Out on a Limb - Troubles Abroad

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Out on a Limb - Troubles Abroad

You are an EM resident from the US working in a rural South African hospital as part of a global health elective.  The political climate is such that a prolonged government strike is leading to severe staffing and resource shortage.  There are no disposable gloves and many procedures are performed barehanded.  One day during rounds in the Labor Ward, the Chair of the department asks you to draw blood from an HIV-positive woman in labor as the team is presenting the patient in her room.  The only remaining gloves in the hospital are a few pairs of sterile gloves reserved for emergency cesarean deliveries.  There are high rates of HIV-exposure and many staff members are currently on post-exposure prophylaxis.

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Out on a Limb - "Is there a Doctor on Board?!"

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Out on a Limb - "Is there a Doctor on Board?!"

You are enjoying a cocktail on the way to Hawaii on a well earned vacation when a voice comes aloud overhead, “Attention all passengers. If there is a doctor or health care provider present, we ask that you please come to the front of the plane immediately.” From your vantage point in the back of the plane, it becomes clear very quickly that no one is volunteering. You find yourself being stared at by a plane full of people as you make your way to the front, to find a morbidly obese Caucasian female with a flight attendant at her side. You start your encounter…

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Favorite Positions!

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Favorite Positions!

Multiple casualties are brought to you from a house fire.  There are four victims:

  1. A 5’11” 70 kg woman with a GCS of 8
  2. A 5’9” 140 kg man with circumferential burns of the chest and neck
  3. A 20 month-old with a pedi-GCS of 10
  4. An elderly, 5’6” 65 kg man with no burns, but a history of severe CHF and complaining of chest pain and dyspnea

You determine that they all require intubation for various indications.  You choose RSI as the method for all except the morbidly obese patient, who you intend to intubate awake, with sedation and topical airway anesthesia.

Question:

How would you position each of these patients to optimize your chances of successful intubation on the first attempt?

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Global Health Case Files

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Global Health Case Files

Imagine:  you are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria.  You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics.  Your clinic does not have any power.   Your diagnostics include:  urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria.  You have 2 nurses, one of whom acts as a translator (from Swahili to English).  You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.  

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Endotracheal Intubation vs. Supraglottic Airway Placement for Out-of-Hospital Cardiac Arrest

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Endotracheal Intubation vs. Supraglottic Airway Placement for Out-of-Hospital Cardiac Arrest

If you want to get a group of prehospital providers riled up, simply ask them how the airway should be managed during out-of-hospital cardiac arrest.  "Supraglottic airways are easier!"  "No, you gotta stay with endotracheal intubation!"  "Forget advanced airways, a bag-valve mask is all you need!"  "Only apneic oxygenation!"  Don't believe me?

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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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Disaster and Emergency Medicine: An Overview

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Disaster and Emergency Medicine: An Overview

Disaster. It’s trending right now. In the last few years we have seen epidemic outbreaks of hemorrhagic fever, earthquake induced nuclear meltdowns, and large-scale civil war. It is no secret: both the scale and frequency of disasters are increasing. This appears to be due to a complex interplay of interconnected, global factors that show no signs of slowing. More people means harvesting more food, tapping more clean water, clearing more land, crowding more cities, and releasing more harmful products into the environment. The consequences to this include rising water levels, widening temperature extremes, increasing erosion, and a growing number of vulnerable people. With inevitably more disaster on the horizon, preparedness and experienced leadership are critical for the world’s future.

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Grand Rounds Recap - 5/20/15 - Disaster Day!

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Grand Rounds Recap - 5/20/15 - Disaster Day!

Explosive Injury with Dr. Calhoun

Explosive injuries cause high numbers of casualties compared to chemical and biological incidents

Determinants of injury

  1. Type of blast: high vs low explosive (has to do with how rapidly the gas is released)
  2. Environment: close quarters vs open field
  3. Presence of projectiles
  4. Distance from the explosion
  5. Shielding
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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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Pediatric Abdominal Ultrasound

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Pediatric Abdominal Ultrasound

After a long shift in the adult ED, jam packed with patients presenting with abdominal pain, your looking forward to a brand new day in the Peds ED.  Your first patient, however, gives you PTSD-like flashbacks to the previous days shift.  

Alice is a 8 year old girl who developed abdominal pain last night.  Her parents thought that she would be okay waiting until morning, that the pain would pass in the night.  On waking this morning, however, the pain was still there.

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CT Abdomen and Pelvis - Hollow Viscus

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CT Abdomen and Pelvis - Hollow Viscus

It's weird how you get runs of patients in the ED.  Some days it seems like it's nothing but wall-to-wall low risk chest pain, altered mental status, or back pain.  Today (and a lot of other days), it's abdominal pain.  Scanning the board you see seemingly nothing but Level 3 acuity patients with the chief complain of "Abdominal pain."  Out of the scores of patient's, you seen so far, the last 2 worry you the most:

Andrea is a very pleasant 20 year old student from a local college.  She came in after having symptoms of right lower quadrant pain over the course of the past 8-12 hours.  She didn't recall any migratory symptoms but does endorse a lack of appetite, nauseousness, 2 episodes of vomiting (started after the pain), and steadily worsening pain.

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Grand Rounds Recap - 4/29/15

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Grand Rounds Recap - 4/29/15

Morbidity and Mortality Conference with Dr. Stull

1. Pericardiocentesis tips and tricks

  • Your needle should be at a 45 degree angle when entering the chest at the xyphoid process, aim to the L shoulder/scapula
  • Use a spinal needle and keep the stylet in while entering the skin in order to prevent needle clogging
  • Keep head of bed at 30 degrees to encourage the fluid to drain inferiorly
  • Can attach an EKG lead to the needle by an alligator clip. You will get an ST elevation in that lead if you hit the myocardium
  • Can use an A.line kit to place a catheter into the pericardium for continuous drainage
  • US probe position: subxyphoid
  • How to Video on TamingtheSRU - http://www.tamingthesru.com/blog/acmc/pericardiocentesis
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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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Grand Rounds Recap - 4/22/15

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Grand Rounds Recap - 4/22/15

Oral Boards Practice Cases

Case 1 - 22 yo F in a "coma" with normal vital signs. Not responding to Narcan and Dextrose. Found in a garage. On exam, she has sluggish and dilated pupils. pH 6.98, pCO2 29, bicarb 2

High concern for toxic alcohol ingestion: consult DPIC and nephrology for dialysis

  • Fomepizole is the antidote for ethylene glycol only
  • Can use ethanol drip to treat both ethylene glycol and methanol
  • Replace folate aggressively and early 
  • Methanol is metabolized to formic acid, if you give folate you can prevent methanol from going down the formic acid pathway
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