February 18, 2014

Lessons in Transport - Upper GI Bleeding

February 18, 2014/ Ryan Gerecht, MD

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...

February 17, 2014

Resuscitation of Penetrating Trauma Patients

February 17, 2014/ Jeffery Hill, MD M.Ed

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.

February 14, 2014

Traction Splints - Applying the KTD Traction Splint

February 14, 2014/ Jeffery Hill, MD M.Ed

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.

February 11, 2014

Needle Thoracostomy

February 11, 2014/ Jeffery Hill, MD M.Ed

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?

February 10, 2014

Who Gets a Pelvic Binder? Lessons from the #HEMS #FOAMed World

February 10, 2014/ Jeffery Hill, MD M.Ed

In 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

February 07, 2014

Application of Pelvic Binders

February 07, 2014/ Jeffery Hill, MD M.Ed

As 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%

February 04, 2014

Evaluating Blunt Trauma Patients

February 04, 2014/ Jeffery Hill, MD M.Ed

A 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.

January 31, 2014

On Tourniquets and Lives Saved

January 31, 2014/ Jeffery Hill, MD M.Ed

Though tourniquets were likely in use since Roman times, the term “tourniquet” was originally turned by Louis Petit, the 18th century inventor of the screw tourniquet. Though numerous design advancements have occurred and new devices have been made in the centuries that have followed, the basic principles of tourniquet use are essentially unchanged. A tourniquet applies an external pressure to a limb (usually) that exceeds the arterial pressure in that extremity. In this way the inflow of arterial blood to an extremity is stopped. For a surgeon, in the setting of a prospective extremity surgery, this allows for the creation of a bloodless operative field. For Emergency Medicine providers, tourniquets can aid in the exploration of extremity wounds, allowing the identification of injuries to tendons, joints, and vascular structures. And perhaps most importantly, tourniquets applied proximal to the site of penetrating traumatic extremity injuries can cease bleeding from arterial injuries.

January 28, 2014

Reconfiguring the EC145 for Two Patients

January 28, 2014/ Bill Hinckley, MD

Our EC145 aircraft have the capability to fly two patients. However, doing this is never our preference. Those of us who have had the chance to fly two patients can attest that it’s quite challenging, especially if one or both are truly critically injured. Your crew:patient ratio is halved. And if you’ve ever thought that ergonomically your space was limited in the helicopter with only one patient, it’s much worse when there are two. Therefore, we always teach our EMS colleagues: if you’ve got two patients you need to fly, ask for two helicopters.

January 27, 2014

Lessons in Transport - Surviving Sepsis Part 2

January 27, 2014/ Ryan Gerecht, MD

"Around every 3rd heartbeat someone dies of sepsis"

Blood Product Administration:

Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart disease, we recommend that red blood cell transfusion occur only when hemoglobin concentration has decreased to < 7.0 g/dL to target a hemoglobin concentration of 7.0-9.0 g/dL in adults (grade 1B).
FFP NOT be used to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures (grade 2D).

January 24, 2014

Lessons in Transport - Surviving Sepsis

January 24, 2014/ Ryan Gerecht, MD

We routinely transport patients with severe sepsis and septic shock by both air and ground. Take a few moments to review these high yield management pearls from the 3rd edition of the Surviving Sepsis Campaign Guidelines.

Initial Resuscitation:

Goals during the first 6 hours of resuscitation:
CVP 8-12 mmHg (a debate on the utility of CVP or lack their of is beyond the scope of this LIT)
MAP > 65 mmHg
Urine output > 0.5ml/kg/hr
Central venous or mixed venous oxygen saturation 70% or 65% respectively (grade 1c)
In patients with elevated lacate levels we should target resuscitation to normalize lactate (grade 2c)

January 21, 2014

Multiple Helicopter Scenes

January 21, 2014/ Jeffery Hill, MD M.Ed

It is not uncommon for multiple helicopters to land on the scene of a multi-car accident or a single vehicle accident with multiple seriously injured victims. Assessing, caring for, and transporting multiple victims adds a significant amount of complexity to these scene flights. With multiple helicopters flying in, it is especially crucial that we heed all the lessons of crew resource management. Situational awareness both in the air and on the ground is key. But the challenges of multiple helicopter scenes are not limited only to safety considerations.

January 17, 2014

Lessons in Transport - Avoiding Medication Errors

January 17, 2014/ Ryan Gerecht, MD

It takes an estimated 80-200 correctly executed tasks to successfully administer a single dose of a medication to a critically ill patient...

Our reality in transport medicine... We routinely work in an environment that is prone to medical error. An environment that is...

Dynamic and potentially dangerous
Fast paced... where speed is perceived as excellence
Limited in space, resources, and personnel
Built on inferred indications with little access to confirmatory tests
Frequent patient care hand offs of high acuity patients
Defined by actions and inaction that have immediate consequences with little recovery time to stop sequential errors
Not reproducible... No mission is ever the same

January 13, 2014

Survival and the Rule of 3's

January 13, 2014/ Jeffery Hill, MD M.Ed

Thankfully survival situations are uncommon. Because these situations are so uncommon, however, when confronted with a survival situation, we often find ourselves woefully unprepared. Some of us have had formal survival training through Boy Scouts/Girl Scouts/military/Wilderness Medicine courses. Many of us, however, have had to rely on the Air Care & Mobile Care training sessions or maybe even what we see on Survivorman or other such TV shows. Some of us may hope just being near Dr. Mel Otten has allowed us to glean the crucial bits of knowledge we may need.

January 10, 2014

Keep Calm and Don't Walk into the Tail Rotor

January 10, 2014/ Jeffery Hill, MD M.Ed

Funny things happen when you start work in new environments. Surely most clinicians have experienced this first hand. Think back to that first time you scrubbed in and walked into an operating room, the first time you set foot in an ICU, the first time you worked in an ED different than the one you trained in. What was that like? overwhelming? empowering? disorientating? Did you ever get caught up in just trying to figure out where the heck the 25 gauge needles and 10 ml syringes were in the supply closet?

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