotomy

Needle Cricothyrotomy

Circumstances 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 More

Intubating (not in the SRU)

Intubating (not in the SRU)

Logistics 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 More

Pericardiocentesis

Pericardiocentesis

First, 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 More

Lessons in Transport - Plasma? We Got That...

Lessons in Transport - Plasma? We Got That...

Why is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.

Read More

Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

TXA… 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 More

Lessons in Transport - Cognitive Biases in Critical Care Transport

Lessons in Transport - Cognitive Biases in Critical Care Transport

As critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!

Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.

Read More

Drill, Baby, Drill

Drill, Baby, Drill

You 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 More

Ultrasound in HEMS

Ultrasound in HEMS

Critics 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 More

Finger Thoracostomy

Finger Thoracostomy

We 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 More

Transporting Intra-Aortic Balloon Pump Patients by Air Care

Transporting Intra-Aortic Balloon Pump Patients by Air Care

Many 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 More

Lessons in Transport - Upper GI Bleeding

Lessons in Transport - Upper GI Bleeding

It is 2am on a cold, dark, winter night and you are dispatched to a small rural hospital to transport a patient by ground with a GI bleed back to UCMC medical ICU. Enroute dispatch notifies you that your patient has deteriorated and is profoundly hypotensive. The ED physician at the outside hospital is attempting intubation for airway control. On arrival you find a middle-aged male with all the classic stigmata of end-stage liver disease. More importantly he has a systolic blood pressure of 60 and a HR of 130. A literal fountain of blood spews from the patients mouth, around a successfully placed endotracheal tube, and is now beginning to pool on the floor. You know this patient needs massive resuscitation from his likely bleeding esophageal varices... but you are 55 minutes by ground to UCMC and know that your patient will not survive the transport unless something is done to control the bleeding...

Read More

Resuscitation of Penetrating Trauma Patients

Resuscitation of Penetrating Trauma Patients

In 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 More

Traction Splints - Applying the KTD Traction Splint

Traction Splints - Applying the KTD Traction Splint

Immobilization 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 More

Needle Thoracostomy

Needle Thoracostomy

There 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 More