Archive | March 2014

The full video from #smaccGOLD Airway talk by Levitan

The video out of Richard Levitans Airway lecture 22min long, graphic

Stopping a femoral artery bleed with your leg.

Video of a mountainbiking accident, where a knee is used to apply direct pressure to a lacerated femoral artery. 

Was taught to do this for single medic work, leaves your hands free to complete a survey, grab kit from bags, set up junctional tourniquets (if you don’t have them your stuck in place till you get evac….)

 

Warning, this video is bloody

http://www.pinkbike.com/u/mattwragg/blog/Video-CGs-Bloody-Crash.html

Prehospital intravenous fluid administration is associated with higher mortality in trauma patients

Some discussion on prehospital fluid administration, based on a study from the outcomes of the national trauma register. 

Click to access file_metadata_1223533.pdf

One issue, the placement of an IV doesn’t mean we give fluid. the practice around here with big trauma is to try and get them en-route, sometimes with a 30 second curbside stop to get the needle and cannula in if its a difficult one. 

Two replies to the paper.

http://journals.lww.com/annalsofsurgery/Citation/2014/02000/Prehospital_intravenous_fluid_administration_is.37.aspx

a reply to the same letter from the study authors

http://journals.lww.com/annalsofsurgery/Citation/2014/02000/Reply_to_Letter____Prehospital_Intravenous_Fluid.34.aspx

 

Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors

Open access paper on, prehospital use of ultrasound, they seem to have limited the utility some what, failed to mention its utility in gaining peripheral IV access in larger patients, or difficult cannula, assessment of ET tube placement,    

http://www.biomedcentral.com/1471-227X/14/6

Diagnosis Wenckebach

Diagnosis Wenckebach

For those coming up to ECG’s and Cardiology study… My whole class was humming sexy back during the exam

 

The Spinal Immobilization, what will we do?

Spinal immobilisation, in recent years we’ve moved away from the model of spine board everyone(the dogma when I was at uni)! This idea that every single person present at an accident got collared and a 20 minute trip to the hospital on a spine-board was absurd (although with good intention).I’ve spent a substansial period of time on a spine-board roughly minutes as part of an exercise in remote firstaid, I can tell you its one of the most traumatic experiences of my life, at the conclusion of the exercise I could barely get my self up off the board, my legs were stiff and completely numb, my neck was in spasm and my eyes felt like they were about to pop from my skull, in addition to 80minutes of breathing poorly from having spineboard straps cranked down on my chest. From this day fort I promised my self and my patients(they didn’t exist at this time, but I promised future patients) that I would never transport them on  back board!Immobilized by a few class mates during a prac session

No longer does every fall get a spine board and collar as they once did. Most services in Australia have removed the blanket spinal immobilisation rules and allowed for selective imobilisation. Not at all scientific, hilarious though a short video on Mechanism of injury;   http://www.youtube.com/watch?v=0HAGMb_jAdU

The standing take down, for those who aren’t familiar http://www.youtube.com/watch?v=QxzQxTKNA6M

“Conclusions Conventional extrication techniques record up to four times more cervical spine movement during extrication than controlled self-extrication. This proof of concept study demonstrates the need for further evaluation of current rescue techniques and the requirement to investigate the clinical and operational significance of such movement.(Mark Dixon, Joseph O’Halloran, Niamh M Cummins,2013)” I’ve quoted the authors conclusions directly, the take home point however is at this point, rescuer extraction produces more movement than self extraction(obviously not applicable to trapped pts, the pt population studied was presumably GCS 15 and compliant so you’d hesitate to use it on others).

KED

Authors said it best, while this trial is simulation only, the myth that us dragging out patients out of cars produces fewer movements is starting to look more and more dogmatic.Obviously this doesn’t apply to entrapped or confined patients, the spine-board is a very useful tool to get these people from the car to our stretcher, transport on a spine-board is never indicated! but I think we’ll see it stick around (don’t start gluing them together to make canoes yet! )

This was a study of the quality of spinal immobilization  (the old way, i.e EVERYONE GETS A BOARD!)50 patient study of quality of their immobilization, what did it show? That 88% of patients weren’t actually well attached to the board and in 30% of patients they had nothing to prevent their head moving about (routinely in the US tape is used), in this small study of patients arriving by Ambulance at a trauma center in North Carolina.

The next part of the package, the Hardcollar, C-Spine Collar, SMR, ect.

  • They increase ICP
  • They increase pain, anxiety, in patients who are non compliant they cause themselves harm.
  • They make breathing harder, jaw opening decreased.

What I’m trying to get across here is that backboard immobilization for transport has NO place according to current literature and routine placement on a backboard for transport is a process that needs to disappear. While being written out of most guidelines and protocols it seems to be common practice in north america, and I still sometimes see it from time to time on the news.

Hopefully one day we’ll see a completely different practice of immobilising patients. Or decision tools for the field to help us immobilise far fewer patients than we currently do.
There are numerous services in Australia using the NEXUS criteria that’s gets applied in the emergency department to take collars off, why can’t paramedics with further education take that downstairs care out into the community and use it to make a more comfortable journey for patients.

Looking to the future we may see more transport solutions like the Vacuum splint.   http://www.neann.com/vim.htm

Comments on the site or @jrparamed on twitter.
Disclaimers; Don’t violate your protocols.
This isn’t the official view of my  employer
My views not anyone else’s

If I mention products I have no financial interest, I’m a keen observer
If you leave your patients on a spine-board you are a sadist!

 

SMACCgold pocket guide

image

My smacc Gold program,  took a beating in my pocket over the 3 days

Lessons from SMACC Gold

Wow! SMACCGold, amazing conference, I’m now sad its over.

There some amazing people out there doing some good research, case studies and prepared to go out on a limb to lyse the dogma that is so pervasive in medicine

Minh le Cong is very approachable man and just quietly amazing.

ATLS is wrong about palpable pulses and blood pressure correlation

The sniffing position for BVM and intubation is probably not the best. Shoulders up ears to sternal notch aligned

Some of the common mechanisms of injury causing severe trauma to motor cyclists

The future of pre hospital is coming, mechanical CPR, PATCH trial
Lessons in logistics,  paramedics do it better. Scene control,  situational awareness.

We can’t save everyone but we have a duty to try.
Remote practice offers its own challenges, lack of resources,  expensive patient movements,  different patient populations with different values.
Some unique tricks for removing motor cycle gear (used yesterday)
Cutting out padding, learning to look for seams to cut the path of least resistance
How poorly healthcare groups integrate, how through error in communication and culture we conflict with each other.
Large pts need to be postured sitting, never supine
They won’t be able to breath,  they will become hypoxic and arrest,  especially in the critically ill.
The challange of clincal risk assessment based in a presentation about deep sea exploration
How to practice reflection and examine what we do, how to do it better, via lessons hard learned from broome docs.
Education,  teach less people remember more.
How palliative and end of life care is approached in hospital to provide most appropriate end points for pt.
Rural and remote practice,  relies on retrieval for pts requiring high level or unavailable care, but front line providers need to be ready for anything.
The airway q&a will be one to watch for! The gods of airway answer every question the audience can throw at them.
The podcast of that will be amazing worth the listen
When should resus stop another stunning lecture from Cliff Reid, on the topic of when to stop but also when to continue, filled with humor and reminders of why we do what we do.
The checklist debate, which was amazing,  education is the key, a checklist wont make you an instant Scott Weingart or Minh le Cong you need the thousands of intubations, where checklists can help is alleviating equipment issues, helping get the team on the same page, but the education on checklist implementation is what helps in time critical situations.
Lessons from Tim Leeuwenberg on planning and implementation of change to a resus room, some cool ideas like, CAT use, colour coding bins of equipment and medications on the wall for all to see.
Brian Burns did a series of case presentations on PHARM missions and what do expect,  how to plan, to expect the unexpected.

Arterial Tourniquet use!

Interesting question asked by a firstaider the other day.
Can I use Arterial Tourniquets on others.
My answer, I don’t know, but I know someone who does!

A Class B recommendation from Australian Resus Council. For the use of tourniquet use in the first aid setting, this means you can carry and use a Tourniquet for use on others.  Only in the setting of life threatening bleeding where direct pressure had already failed!
When I used to have a lot to do with being a long way from civilization and long evacuation times, I carried them for use on my self only.

http://www.resus.org.au/policy/guidelines/section_9/principles_of_control_bleeding.htm

Most Australian ambulance services now carry an Arterial Tourniquet of some kind. For years the Tourniquet consisted of a large rubber band that had to be wrapped and secured. Rarely contained the blood flow and took a few minutes to apply correctly.
With commercial ratchet devices now available we are seeing quicker application times and more successful applications of the tourniquet use.
Limb ischemia is often a concern so while chatting to a Surgeon at the local hospital I had the opportunity to ask about this.  He put it quite simply, they have been validated in a study of trauma in Afghanistan for upto 6 hours with good recovery, patients can mostly survive the loss of a limb, they won’t survive losing their entire blood volume in the back of the ambulance/on the street. No time is to short for application, when it takes 30 seconds and only benefits the patient, can be done on the move without delaying transport. Its a worthwhile crucial intervention.

A few journal papers on the collective experience of useage;

http://journals.lww.com/jtrauma/Abstract/2003/05001/Tourniquets_for_Hemorrhage_Control_on_the.38.aspx
http://www.jem-journal.com/article/S0736-4679(09)00638-6/abstract

I’d love to read and summarise the new guidelines however they appear to be pay-walled.
http://informahealthcare.com/doi/abs/10.3109/10903127.2014.896962

 

Types of Arterial Tourniquets:

SOFTourniquet;

best by far, Widest of the bunch, metal windlass bar, doesn’t snap or buckle undertension. Gold standard by far.

sof-tac-tourniquet-wide
EMAT: hard to achieve high tension, little mechanical advantage from the small tab, far to easy to release the tension, with the large red button on the side.

 

Pyng-0618b

CAT, Plastic bars have been know to break, thinner bar, cheaper than SOFT.
cat-tourniquet

 

 

 

New format for the Blog (?Podcasting?)

Paper review: I’m going to try and find a decent paper a week to bring to you guys
Courses/Conferences: Whenever I attend one I’ll try and talk about what it means to prehospital and bring any cool tips and tricks
CC(Casual Cases): another weekly one, I’ll try and find an unusual (hypothetical or real) case to discuss, nothing current and nothing identifying, from time to time I’ll be trying to get a guest to chat with

FINALLY!
I’m looking to do a podcast! YES AND ACTUAL AUSTRALIAN PODCAST, what I need is a bit of support, I need you ladies and gents and who ever comes accross this to Retweet, facebook, blog about this, I’m wanting to find some intereting people to deliver content, Students, Paramedics, anyone who’ll sit with me infront of a microphone or on skype… It will be tough to do, but I’m sick of the american podcasts harping on about STEMI’s… yes we get it… ST Segment up…. Badness ensues! 

So please help me on this one!
Mitchell Thomas