A Look into the Code STEMI - Flights Case 2 Recap

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A Look into the Code STEMI - Flights Case 2 Recap

It’s true that sometimes critical care transport missions to transport STEMI patients to PCI are fairly uneventful.  But if we allow ourselves to get lulled into a “Milk Run” mindset, it will most definitely come back to bite us.  The jovial, normotensive, fairly comfortable-appearing STEMI patient may be only a couple of minutes away from V Fib arrest or florid cardiogenic shock.  When that occurs, if we have expected and prepared for such a complication, it’s likely that we’ll be able to manage it successfully.

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Flights - Un-Break My Heart

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Flights - Un-Break My Heart

It is early October and you are the flight doc in C-pod on a brisk but clear Saturday morning. The day starts out with several challenging patients with vague complaints and has just begun to ramp up in volume when a patient rolls into your pod by EMS, restrained face-down to the cot, covered in feces and urine, screaming about hearing voices. You begin to take report from EMS when, as if by divine intervention, the tones drop and you are dispatched for an inter-facility transfer. You gleefully (almost too gleefully…) give a brief patient sign-out to your staff, grab the blood cooler, and head to the roof...

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A Lonely Road - Recap and Expert Commentary

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A Lonely Road - Recap and Expert Commentary

A couple of weeks back, we kicked off our “Flights” portion of our Air Care Orientation Curriculum.  Dr. Latimer outlined a challenging patient case for use to consider and an excellent discussion ensued.  As a reminder of the case, here’s how it was posed:

Your patient is a 56 year-old male with unknown medical history who was an un-helmeted motorcyclist found in a ditch roughly 40 feet from his motorcycle which was discovered in the middle of the road by a passing motorist. The accident was un-witnessed, but the bike was found just beyond a sharp downhill curve in the rural farm road. EMS has BLS capabilities only and they have placed the patient on a backboard and loaded him into the unit.

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"Flights" - A Lonely Road

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"Flights" - A Lonely Road

It is mid July and your first shift as the coveted H2 Doc at Air Care 2 is finally upon you.  It has been an especially warm and beautiful Saturday and you ponder the possible flights for the evening as you take the scenic drive to Butler County Regional Airport. 

You finish checking the aircraft with the flight nurse and sit down to begin the 20:30 brief with the flight crew when the tones drop and you are dispatched for your first flight of the evening, a scene flight to Franklin County, Indiana for an “un-helmeted motorcyclist”. You grab the blood cooler, perform a safety walk-around the aircraft and strap yourself in back

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"Flights" - Shaken Recap & Expert Commentary

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"Flights" - Shaken Recap & Expert Commentary

Thanks to everybody who commented and contributed to the discussion on our final “Flight!”  If you missed out on the case, check it out here. Below you’ll find a curation of the comments to each question and a podcast with expert commentary from Jenn Lakeberg, APRN.  This was the final “Flight” for this spring/summer.  Look for the cases to return again in January 2016 as we begin Flight MD Orientation with the next class of future Air Care Flight Docs.

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Flights - Shaken

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Flights - Shaken

You are sitting on the helipad during your UH shift talking with the flight nurse when the tones drop for a pediatric scene call.  You gather yourself after you have that crap your pants moment that everyone has with pediatric scene calls and whip out your smart phone with your pediatric application of choice.  You begin to write down doses and sizes on your tape on your leg based on the report of the patient’s weight from the providers on scene.

You land in an elementary school parking lot to the delight of the children at the local school.  Cars begin to slow and pull over as you exit the helicopter and walk to the squad.  You walk to the side door of the ambulance and find 6 EMTs crammed in the squad.

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A Pain in My Heart - Curated Comments and Expert Commentary

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A Pain in My Heart - Curated Comments and Expert Commentary

Thanks to everybody who chimed in on our last "Flight"! We had a great discussion on the management of the STEMI transfer patient.  These aren't just "milk runs" as pointed out by Dr. Hinckley.  The highlights of the discussion are below with additional commentary on the case by Dr. Bill Hinckley and Air Care Resident Assistant Medical Director Dr. Matt Chinn.  Out final flight will be lifting off June 1 and it's a doozy - looking forward to the discussion!

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Field Amputation

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Field Amputation

Hey, everybody! Today we are going to talk about field limb amputation.

I know what you are all thinking… No, I’m not crazy. Yes, you’ll probably never do one. No, this is not a common procedure. You just might, however, be in a situation on Air Care where knowing how to correctly perform this procedure can safe a life. 

First, let’s provide a little background on the pre-hospital limb amputation. The procedure itself has gained much more press in the FOAMed world and the emergency medicine and pre-hospital literature since the 2010 earthquake in Haiti during which early physician responders were faced with large numbers of patients trapped under debris and few responders with familiarity or basic working knowledge of the procedure (Lorich et al, 2010). A few of case reports and articles surfaced around this time and the field amp even made an appearance in an episode of the popular television show ‘Greys Anatomy’ in 2011. 

So I was told… 

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Flights - A Pain in My Heart

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Flights - A Pain in My Heart

You are the Pod doc overnight on a particularly quiet Sunday night.  You have been looking for an excuse to leave the pod and do anything other than treat abdominal pain for the past several hours when the tones drop.  You thank whatever celestial being you believe in and grab the blood and run out of the department full of glee.  In route to the helipad you are told it is a Code STEMI.  At this point, even that seems more interesting than sitting in C Pod.

You buckle into the helicopter and take a quick flight to the outside hospital.  You grab a set of gloves and unload the cot carefully and walk inside.

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Flights - A Blow to the Head Recap and Expert Commentary

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Flights - A Blow to the Head Recap and Expert Commentary

Thanks to everybody who commented and contributed to the discussion on our last "Flight!" If you missed out on the case, check it out here.  We had a great discussion which we have recapped here.  Take a look below and a listen to the commentary provided by Dr. Bill Hinckley in the embedded podcast.  Look for our next flight to lift off in the next couple of weeks!

What medications could be used in the care of this patient? If the patient loses his IV, how does your treatment strategy change?

This first question sparked quite a bit of debate within the community.  Everybody agreed that this patient requires sedation, intubation, and more sedation.  There was, however, some significant differences in how the providers would go about attaining adequate sedation.

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Flights - A Blow to the Head

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Flights - A Blow to the Head

You’re working as the Pod-Doc, having just taken the radio from the off-going UH-doc, you just finish admitting the patient in C40 for NSTEMI when the tones go off.

“Air Care 1 and Pod Doc respond to a scene for motorcycle crash, Northern Kentucky”

You call the B-Pod attending, sign out the pod, grab the blood from the blood cooler and head to the helipad.  Flying over the river, landing at a local firehouse’s parking lot you hop out of the back of the helicopter and head to the awaiting squad.

Your patient is a 29 year-old male who was riding his motorcycle (without a helmet) on a local country road.  Coming around a blind corner he unexpectedly found a car stopped in the middle of the road.  Striking the car from behind at ~35mph, he flew over the handlebars and impacted the back of the car.

On EMS’s arrival he was initially unconscious, but since their arrival has become increasingly combative

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.”  If you didn’t get a chance to check out the case and the discussion, check it out here.  Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng

Q1 - Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa.  As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.”  Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries.  This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.

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Flights - A Stab in the Dark

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Flights - A Stab in the Dark

You are working overnight as the H2 doc based at Butler County Regional Airport.  It’s bitter cold out (for Ohio that is).  Its only 11 PM and already the temperature has dropped to 9 degrees fahrenheit on its way to a low of 0.  You are in the lounge refamiliarizing yourself with the contents of the critical care cells when the tones go off: “Scene: stab wound – Hamilton Ohio”

You and the nurse grab your equipment, the blood cooler, and head to the helicopter.  You put the critical care cells back in their spot in the rear of the helicopter and then buckle in for the short flight to the scene.

Your patient is a 23 year-old female who was in an argument with her boyfriend earlier in the evening.  The verbal argument quickly escalated, her boyfrienf pulling a knife and stabbing her multiple times in the right arm and right chest.  He fled the scene and she managed to call 911.  The first responders found the patient with significant active bleeding from her arm as well as chest.  She was initially responsive, but is now only awake to painful stimuli.

You meet the EMS crew in the back of the squad truck and assess the patient from the head of the bed.

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Flights - One Road too Far - Curated Comments & Expert Commentary

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Flights - One Road too Far - Curated Comments & Expert Commentary

Thanks to everyone who chimed in for our first ever "Flight"!!  If you didn't get a chance to read the case, take a look here.  There was some excellent discussion on how best to care for the blunt polytrauma patient.  Below is the curated comments from the community and Dr. Hinckley's take on the questions posed to the community.

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Flights - One Road too Far

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Flights - One Road too Far

You are working as the UH-doc.  Driving into your shift with the windows down and music playing, you figured the first warm day of the year would result in a busy day for you and the rest of the Air Care 1 crew.  You arrive for your shift, grabbing the radio from the Pod doc when the tones go off for your first flight of the day.  You grab the blood cooler head to helipad, checking your pager you find you’ll be responding to Southeastern Indiana for a “MVC rollover, entraped.”

You strap into the helicopter and fly over the city and to the rolling hills of Southeastern Indiana.  Landing on the 4 lane divided state road, you unstrap and head to your patient who is waiting with the BLS squad.

You open the side door of the EMS truck and head to the head of the bed to assess your patient...

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