Look Back at Analgesia

It seems like a simple thing that’s a given – delivery of good analgesia. Except for the bit where good clinicians fail over and over at this. Here’s Dr Alan Garner checking out a recent study from the Swiss that looks at some of the holes. 

As prehospital clinicians I think we all aim to provide as technically sound and evidence-based management as we can.  This is a given but when I think about what I would like for my own family or myself I also want “care”.  This is what makes health care interactions more than just an exchange of services for money. And this is what sends me crazy when I hear patients described as “clients”.

But I am digressing.  A major component of care is the relief of suffering and the most common form of suffering we see in the prehospital world is pain.  Good pain relief early might not change the patient’s probability of death in the longer term but it might well change functional outcomes such as symptoms of post traumatic stress disorder.  But most of all we should do it, and do it well because we care.

There have been a lot of studies published about management of pain in emergency departments and it almost always looks bad.  People with obviously painful conditions either not getting analgesia, getting it late or not getting enough.  Given that the most common single presenting complaint to emergency departments is pain of some kind, I would argue that a fundamental KPI of good emergency care should be time to adequate pain relief and this should be reported above the 4 hour rule, access block and any other process indicator.  Waiting for a bed for hours is regrettable but waiting for hours in agony is simply barbaric.

If EDs are doing it badly you can be reasonably confident that prehospital is worse given all the additional constraints.  A new study has just been published by the guys from REGA (Swiss Air Ambulance) building on some work they have done previously around the prehospital analgesia question.  The work arose from a quality assurance project on analgesia that they have been conducting across their organisation to try and improve pain management and they are much to be commended for sharing their work on this.  They have allowed us a view into their struggle so we can learn from them.

And it has been a struggle.  In this new study they documented that one in six patients with moderate to severe pain (defined as >3 on a 0-10 numerical rating scale as reported by the patient) did not get any prehospital analgesia at all!  This is even more noteworthy given that the physician documented the pain score of >3 at the scene but apparently did not act on it for some reason.  One clue might be that a predictor of inadequate analgesia was shorter scene times and more severe injury (higher NACA score).  I was wondering if hypotension therefore might be one of the drivers for no analgesia but “circulation insufficient” was pretty uncommon being present in only 13 of the 778 conscious patients in this study (this stuff is in Table 1 in the paper).

 

Local Stories

Several years ago we audited the analgesia given to children by our own service.  In some cases we did not give analgesia for clearly painful injuries (like bent long bones) but there was evidence that the road paramedics who had been there ahead of us had done so.  There is no mention of this occurring in the Swiss study.  Perhaps this might partially explain the lack of analgesia given if this is also occurring in their system.  Although even if this did occur the physicians still documented pain scores >3 whilst the patient was in their care which you would have thought would prompt further analgesia.

I am not meaning to be too critical here.  In the audit of our own service that I mentioned we also found cases with clearly painful injuries and no record of analgesia given by road paramedics or our doctors.  This prompted a major rethink for us in our approach to analgesia in the field including formally recording pain scores on our observations chart to prompt our teams to keep this front of mind.  Analgesia is also included as an item in all our Carebundles for traumatic conditions, and for intubated patients regardless of the underlying pathology.  One of the risks for inadequate analgesia identified in this new study was that the patient had a non-trauma problem.  It might be timely for us to review our Carebundles for non-trauma conditions too.

Digging Deeper

Another risk factor for inadequate analgesia was severe pain from the outset (score 8 or more).  In this situation it seemed a single agent just was not enough.  Judicious use of small amounts of ketamine in addition to the opioid appeared really useful here.  And it appeared the combination was better in severe pain rather than just ketamine as a single agent.

I am also a little surprised about the narrow modes of delivery utilised with all analgesia given IV.  In our system the nasal route for fentanyl is used frequently particularly for children and it works a treat.  I also think that regional blocks have a place, particularly where the injury mechanism and your exam indicate that the injury is confined to a limb and the situation is not time critical (the time it takes is probably the major contraindication prehospital).

We have recently formally introduced fascia iliaca blocks to our service.  There are lots of other blocks you can utilise , particularly if your service carries an ultrasound machine with an appropriate probe for nerve localisation.  This is a skill you are unlikely to learn prehospital (except perhaps for femoral or fascia iliaca blocks) as you will never do enough of the other types to develop any skill.  If part of your practice is in the hospital context where you can get lots of practice however, these are well worth learning.  Done well they can completely remove the need for parenteral opiates.  The context that we have used regional blocks (other than femoral or fascia iliaca) is in limbs trapped in machinery.  Not a common circumstance but a useful tool to have in the box when it occurs.

The Other Bits We Rarely Look At…

I don’t think this was the aim of this study but it would also have been nice to see some attention paid to non-pharmacological methods of pain management.  Good splinting and packaging is the obvious first line for prehospital services and is one of the basics that is worth doing well.  We don’t carry hot or cold packs in our service due to the weight, but they are available from our local ground ambulances.  These can also help in the right patient.

Plus a Slightly Unexpected Elephant

And lastly they claim a slightly unexpected elephant is in the room.  Treatment by a female physician is reported as being associated with a higher likelihood of arriving at hospital with inadequate analgesia.  To be honest I’m not quite sure what made them look at the gender of the practitioner but there it is, written up. Before anyone assumes this was some situation induced by most of the patients being middle-aged blokes, it wasn’t about the patient gender at all.

IMG_5815
An actual elephant not in a room as opposed to the elephant in the study that is probably not an elephant. 

So what is going on? I can’t quite figure out why this would be the case although the Swiss group has documented this previously in their own system.  Is this a Swiss peculiarity or is it more wide spread?

Well to me it looks like there are a few holes in the information provided that make me wonder if it’s a blip rather than an actual pachyderm. For example non-trauma patients were more likely to arrive at hospital with insufficient analgesia than trauma patients. I can’t construct what proportion of those patients got a physician of a particular gender by chance from this report though. Could it be that the real issue is that clinicians interpret the significance of pain differently based on the context or mechanism? If it’s “medical” pain rather than traumatic pain do we tend to wait for the medicine to fix the medical, rather than treating pain separately? There’s at least one confounder for you without even trying so I’m not convinced a strong case is made that provider gender is a crucial determinant of analgesia efficacy.

A question the physician gender stat does raise that is beyond the scope of this study is the need to consider the particularities of the provider in the mix. Beyond breaking things into much larger groups (like physician vs paramedic) I don’t recall seeing much on what characteristics of a clinician make them more or less likely to provide the good juice. If we don’t understand biases that might be in play I’m not sure we can do the most effective job of changing practice.

 

The bottom line – be obsessed with good analgesia.  It’s easy to get obsessed with all those interventions we think of as advanced, but the long-term quality of life of patients will probably be equally influenced by getting this bit right. Use a multimodal approach rather than just the parenteral one.  Combine agents if severe pain requires it.  Consider local and regional blocks if you have the skill.

And if anyone can figure out if the physician gender difference in this study is a blip or a real thing of some other sort hidden somewhere in the unreported elements, I’d like to know.  It’d be good to show that elephant the door.

 

Notes:

Yes. That’s a real elephant and the photo is via @AndyDW_

Oberholzer N, Kaserer A, Albrecht R, et al. Factors Influencing Quality of Pain Management in a Physician Staffed Helicopter Emergency Medical Service. Anesth. Analg. 2017. 

 

The Red Line – Getting That Arterial Line

There are plenty of times in the land of retrieval (and in some prehospital settings) where you need a little bit more than the simple squeezy cuff gives you. An arterial line. Maybe we could share some tips that work for at least one person with the hope of encouraging people to share theirs. This post is from Dr Andrew Weatherall.

There are things in medicine that are more than a bit disconcerting. Clinical practice pretty regularly asks us to skate back and forth between degrees of uncertainty and deal with it. So you take your reassurance where you can and sometimes that is in the form of a red wiggly line – the arterial pressure waveform. Yes, I’m that sad.

XoMEoX
Look, here is the very evocative image that flickr threw my way when I searched for “red line” under Creative Commons. Think about it.

Given the problems associated with other monitoring methodologies in retrieval medicine having a more accurate option for providing haemodynamic information is invaluable. Add in the option for easy blood sampling and moving a critically ill patient is clearly made a lot more appealing with an arterial cannula in place than without it.

They can be a bit of a bugger to get in sometimes though. Particularly in the area I spend most of my time which is paediatric anaesthesia. Now I don’t have a bazillion answers as to how to make it sure it always hits the spot but there are a bunch of things I always do to try and increase my chances of success. Now these might be things for deploying in little people but lets face it, adults are just big kids. Pathetic, large, disintegrating kids. Anyway, in no particular order here’s a few:

1. Check them all

It’s pretty rare that you need to specifically place an arterial line in one chosen artery for prehospital or retrieval work. Not all pulses were created equal though so it’s worth taking a moment to feel all the candidates to measure them up. Choose the best one for that first shot.

2. Get the position right

Whichever one you choose, it’s worth getting the position at its best for that particular artery. At the wrist I think a lot of us have been shown the wrist extended position, and that is usually pretty useful. It’s worth exploring how extended you need that position though. Sometimes when you go to extreme you can distinctly feel the pulse get a little harder to feel. And while a roll under the hips can make a femoral line just that bit easier, it’s worth doing a before and after check. . The bigger point is that you don’t want to just choose the best pulse, choose the best position for that pulse.

3. Know your kit

This is sort of a good rule for lots of prehospital and retrieval work. You need to know your kit and choose it well. Or if you’re utilising something at the place you’re picking up the patient, make sure you understand it. Different cannulae meet up to to the needle component differently. If you’re planning to have a wire as a back-up to get in (assuming it’s not an inbuilt option) you might want to double check the wire will get through the cannula. Know what you’re wielding. Plus at the same time it’s worth remembering that a smaller cannula in the artery is a lot better than a bigger one you can’t feed in. Choose the cannula you’re sure will get in.

Red dots
This also came up when I searched for “red line”. Bit of a fail there. That’s not a red line, it’s a line of red dots. It’s even called “Red Dots”. What gives flickr?

4. The Wire Bit

While I’m there, a wire can obviously be a pretty good friend. I know plenty of people who prefer the technique where you transfix the artery, come back and feed the wire up once the blood is flowing back freely. Plus get a smaller cannula in (see above) and that wire becomes the tool to dilate up to a larger bore cannula.

5. Sit Down

I know this seems really minor and maybe you feel strongly that you’re only doing it right if you’re in a moving vehicle and the family cat you brought with you to comfort the owner is sinking its claws into the back of your neck or up your nostril or something. The thing is trying to not let the environment control you is part of the gig. When you sit down you can set up your ergonomics a whole lot better and position yourself to take away muscular strain and fatigue while you’re doing it. So if the space allows it, sit down and get comfortable.

6. Side to Side and Up and Down

Now that you’ve hopefully found a comfortable position, it’s worth really mapping out that artery. Maybe other people have more sensitive fingers than me but I generally find that placing a single finger on the pulse and trying to centre it in the middle of the pad of my fingertip helps me get a sense of where it is. I then use that same finger to feel up and down the artery and figure out its course so I can mark it on the skin. It actually doesn’t matter a huge amount if the mark is perfect as long as I can go back, feel and understand where I’m feeling the artery in relation to the obvious mark I’ve made. I do this every time to help construct a picture in my head of how it all lies, even before I get onto ….

7. Use an ultrasound

If it’s available, then probably just use it. The evidence says that you’re more likely to get it in without incident and it’s unlikely to be a slower endeavour. Using the ultrasound well still demands good patient and clinician positioning as well as a scout scan up and down the artery to understand its course and any surrounding stuff. Small ultrasounds are now good enough that you should be able to pick up the tip of the cannula all the way into the middle of the vessel (and spot when you’ve still got a little bit of tissue indenting at the wall). Just use it.

8. Short, sharp, flat

It makes pretty obvious sense to approach without too steep an angle (though sometimes you can pop through the skin better with that sort of angle). A flatter approach maximises your path in the vessel which maximises your chances of staying in there. When it comes to movements I find an approach with short, sharp advances more successful than a slow steady push. At least in kids sometimes the latter seems to allow that artery to squeeze out of the way (but I’m happy to be pulled up on that one).

9. Also use local

If the patient is awake of course. Why?  I think that’s actually an obvious one.

Marco Galasso
This one, also came up on the “red line” search but really it’s about the dog. So maybe if you want to get arterial lines in, think more about puppies?

10. Be ready for success

You’re probably going to be brilliant so be ready for that not surprised. Having those tapes and connections ready so you can focus on the bit after the cannula (particularly trying to maintain a clean and dry field so everything sticks and you don’t have a bunch of stuff to clean up) lets you get on with actually using the monitor.

 

So there is my meagre collection of practical bits and pieces. In the prehospital and retrieval space I can’t always guarantee that I can set myself up like I can in an operating theatre. When I make the effort though it turns out I usually don’t have to compromise that much. And that effort usually makes the whole thing go a little bit smoother.

It’s also not an exhaustive list. So if you’ve got a top tip then hit up that comments section. I could use a tip to be better next time I’ve got to step up to the red line.

 

Notes: 

The main reference to read for this one would be this Cochrane review looking at success rates for arterial cannulation in kids using ultrasound. The short version is yes, do that.

All the images here were from Creative Commons posts on flickr.com. The first is from XoMEoX, the second is from Håkan Dahlström and the third is from Marco Galasso.

 

 

 

 

I Wish I Knew Then What I Know Now: Simple Airway Management

This is a popular series and it’s not hard to see why. Greg Brown drops back in to talk about the airway device that is now his go to item. 

I clearly remember a time when the escalation of airway management in prehospital care resembled the fabled Underpants Gnomes from South Park and their three step plan to making a profit.

Back then, airway management looked something like this (and yes there were four steps, not three like in South Park):

  1. Patient’s own airway – bummer; that’s no fun for anyone.
  2. Oropharyngeal airway (aka the Guedel) – fun but not that inspiring.
  3. Endotracheal tube – break out the high fives, it’s a good day to be a medic.
  4. Needle cricothyroidotomy – if an ETT doesn’t do it, a 14 gauge cannula in the throat ought to fix it. Then there are the mutual backslaps.

Back in the day when I was new to military prehospital care (and at a time where not much was happening in the world) the focus seemed to be on big ticket items and not the purpose of the interventions. Indeed, it seemed to me that the drug of choice for any airway problem was plastic; and the bigger the problem, the smaller the dose.

What I know now is that the one’s choice of procedure must consider a whole lot more than just self-gratification. Airway problems are generally either an oxygenation or a ventilation issue, and the choice of procedure must take at least this into account. However, the purpose of this post on the Collective is not to discuss the differences between CICV and CICO (nor the relative advantages of DL vs VL) but simply to discuss basic airways.

Simple Is As Simple Does

There is no doubt that a patent airway that was issued to the patient at birth is best for the patient. Therefore, it goes without saying that anything that can be done by the treating professional to maintain a patent natural airway should be at least considered. I am not going to go into how best to clear an airway and position a patient as there are a myriad of reputable sources out there for you to conduct your own research but I will make two important points:

  1. In a perfect world the “ideal” position will align (and therefore open) the upper airway; seemingly minor changes in positioning can have significant detrimental impacts on airway potency (and vice versa); and,
  2. If you don’t know how to position a patient or provide manoeuvres then you might want to consider taking a step back and booking into a first aid course. Quite quickly. Like right this second. Just do it ….

Still here? Good then, on with the show.

Which means it’s time to introduce one of the heroes: a simple artificial airway. To Guedel or not to Guedel? For many years that has been the question, and the oropharyngeal airway (OPA) was definitely my plastic of choice. Simple to insert and effective – two of my favourite things in a medical device. But are they deserving of their historical gold medal for simple airway adjuncts? Well, maybe yes and maybe no.

You see when it comes to simple adjuncts I have become, over the years, a massive fan of the nasopharyngeal airway (NPA). I would argue that they are just as simple to use as their orally inserted cousins – the operator just needs to be trained in their use. And whilst there are pros and cons to all medical interventions in my mind the NPA has one big benefit over the OPA – when (if) the patient starts to rouse the NPA can stay in, a handy thing for those pesky patients whose level of consciousness ebbs and flows.

Over the last ten years the NPA has gained popularity amongst first responders with thanks to support from some international heavy hitters, and not before time. You see, the NPA was actually invented before the OPA – 38 years earlier, in fact, by Joseph Clover of the Royal College of Surgeons (he later became a founding member of the Royal College of Anaesthetists) in 1870. The first OPA was designed by…. wait for it… Frederic Hewitt in 1908. The first “Guedel” was not even invented by Arthur Guedel whose name is now synonymous with the device. He didn’t enter the scene until the 1930’s (but I will grant that he made huge improvements to Hewitt’s rudimentary designs).

However, it was not until 2002 and the widespread introduction of Tactical Combat Casualty Care (TCCC) in militaries worldwide that the NPA started gaining favour once more. With thanks to a push from the United States Department of Defense’s Special Operations Command, NPA’s started making their way into the individual first aid kits of soldiers, sailors and airmen employed in combat operations. Indeed, by 2008 every Australian serviceperson employed in combat roles carried an NPA in a pouch alongside appropriate haemorrhage control devices. NPA’s are now taught as part of C-TECC guidelines (the civilian version of TCCC) and are now commonly the first artificial airway device reached for by those employed in first responder roles worldwide.

Table

Are there risks associated with the of an NPA? Well, this is medicine, isn’t it? Of course there are risks. The big one that everybody immediately jumps to is in the patient with suspected basal skull fracture (or a fracture of the cranial vault). The risk in inserting an NPA here is that the tube may indeed enter the cranial cavity instead of heading into the nasopharynx. But a review of the literature reveals only two cases where this occurred thus making it a rather extreme reason to be afraid of using an NPA. (Note: that same review of the literature also revealed an article advocating the use of nasopharyngeal airways in the treatment of watery diarrhoea…. Four words: single use only please!)

Putting It To Work

So how do you utilise an NPA (and I’m talking about as an airway device, not in treating diarrhoea of any consistency)? Well firstly, size matters. I am sure that at some point you, like me, have taught various methods. The first common method is to look at the diameter of the patient’s pinky finger – in theory, this is the same diameter of the nares (nasal openings). Therefore the NPA of choice should be the diameter of the patient’s pinky. Yes?

Alternately, the second common method of sizing pertains to length – in theory the distance from the nostril of choice to the tragus (that flap at the front of the ear where it meets the cheek) is the same as from the tip of the nose to the upper pharynx. Yes?

Well, research by Roberts et al in the EMJ found that a combination of the two methods is required to get reach NPA nirvana and that in fact the patient’s height was a better determinant of requisite NPA size. They used data from MRI scans to determine that, all things considered, the law averages reigned supreme. Average height male? Size 7.0mm Portex NPA. Average sized female? Size 6.0mm NPA. Or, you could await the rollout of the MRI App on your smartphone of choice…

Once you have selected the correct size NPA you simply pick the largest nostril, lubricate the outside of the NPA (the patient’s saliva is usually sufficient) and insert whilst aiming for the patient’s ear (the same side as the nostril you are using). By aiming for the ear you are pushing backwards, not upwards, thus reducing the risk of the NPA entering the cranial vault in that patient with a suspected basal skill fracture. For this reason the presence of a suspected basal skull fracture has relegated to the status of relative contraindication (no longer an absolute contraindication). If any significant resistance to insertion is felt then the attempt should be aborted and the other nostril attempted.

Be sure to consider how you will secure the NPA. Certain members of society have naturally wider nares and I’ve seen them inhale their NPA. Placing a large safety pin through the shaft of NPA just below the flange decreases the chances of this happening, but in most patients I’ve treated the safety pin has not been necessary.

 

So there you have it – another thing that I know now that I wish I knew then is that the NPA is not an evil device guaranteed to lead any patient who has ever experienced a blow to the head on a one way trip to the morgue. Rather, the NPA is now my simple airway of choice, an intervention that I have used countless times both on battlefields and in emergency departments, and is the only airway device that I carry on every single job. Oh, and it also has some purpose in treating patients with watery diarrhoea…apparently.

 

Notes:

Remember if you like things on this site there’s a box somewhere where you can throw your email address so you get a regular email when a new post hits.

Want to know about how your choices of airway adjuncts can affect ventilation? Then go here.

Interested in reading more about the facts and myths of NPA’s? Try this.

Here’s a cool little video about airway manoeuvres and simple adjuncts from that good crew at Life in the Fast Lane.

And a previous post that included the use of NPA’s in the tactical environment can be found here.

 

Sedating Kids in Strange Spots

This post is based on a talk prepared by Dr Andrew Weatherall for the South African Society of Anesthesiologists Congress for 2017 held in Johannesburg. As invited faculty 

I think when they first offered this the plan was to do sedation in the dental chair. Which I’ve never done. And this is for a refresher course.

So we changed the topic to sedating kids in strange places. Which I have done.

But they’re strange places so by definition they should seem weird to you which means you probably haven’t done it before in which case it’s not a refresher course topic at all. Just like it’s hard to have a refresher course on swimming with sharks in bathtubs, it’s hard to have a refresher course on undertaking sedation in places people don’t do sedation.

So I guess I’ve screwed this up every which way.

Nothing for it but to sedate someone though. So let’s start with a 18 month old who has a hand injury. We’re going to sedate him to get things fixed up rather than waiting for a free operating theatre.

At the start of any sedation we need to ask some questions of ourselves. And I like to start with the Cluedo questions. The ones about “Who?” or “Where?” or “How” that help us make the choices to get this sedation done.

 

What are we talking about?

It’s pretty vital up front to understand what we’re describing. We need to understand what we mean when we talk about sedation.

Well as good a place as any to start is with the ANZCA documents on this (this is my low rent version of international colour for this one). ANZCA include a couple of key points:

  1. There is an implication that you’ll be using pharmacological support to improve tolerance of uncomfortable or painful procedures.
  2. They try and separate out some levels of sedation.

That latter one can be a little problematic but they do talk about conscious sedation, where the individual will produce a purposeful response with minimal stimulation, and deep sedation where there will only be that purposeful response with painful stimulation.

To be just this side of general anaesthesia however you do need to have some sort of response. Plus you need to consider if what you’re really talking about is analgo-sedation because you’re expecting some pain to be dished about.

Who?

The “Who?” is important in planning for a bunch of reasons. Is it you or someone else actually delivering the sedation? What’s their level of experience or expertise? What’s their clinical background? The background of the practitioner is highly likely to influence the choices they make, particularly when it comes to pharmacology.

The “Who?” also covers the patient at question because the needs of an 18 month old are not the same as those of a 12 year old, and aren’t the same as the needs of a 40 year old.

Lastly, the “Who?” question applies to the proceduralist. If you’re giving sedation to get a job done, then the needs of the proceduralist to get things done have to be taken into account.

Where?

Well, we’re talking about strange places, right? So that definitely matters for this scenario, but it matters for every sedation scenario. It will influence what you feel comfortable offering, and what help is available. It will also heavily influence where they get looked after when it’s done and might influence how quickly you want them back to their entirely normal state.

Wait, this is the strange places post so I should probably mention something….

Today’s patient is in a bathtub. He’s had his hand stuck down the drain for 2 hours with people trying to get it out. It’s 22:00. It’s about 6 degrees Celsius outside. Your proceduralist is the rescue volunteer with the jackhammer who is going to have to work through concrete to reach the bath and dismantle it. 

Ready then?

When?

Well I think in this case we already know that. For other sedations though it’s worth making an assessment of when it has to be done? Does it really have to be now or can it wait a little if you have concerns with sedation. Will the timing matter for available care afterwards?

What about that fasting question? All if it helps at all there is very limited evidence that fasting intervals influence things like aspiration rate. The Pediatric Sedation Research Consortium looked at 139142 patient records in 2016. They found a total of 10 aspirations and 75 major complications. 8 of the aspirations were in kids fully fasted (though that was from 82546 records whereas the non-fasted made up 25401 cases with details). Both rates were < 1 in 10000.

Another look at 12 years of nitrous oxide procedural sedation in kids not necessarily fasted revealed 1058 cases with 0 major complications (and I think quite astonishingly only 11 cases of nausea and vomiting).

So I probably would still make an effort to fast most times, I’d also be pretty relaxed if clinical need indicated we were in a “right now thanks” scenario.

Why?

This isn’t a moment for an existential pause. It’s the key question about our goals of this sedation. Personally I find it useful to think about the ins and outs of it. Roadside Pictures Hamburgers

What are the sensory inputs we’re going to inflict on the patient and what is the level of cerebral output we’re aiming to see?

In radiology you might just need a little stillness. The inputs might be almost nothing, or just a little noise. That’s clearly different to a burns dressing, or a quick pull on a fracture.

Remember our little punter? This kid is stressed after 2 hours of messing about and there are 10 weird people in bright orange in the bathroom with him. They’re using noisy tools. His hand is sore. He is way past his bed time. The extrication is thought to be a 2 hour job.

Our goals are to achieve a comfortable light snooze that might have to deal with variable pain input.

How?

Finally we get to it. And you might figure we’ll dive straight into drugs. Nope. This is a super short chat so I’m more interested in an approach that will work, while assuming that clever people checking this out have an armamentarium of things they are good with.

So I think when we get to the “how?” it’s easiest to remember we need to offer some REST.

That’s

Rapport

Environment

Safety

Therapy.

Let’s work through them.

1. Rapport

In most sedations establishing a good rapport with the patient is vital. Sedation isn’t like general anaesthesia and there is the potential for recall and moments of discomfort. Establishing trust is therefore a big help, because if there is one of those moments it’s a lot more ideal if the relationship you’ve established means they’ll trust you when you try to provide reassurance. The same goes for if you’ve got a carer around.

So there are plenty of ways to work on that beyond this scope, but slowing down to take this step pays off.

 

Lorenzoclick clown
Look I wouldn’t try this approach personally, but whatever works for you…

2. Environment

As much as possible setting up an environment to support the sedation is ideal. Simple things like choosing a specific spot where you can, reducing noise in the area (bugger, jackhammer), ensuring easy access to the patient and controlling the numbers of people in the space can make it a much calmer experience all round. If the environment is good, really you should need less pharmacology. The environment is also a key element of …

3. Safety

Sedation is actually pretty safe overall. Biber et al have published stats showing a 4.8% adverse event rate in 12030 patients. For the really concerning ones they only observed airway obstruction in 1% of those sedations and laryngospasm in 0.6%. 1.2% of patients needed some bag-mask ventilation. Unsurprisingly issues were highest in the 0-5 age range.

Obviously we need to be actively focussed on safety though. And I’d start with your eyes, ears and hands. Personally I think delivering good sedation can be much more taxing than giving a general anaesthetic. To keep them consistently at a state of sedation, which can be a lot more dynamic than anaesthesia, requires a continuing close quarters assessment of where they are right now and what the inputs are about to be.

So being able to reach out and touch or gently stimulate the patient matters. Close observation of respiratory patterns matter. This doesn’t suggest we should abandon monitoring. We should have at a minimum pulse oximetry, a means of measuring pulse rate and BP and I’d argue that in hospital or static settings capnography is a must.

Every sedation also requires a plan for how to manage airway complications, support breathing well and manage any circulatory issues, rare as they all might be.

Safety requires a team too. The ANZCA documents suggest that beyond yourself you need at least one person available to assist you at the drop of a hat. Or a clatter of the safety helmet I guess.

Which brings me to the last point, don’t forget PPE. That’s not just for you either. Your patient might need it.

4. Therapy

We finally got there. This really comes down to two big groups:

  • Non-pharmacological, which should absolutely not be considered as a lesser item. If you have some good distraction and redirection techniques they can get you a long way there.
  • Pharmacological.

When it comes to agents this isn’t really the space to argue for one over the other. I would say that if you’re sedating in a new spot or new situation, I wouldn’t try out that cool drug someone told you about for the first time.

Each agent has its pros and cons. Propofol is great for sedation when used right but can sting a little and respiratory depression can be an issue. Ketamine has a lot to recommend it but I have seen nasty dysphoria and that shouldn’t be dismissed. Dexmedetomidine has some strengths but there’s no doubt patients are sleepy for longer afterwards. Nitrous oxide clearly works but you do need a way of delivering it and you might not want it for too long in a tight space. Opioids obviously are superb for analgesia but require caution, particularly if used as an additive to another agent.

Again the key thing is to choose agents whose characteristics feel familiar to you and use them to manage the goals you came up with in the “why?” bit.

Is it just sedation you need. If it’s painful, how painful? Is that pain likely to be consistent or variable in nature? Does the time to wake matter? Would regional options help with those inputs?

Now choose the agent that lets you get things there.

Because a strange spot for sedation is really just a different office to do your work.

Bathtub

Here’s your patient. You can only just see some of the elements here, but the patient is covered up in blankets. They have earmuffs on. They have oxygen going and a cannula in place. After some midazolam, fentanyl and ketamine in we managed to sneak in digital nerve blocks. From that point on we really didn’t much of the ongoing infusion to have the patient snoozing but rousable to touch. The one obvious flaw here? We didn’t control the environment quite well enough to know the family had sent in a news reporter to get a shot. 

And one hour in, with the patient relaxed we figured we might as well try a gentle pull on that hand. And it slid right out. Pity about the bath. 

And all it needed was a bit of REST. Maybe that’s not so strange after all.

Notes:

It is very cool that you dropped by here. Remember that if you like the stuff we have on the site you can sign in for an email update when a new post goes up. Have a look around, it’s here somewhere.

Of course none of the posts are meant to be the final word. We’d love to learn from anyone if you have the time to leave a comment. No pressure though.

Yep I’ve had previous clearance to use this case in public.

The image of the job is as it appeared in the local paper, The Illawarra Mercury.

The other images are both from flickr in the Creative Commons area and are unchanged. The clown was posted by lorenzoclick and the sign came from Roadside Pictures.

Now, reading things:

Here are those ANZCA Guidelines.

Here are those fasting type things:

Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room. Anesthesiol. 2016;124:80-8.

Pasarón R et al. Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients. Pediatr Surg Int. 2015;31:173-80. 

Here’s that adverse events one I looked at (though in GI endoscopy work):

Biber JL, et al. Prevalence and Predictors of Adverse Events during Procedural Sedation Anesthesia – Outside the Operating Room  for Esophagogastroduodenoscopy and Colonoscopy in Children. Pediatr Crit Care Med. 2015;16:e251-e259.

Now here’s some more general reading of things that might have some interest:

Mahmoud MA, Mason KP. A forecast of relevant pediatric sedation trends. Curr Opin Anesthesiol. 2016;29(suppl 1):S56-S67.

Alletag MJ, et al. Ketamine, propofol, and ketofol use for pediatric sedation. Pediatr Emerg Care 2012;28:1391-5.

Phelps JR, et al. High-dose dexmedetomidine for noninvasive pediatric procedural sedation and discharge readiness. Pediatr Anesth. 2015;25:877-882.

And here’s a couple of things I’ve had a chance to contribute to:

Marland S, et al. Ketamine: Use in Anesthesia. CNS Neurosci and Therapeutics. 2013;19:381-9.

Weatherall AD, Venclovas R. Experience with a propofol-ketamine mixture for sedation during paediatric orthopaedic surgery. Pediatr Anesth. 2010;20:1009-16. 

Now have you scrolled all the way down here? Then I have a bit of a treat. In the presentation version I had a multi-exposure shot of Danny McCaskill in action in his film Cascadia. You could watch it by clicking here and reflect on safety. Or maybe just watch it because it’s amazing.

 

Kids Prehospital Care Here and There

This is the written version of a talk by Dr Andrew Weatherall for the South African Society of Anesthesiologists Congress 2017, just held in Johannesburg. It’s probably just about the shiny things. 

You probably figure that a talk on prehospital paediatric medicine in Sydney should be about shiny pictures of that thing we call the coat hanger. Or maybe actions shots of this character …

IMG_5023
Morning BIF.

And of course there are a lot of cool things we can do in prehospital paediatric care. Maybe the best thing to do is to start with a story. It’s a story of a kid we’ll call B.

Lazy Mornings

One of the odd features of Sydney is that on its edges there are some areas that are essentially rural. They’d take an hour or so to drive to from the CBD, but are probably only 10-15 minutes flight from the base.

One day, a Monday I think, on one of the properties out that way there’s a Dad watching cartoons with a couple of his kids. They want to keep hanging out and he has a bit of work to do moving some earth so he heads out, kids parked firmly on the couch and closes the door behind him.

In the truck he starts to manoeuvre to turn it around. Back. Forward. Back with a glance at a side mirror and he sees legs. They look like the legs of his 4-year-old and they are sticking out from under the wheels.

I imagine the seconds it took to reach her felt like a long time. I imagine the wait for help to arrive felt a lot longer.

Things That Aren’t Common

The weird thing about being an Aussie talking about trauma in South Africa is that I am not talking about something that is common to us. Most of the audience would laugh at our numbers. The NSW Institute of Trauma and Injury Management published some stats from the 2015 annual review and across the whole of NSW there were 3970 major trauma patients. The busiest adult trauma centre would see a bit north of 600. Across the state the kids’ hospitals would see less than 200 severely injured kids between the three of them.

So I should pack up and stop talking I guess?

Well I guess the thing we could reflect on is that if you can’t rely on exposure to numbers to get everybody better and produce better outcomes there are other things you can focus on. You can start with the system to make the response bring the hospital to the patient quicker. It’s over an hours drive back once anyone gets there.

That day the NGO I spend time with was called about B and was airborne in minutes to get to her. This ability to get in the air quickly came from a trial to look at ways of getting care to patients quicker where every second that could be cut down was thrown in the bin.

The perpetual question we are asking is “what can we bring to the accident scene that will make things better?”

Untitled3

Change the Scene

Let’s imagine a different version for a minute. Let’s imagine in the perpetual construction site that seems to be outside most hospitals, this happened out the front door of where you work. What would you offer this kid?

My expectation is you’d rapidly assess for exsanguinating haemorrhage. You’d work as quickly as possible to ensure A, B and C are adequately sorted and you’d get analgesia on board. You’d image, transfuse if you need to, consider tranexamic acid and splint any fractures.

If oxygenation and ventilation means anaesthesia, intubation and ventilation (maybe even chest decompression) you’ll do that. You’ll assess and reassess as things evolve, operate where it’s really needed and keep making new plans to cope with a dynamic situation.

So here’s a question to consider – which one of these should we forget about while the patient travels by road for an hour to reach the front door of the hospital? If you’re the anaesthetist up in theatres who will meet them later, which ones do you not want to have been looked at early?

We can take almost anything we want to the scene. Helicopters carry stuff. So we take with us all the equipment for advanced airway management, a small ventilator and oxygen in our backpack. We can decompress chests. We can splint. We can ultrasound, tourniquet, pack wounds with haemostatic agents, give tranexamic acid and transfuse. We have to get there of course.

And on this day the team did. They were confronted with a child looking more than a bit pale and cool peripherally. Her HR was 140 and above with a brachial pulse palpable. Her GCS was 9/15. Her injuries were apparently below the umbilicus but looked like they included a fractured pelvis and right femur. She had been eviscerated and had a large skin flap extending from the front of the abdomen all the way around her back. She was still under the truck.

Over the next 50 minutes or so, the team obtained intraosseous then intravenous access. They performed a controlled rapid sequence intubation. They splinted fractures and covered up defects. They delivered warmed red cells. They got her to the hospital. She was fairly stable through the emergency department and then the operating theatres. She made it to PICU.

She made it home.

Cool story, huh? But also really irrelevant if you’re talking at a conference in a different health setting, right?

Another Change of Scene

What if this happened in Cape Town? Which team would turn up then. The dispatchers are likely not to have medical background. An activation of advanced teams will happen some time after the sent team gets there. The team that first arrives will have paramedics with variable levels of training. They might not be able to give a range of stronger analgesic agents. They will have more limited options for airway management. They are likely not to feel as comfortable with cannulation in kids as in adults.

The kid gets what they get.

The thing is, I could be describing the same back in Sydney. I gave you a story from the system on a good day. We know a system like that is there but we don’t really offer it. Most days our kids will get teams that finds kids really challenging (because they are of course).

Getting the Team There

How do I know this? Well we looked.

A while back CareFlight was running a randomised trial to try and activate advanced teams to patients on the basis of the initial information that gets called in using a strict protocol. The trial applied to adults but we were asked to offer it to kids as well.

The crew (doctor/paramedic/pilot/aircrew) next to the helicopter had access to the screens and took it in turns to match the high acuity calls to tasking criteria and even to call back for more info if required. A decision to get in the air, cross-checked with central coordination for kids) had to be made within about 5 minutes of the start of the call.

For a while the systems (crew watching and central coordination watching) operated alongside each other. So we had a look at how that worked out. Over a period of time where the Sydney area had 44 severely injured kids, on that initial info the advanced care crew picked up 20 of them. The central guys looking noticed 3.

The numbers are obviously small (not much trauma, remember) but when the crew were watching and going to jobs it also made differences to the system. As they always brought kids back to the kids’ trauma centre, the time to get there averaged 92 minutes. When they were not available (on another job or offline) that time became 296 minutes. That’s for a few reasons but in no small part to some of those patients getting taken to other hospitals and waiting for transfer.

So there’s one thing you can do for your more trained up teams without much infrastructure required to get the right team there.

And I hope someone picks it up because in Sydney they abandoned it. At the end of the trial the screens went.

Another Look

So we had another look to see if the system had picked up the slack. We looked at the time when the advanced crew had the screens and the time after that. These were longer time periods (34 months in the first epoch and 54 months after which equated to 71 severely injured kids before and 126 after).

In the first 34 months the collaborative system picked up 62% of those severely injured kids and the average time to hospital was 69 minutes. In that latter period, with centralised looking alone, 31% of kids were triaged to advanced care, the version of care the system says it wants. The time to reach the kids’ hospital averaged 97 minutes.

You can imagine that this is something I find … disappointing.

But you might also be thinking “If you are suggesting I try and change a whole system then you are an extremely crazy person affected by anaesthetic gases that have rotted your brain because that will involve meetings, and talking to people who do politics and some of those people will expect me to wear ties and that is not why I got into anaesthesia”.

And that is fair.

But a much as I’d love us to do things about systems there’s something we could all focus on right now to try and make a difference.

If the system is mostly going to send the “not pointy end” part of the system, then we should also look at the care most of the kids will receive.

The Big Story

Every talk on prehospital stuff by a doctor can end up being mostly about the really sharp edge. But in NSW less than 1 in 5 kids ever see the advanced care team. So the biggest bang for our buck is in making sure all the kids get access to prehospital clinicians who feel confident working with kids and give them what they need on indication, not influenced by age alone.

When we focus on the pointy end the chances for gains are pretty marginal. Let’s look at intubation for example. Advanced EMS practitioners in Switzerland have published on their efforts and the highly trained and experienced professionals mostly get the tube in without incident but almost 1 in 5 kids had the wrong-sized tube and the majority were placed too far down the airway. Bringing up the whole of the prehospital provider group to a level above Swiss advanced EMS is probably a pretty big effort.

Particularly when you look at stats like those from Prekker et al looking at a big EMS system in Washington where intubation was an option. A paeds response happens for them in 1 in 2198 callouts (there were 299 in total in 6 years spread across all the practitioners). Their first pass success was 66% (though they did eventually get there in 97%) and 10% of the patients needing intubation needed 3 or more attempts.

And I can’t tell you what the oxygenation was like through that and really oxygenation is the name of the game.

The simple truth is kids get a raw deal at the pointy end. Everyone finds them tougher. Bankole et al compared kids receiving high level EMS care around New Jersey with a severe traumatic brain injury and compared them to the adults being looked after by the same really well trained first responders.

20% of kids with a GCS under 8 had no attempt at airway intervention. Of those intubated 69.2% had complications and 29% (vs 2.27% in adults) had a failed intubation. Even cannulas were placed in only 65.7% vs 85.9%.

It starts making you think that if those of us in prehospital medicine looked harder at the thing we want to achieve, oxygenation, rather than interventions that sometimes can do that but have big potential complications we might be able to change things for a bigger population of kids.

Recalibration

Although there are problems drawing on battleground experience in civilian trauma care, particularly in kids, there is a quite interesting paper from Sokol et al. looking at the Camp Bastion experience with 766 kids with traumatic injuries. 20% of them needing some sort of intervention and circulation measures (particularly stopping bleeding) was the most effective. Simple airway manoeuvres were done not often enough and interventions for breathing (like chest decompression) were a lesser order issue than circulation issues.

So perhaps what we should focus are things we could train more people in and more prehospital providers of all experiences could deliver:

  • Recognising the sick kid.
  • Stopping haemorrhage effectively.
  • Assessing A and B and delivering effective bag-mask ventilation.
  • Cannulation and appropriate fluid use.

Recently we’ve done some focus group work at The Children’s Hospital at Westmead with clinicians who do paediatric airway management and one of the strong themes emerging as we write up is that all of them rate airway assessment and bag-mask ventilation as the most vital skill they want to be good at and they’d like to pass on.

There are all sorts of interesting hints here. Hansen et al conducted an exploratory study in 2016 to look at how well paramedics recognised and treated in croup. After whittling through records their small study looked at 14 patients with a primary upper airway issue. 8 of the patients had “stridor” or “croup” explicitly noted in the tasking or information noted by the responding paramedics. 6 had trigger words like “barky cough” or something pretty convincing. All of them received salbutamol, not the nebulised adrenaline or other treatments on offer.

But Some Things are Easy, Right?

Analgesia though, that might be an easier target because relieving pain in kid sis a no brainer.

Well, no.

Samuel et al. published a systematic review of evidence looking at analgesia provided by prehospital providers for kids in 2015. In it they describe a review of 55642 patients where 26% of the kids had trauma and another 16.1% of kids had a primary complaint with significant pain.

0.3% of the kids were given any analgesia.

There were other studies included reporting rates of analgesia administration for fractures of 2.1-3.2% (and at  least one with 0% in the under 5s with fractures).

What is going on?

Well sometimes there might be limitations in what the paramedics have available (e.g. opioids or not, ketamine etc). One physician system showed 92% getting given strong analgesia in these sorts of patient groups.

There may be a fear of drug errors because there is work suggesting issues with drug dosing in kids in more than 30% of prehospital cases.

However Rahman et al have also done work exploring the perceptions of paramedics in providing analgesia to kids and showed very high levels of reported discomfort with providing and assessing analgesia in kids. More alarmingly 25% of respondents indicated that kids needed less analgesia because of immature nervous systems.

These are not small chips either. Schreier et al looked at PTSD symptoms after just mild to moderate trauma (things like isolated fractures) in kids. At 18 months (in an admittedly small study) 38% of the kids they looked at had at least mild symptoms.

PTSD in kids expresses itself as poor attendance at school, missed marks in education and social disengagement.

While < 4% of kids are getting analgesia for obviously painful things, there are things we can tackle that don’t need a rapid sequence intubation and a snorkel.

What is the cost?

So the cost to patients will undoubtedly be big if we are sending teams who don’t feel comfortable in kids, but is the cost of addressing it prohibitive.

I reckon not. Here’s one example.

CareFlight, that little charity I mentioned, has started to treat education of first responders as a way of providing service to the community. By taking simulation education and courses mobile to rural and remote first responders maybe we can make the first person who turns up to the injured just that little more comfortable that there are things they can do.

Uluru 3.JPG
The MediSim crew in action next to a big red rock.

Since 2011 they’ve reached almost every state in Australia and trained more than 3000 people. Participants don’t pay.

In the Western Cape there is an EFAR program that would be worth checking out that is seeking to enhance the response of first-aid responders.

But if you’re an anaesthetist or other critical care provider, then there would have to be ways for you to link up with local prehospital services and offer to help paramedics gain skills and experience.

Everyone in the room (or reading this) can probably provide analgesia. Everyone has seen a sick kid. Everyone knows how to splint and work on stopping bleeding. In particular I am full of a room of people who have exquisite skills in things we think of as basic, like bag-mask ventilation, but could be the difference between a patient being oxygenated on the drive in, or obstructed the whole way.

The Wish List

If you’re the anaesthetist waiting in that operating theatre when an injured kid is on the way, what’s on your wish list?

Mine would include the patient being identified and getting to me as quickly as possible. I’d hope the team that reaches the patient can recognise if they’re sick and keep reassessing well. I’d hope they felt confident managing the airway and could optimise oxygenation as much as their skills allowed. I’d love it if they turned up with some form of intravascular access and some analgesia on board.

The priorities to start making that happen for more patients is actually not about BIF with the noisy rotors. The priorities are the same if you’re looking at an old bridge across a harbour. Or some mountain near the sea.

Damien du Toit Table Mountain

Or a downtown area closer to the sky.

Paul Saad Jo'burg.jpg

Notes:

I cannot express the depth of my gratitude to the patient and family who have granted permission for the use of their story as part of education in this area.

Thanks also to the clinicians involved in the case, Dr Rob Bartolacci and Ben Southers, super paramedic, for background on their case and the shot from the sky that day.

A huge thanks also to the brilliant Jo Park-Ross, Flight Paramedic from AMS in Cape Town and Ross Hoffmeyr, an anaesthetist also working in this area down in Cape Town for helping me understand more about the local system and checking my work.

A shout out too to Colin Brown and Greg Brown (no relation) at CareFlight for the stuff about the MediSim program.

As part of the invited faculty the organising committee covered travel, accommodation and registration for the conference.

The images of BIF and Sydney are from my personal collection. Other images are from the Creative Commons area of flickr and are unmodified here. Paul Saad posted the shot of Johannesburg and the shot of Cape Town is by  Damien du Toit.

Right, now the things to read…

Here are the trauma stats in NSW for 2015:

NSW ITIM Trauma Stats 2015

Here is the Head Injury Retrieval Trial:

Garner AA, et al. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe traumatic brain injury compared with management by paramedics. Emerg Med. J. 2015;32:869-75.

Here are the tasking studies:

Garner AA, et al. Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew-case identification rates and effect on the Sydney paediatric trauma system. Scand J Trauma Resusc Emerg Med. 2012;18:20:82.

Garner AA, et al. Physician staffed helicopter emergency medical service case identification – a before and after study in children. Scand J Trauma Resusc Emerg Med. 2016;24:92.

The Swiss study:

Schmidt AR, et al. Ease and difficulty of prehospital airway management in 425 paediatric patients treated by a helicopter emergency medical service: a retrospective analysis. Scand J Trauma Resusc Emerg Med. 2016;24:22.

The thing by Prekker et al.:

Prekker ME, et al. Pediatric intubation by paramedics in a large Emergency Medical Services System: Process, Challenges and Outcomes. Ann Emerg Med. 2016;67:20-29.e4

And the first responder TBI comparison:

Bankole S, et al. First responder performance in pediatric trauma: A comparison with an adult cohort. Pediatr Crit Care Med. 2011;12:e166-e170.

Here’s the battlefield stuff:

Sokol KK, et al. Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs. J Trauma Acute Care Surg. 2015;79:983-9.

The thing on assessment and treatment of upper airway obstruction by paramedics, which is exploratory but interesting is here:

Hansen M, et al. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Children’s Safety Initiative – Emergency Medical Services. Amer J Emerg Med. 2016;34:599-601.

Now here’s that analgesia review that is a sobering read:

Samuel N, et al. Prehospital pain management of injured children: a systematic review of current evidence. Amer J Emerg Med. 2015;33:451-54.

Here’s the thing about comfort level of paramedics in providing analgesia to kids:

Rahman A, et al. Emergency medical services provider comfort with prehospital analgesia administration to children. Prehosp Disaster Med. 2015;30:66-71.

Plus that little PTSD study:

Schreier H, et al. Posttraumatic Stress Symptoms in Children after Mild to Moderate Pediatric Trauma: A Longitudinal Examination of Symptom Prevalence, Correlates, and Parent-Child Symptom Reporting. J Trauma. 2005;58:353-63.

If you wanted to get a little more info on that mobile simulation training CareFlight do here’s a link.

MacGyver Medicine

So you’re out there somewhere and you really want to do a thing you think might help but you don’t have your standard kit. Can you adopt the lessons of Richard Dean Anderson and improvise? Mel Brown has you covered. 

Okay, so I am guessing from the title of this post you have a good idea of my age….I am talking about the original MacGyver, not the new one. And for those of you that are too young to know who I am talking about…..MacGyver could improvise everything he ever needed from anything that was “just” lying around. I once saw him create an explosive device with little more than a pepper shaker and some foil wrapping off some chewing gum.

It is wonderful that we live in a world where most of the time we have access to all we need (and more), including our medical equipment. But what happens when you don’t have what you need (or don’t have enough of what you need) to treat your patient?

So in line with our series on “I wish I knew then what I know now” we are going to look at MacGyvering (improvising) arterial tourniquets and pelvic binders – two devices that we are all very familiar with (or if you’re not you can be if you go …

These easily reproducible techniques are certainly something I wish I knew about when I first started nursing…..and no, it wasn’t when Florence was around (although I am pretty sure she trained one of my lecturers).

Continuing with the History Theme

Did you know that arterial tourniquets have been around for a while now? In fact, the first combat commander to advocate the use of tourniquets was Alexander the Great – he based his decisions on the works of the medical researches at Cos.

However it wasn’t until 1718 that Louis Petit, a French Surgeon, developed a “screw device” that could be placed over blood vessels to stop flow. From the French verb “tourner” (to turn), he named the device “tourniquet.”

Tourniquet
Elegant, non?

Improvised Arterial Tourniquets

One of the most important things to remember with any arterial tourniquet is that indirect pressure MUST be applied whilst the tourniquet is being applied. This will at least minimise if not stop the bleeding whilst the tourniquet is being applied…

Improvised tourniquets need to be at least 5cm wide to ensure adequate arterial occlusion can be achieved. Have you ever wondered why a shark attack victim that has had an improvised tourniquet applied to their bitten leg (usually via a surfboard leg rope) soon begins bleeding again after the bleeding was originally stopped? Well the theory goes that the initial narrow occlusion of the artery was enough to completely occlude the artery but as the pressure proximal to the point of occlusion builds up behind the narrow improvised tourniquet the arterial pressure is able to beat the tourniquet and the patient begins bleeding again. You need something applied over a wide area to get the job done.

So, what should we use? Firstly you need to find a windlass device that is thick enough and tough enough to withstand the pressure applied to it as you twist it to tighten the tourniquet (which can be up to 300mmHg of pressure). Some things (and only some, there would be more) that are readily available include:

  • A thick solid stick (not always ideal)
  • An indicator lever (probably not out of your own car)
  • A screwdriver
  • A tyre lever
  • A set of pliers

As for the tourniquet itself, what should be used? Some materials used with good effect include (but again are not limited to):

  • Triangular bandages (make sure these are the cotton ones and not the cheap paper ones)
  • Seatbelts (once again probably not out of your own car)
  • Canvas belts
  • Shirt sleeve (preferably with non-stretchy material)
  • Neck ties (not sure how many of these are around these days).

One of the issues with improvised tourniquets is the narrowing of the tourniquet at the windlass point. This can pinch the patient’s skin and make an already painful intervention more painful. The narrowing of the tourniquet material can also lead to greater damage to the underlying skin, muscles and nerves. Having said that I am not sure the alternative of death due to blood loss is ideal either.

I think many of us have spoken about how we could improvise an arterial tourniquet….but how do we actually do it? Let’s use the triangular bandage as our improvised tourniquet to discuss this in detail.

  • Ideally you want two triangular bandages – lay the first one along the arm or leg.

TQ 1

  • Wrap the second triangular bandage over the first and around the arm or leg and tie a knot or two.

TQ2

  • Place the improvised windlass rod on top of the knot and tie two more knots to secure that windlass (note: if you can’t tie knots, tie lots).

TQ 3

  • Turn the windlass until the bleeding stops and then turn once more. Secure the windlass in place with the first triangular bandage.

TQ nongaffer

If you forgot the first triangular bandage you can use gaffer tape (or equivalent) to secure the windlass in place.

TQ Gaffer

It is important to still write “T” and the time of application somewhere obvious (maybe on the patient’s forehead would catch the eye) as you would for any arterial tourniquet. Obviously improvising is not ideal when compared to commercially available products. However, they are life saving for your patient when you don’t have the equipment that you need available.

Improvised Pelvic Binding

Improvised pelvic binding has been widely used throughout Australia by our Ambulance services for a very long time – I think most people would be familiar with pelvic sheeting. There’s some nuance around when pelvic binding may or may not be useful (just check out the posts here, here, here and here) but what do you do if you’ve made an assessment it is worth trying and you’re without your fancy gear?

Well we all go driving or hiking with sheets in our car boot (that’d be a trunk for our North American friends) or backpacks, right? I don’t think so, and I know I certainly don’t. So what do we commonly have on us that we could use? A jacket works well as an improvised pelvic binder. Let’s have a look at what this looks like:

  • Prepare the jacket for use. Use the arms as a width guide and fold it up like so.

Pelvic 1.jpeg

  • Place the jacket under the smalls of the knees where there is a natural hollow.

Pelvic 2

  • Preferably with two operators seesaw the jacket up to the correct position over the greater trochanters.

Pelvic 3

  • Bring the arms of the jacket together and tie a knot.

Pelvic 4

  • Twist those sleeves until the required pressure is achieved.

Pelvic 5

  • Secure that knot (gaffer tape works again, or zip ties or equivalent).

Pelvic 6

  • You’re done. And maybe cold, but done.

Once again it is obvious that improvising is not ideal when compared to commercially available pelvic binders. However they are life saving for your patient when you don’t have the equipment that you need available. All interventions, whether improvised or not, must be continually checked for effectiveness – especially if your patient is moved.

Summary

It is important that as clinicians we understand how to use the commercially made equipment we have available to us. However, it is just as important that we know how to improvise life saving interventions as there will be a time when we won’t have our equipment (or enough of it) to treat our patients. This is a predicament that I certainly don’t want to find myself in. So let’s share what we know as shared knowledge is power. Or share what MacGyver knows because that is also power.

 

A bit more reading:

Those posts on arterial tourniquets and bleeding are here.

Pelvic fractures? Look here, here, here and here.

Feel like doing the sort of reading that means your improvisation is actually not just making stuff up in your head quickly?

Try these:

Kragh JF, Wallum BS, Aden JK, et al. Which improvised tourniquet windlasses work well and which ones won’t? Wilderness and Environmental Medicine, 2015. 

Nunn T, Cosker TDA, Bose D et al. Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries. Injury International Journal of the Care of the Injured. 2007;38:125-8.

Ofori-BoaduL, Osei-Ampofo M, Forson PK, et al. Practical Pearl. African Journal of Emergency Medicine. 2013;3:88-9.

Stewart SK, Duchesne JC, Khan MA. Improvised tourniquets: obsolete or obligatory? J Trauma Acute Care Surg. 2014;78:178-83.

Shackleford SA, Butler FA, Kragh JF, et al. Optimising the use of limb tourniquets in tactical combat casualty care: TCCC Guidelines Change 14-02. Journal of Special Operations Medicine. 2015;15:17-31.

 

 

 

 

 

 

 

 

Sucking or Blowing – What’s the Difference?

Sometimes it’s worth wondering if the things we hear, see and feel are quite as we thought they were. Dr Alan Garner has a look at your senses when you get into the chest and wonders whether it’s all as straight forward as we like to think? 

Let’s start this post by stating right upfront that this is about chest wounds.  If that is not what you were thinking then time to look elsewhere.

What I want to discuss is the clinical diagnosis of tension pneumothorax in the field.  The reason for the discussion is that I believe it is way over-diagnosed.  When I worked in the UK 6 years ago it seemed tension was being diagnosed frequently and the reason given was the sound as they breached the pleura with the forceps.  As the patient was positive pressure ventilated at the time then the sound must have been air rushing out of the pleural space as their intrathoracic pressure was positive throughout the respiratory cycle right?

Remember how we can’t rely on the sounds involved in clinical examination in the prehospital environment because they’re too unreliable? Well I was being told this one was always right. ‘Always’ is a big word in medicine

I’m also aware of at least one case where a patient with a single epigastric gunshot wound from a low velocity weapon had intubation and then bilateral finger thoracostomies.  The comment at the time was that the prehospital doctor, who no doubt went into it all in good faith, stated that at the time of the thoracostomies they found a pneumothorax on one side and a tension on the other.

However on imaging and surgery the projectile went straight back into the pancreas and nowhere near either hemithorax or the diaphragm.  Indeed the only injuries identified to any part of the chest were the thoracostomy wounds themselves.  Again an intubated patient so the intrathoracic pressure must have been positive right?  If the lung felt down then it had to be a pneumothorax?  And if there was a sound on breaching pleura it must have been a tension?

Clearly in the second case the signs were misleading so what is happening here? Let’s put aside for a second the challenges of the initial diagnosis of pneumothorax and focus on the feel with the finger and the sound to the ears. Could it be that some of the evidence we’ve been lead to believe tells us we’re dealing with a pneumothorax can mislead experienced, well trained clinicians?

Diving In

Perhaps I have done a few more chest drains than most.  Partly that is due to more than 20 years in the prehospital space but I probably did even more when I was a registrar 25 year ago.  I spent 6 months working for a couple of respiratory physicians and I put lots of drains (mainly for malignant effusions) in patients who certainly did not have a pneumothorax before I started.  It was common to hear a noise as the pleura was breached as the air rushed in.  But this of course was in spontaneously ventilating patients and that is different right?

Obviously we need to go back to the physiology to see what is driving the movement of air either into or out of the hole we have made to determine whether the sound we are hearing is air going in, or air going out.

Back to Basics

Transpulmonary pressure is the pressure gradient that drives normal ventilation.  It is the difference between the alveolar pressure and the intrapleural pressure in the lungs.

Ptp = Palv – Pip. Where Ptp is transpulmonary pressure, Palv is alveolar pressure, and Pip is intrapleural pressure.

(If you’d like a little more on this the excellent Life in the Fast Lane has a bit on transpulmonary pressure here.)

Also it turns out that you can get a google preview of John West’s classic textbook on respiratory physiology. Take a moment to go and enjoy Figure 4-9 on page 59. 

You can see from panel B (I meant it, go and have a look) that intrapleural pressure varies between about -5 and -8 cmH2O at the mid-lung level during normal respiration. It is always negative and that’s due to elastic recoil of the lung which is being opposed by the chest wall. It is less negative at the dependent regions of the lung (reducing alveolar size) and more negative at the apex (increasing alveolar size).

Let’s Add Air

In the situation of a small pneumothorax the air in the pleural space makes the intrapleural pressure less negative and the driving pressure difference for ventilation is therefore reduced.  If the pneumothorax is completely open to the air such as with an open thoracostomy wound the intrapleural pressure is equal to atmospheric pressure, the elastic recoil of the lung causes complete collapse and ventilation by chest expansion is impossible – positive airway pressure has to be applied.

It is not the situation of the pneumothorax that particularly concerns me.  If they are hypoxic or hypotensive and the patient has a pneumothorax the chest should be decompressed – a complete no-brainer.  The question is why are good clinicians decompressing normal chests and thinking there was a pneumothorax or even a tension when there was not? Does the physiology lead us there?

Patient One

First let’s consider the non-intubated patient with normal respiration and no pneumothorax.  This is the situation with the patients with malignant effusions I was putting drains in years ago.  Here the alveolar pressure is never more than a cmH2O or two positive or negative.  The intrapleural pressure however is -5 to -8 cmH2O.  Therefore it does not matter what phase of respiration you breach the pleura, the pressure gradient between the pleural space and atmosphere is negative and air will rush in.

The gradient is bigger in inspiration when alveolar pressure is negative (and therefore the total pressure is around -8 cmH2O) and less negative during expiration when it is more like -5 cmH2O.  It is however always negative.  It does not matter which part of the respiratory cycle you breach the pleura, air is going to flow into the pleural space and the elastic recoil of the lung will drive it to collapse.  If you hear a noise as I often did, it is air rushing in, the classic sucking chest wound. An iatrogenic one.

Patient Two

I don’t think anyone would have an issue with things so far.  So let’s move on to the intubated patient who does not have a pneumothorax.  I am going to assume here that there is not a lot of airway resistance in our trauma patient (which is not to say they don’t have underlying obstructive pulmonary disease, anaphylaxis to the induction drugs you gave or a clot sitting in a big bronchus/ETT) as it makes the discussion a bit easier to assume that resistance is minimal (futile according to the Daleks) and the pressure you are seeing on your ventilator gauge is largely transmitted directly to the alveoli.

Looking at our transpulmonary pressure equation, unless the airway pressure and hence alveolar pressure is higher than about 5 cmH2O then the gradient at the time you open the pleura means air is going to enter the pleural cavity.  (If they have significant airway resistance this could happen with much higher airway pressures).

Just have a quick eyeball of this time pressure chart of a standard volume cycled ventilator with no PEEP (and a self-inflating bag will provide a similar though more variable trace).  And I deliberately have no PEEP in this chart.  PEEP is not likely to be the first thing we reach for in the hypotensive trauma patient we have just intubated where we are concerned about the possibility of a pneumothorax.

chart

With normal lungs the peak pressure here is probably about 20 cmH2O.  What proportion of the total respiratory cycle is the airway pressure (and hence the alveolar pressure in our patient with low airway resistance) likely to be below 5 cmH2O?  If your little prehospital ventilator has a roughly 1:2 I:E ratio as most do, then the answer is most of it.

In other words unless you have PEEP of at least 5 cmH2O even in your intubated patient the transpulmonary pressure is negative for a good half of the respiratory cycle.  During at least half the respiratory cycle, if you hear a noise as you breach the pleura you are hearing air rushing IN.

The elastic recoil of the lung is the reason that you feel the lung has collapsed by the time you pull the forceps out and put your finger in unless you have some PEEP in play.

Now I’m not saying there has never been a time when the air wasn’t rushing in. I don’t think much of the word “always” in medicine, remember? I’m just suggesting that what we know of physiology would argue that there is at least a solid proportion of the time where that transpulmonary pressure gradient is negative when you breach the pleura, which means that there’s likely to be a good proportion of cases where those “certain” clinical signs become less reliable.

For a demonstration of this with the mother of all open thoracotomies (in a cadaver) check out this video.

The cadaver is intubated, a “generous” pleural decompression wound has been created, and on each expiration the lung collapses right down unless PEEP is applied.  And note the collapse is complete on each expiration.

As long as the thoracostomy is big enough to freely communicate with the air (and if you are relying on the open “finger” technique rather than putting in a drain it needs to be large or they may re-tension), when you put your finger in during expiration the lung will be collapsed unless there is a reasonable amount of PEEP splinting things open pretty impressively.

It will be collapsed whether it already was before you made the wound or whether it happened as you spread the forceps and made the communicating hole.  The time between making the hole and getting that sense of lung up or lung down with the finger is ample time for the lung to collapse down. It seems like this particular clinical sign probably tells you nothing about the state of play prior to the wound being made.

So noises can be deceptive and feeling a collapsed lung just means that the lung recoiled as the pleura was opened.  Can you even guarantee which phase of the respiratory cycle the patient was in when you made that hole? Unless you had at least 5 cmH2O (and maybe more) PEEP on at the time you breached the pleura neither of these signs necessarily means anything.

allan-henderson
Maybe none of us can trust our big ears?

Now, what?

Again, I’m not really into saying things like “always” or “never”. What I’m suggesting is that there might be a lot more grey around these clinical signs than might first seem to be the case.

So how do you know if they had a pneumothorax? For me that is almost always by ultrasound now.  I don’t know how I managed for 15 of those 20+ years of prehospital care without one.  Sometimes of course the scan is equivocal and you need to make a call based on the signs you see and the condition of the patient but I find this to be very infrequent with a good high frequency linear probe.

And as for tension the hallmark is abnormal physiology, particularly blood pressure.  If decompressing the chest fixes the physiology then they had a tension.  If it does not then they had a simple pneumothorax – or none at all.  Because the noise you heard as you breached the pleura may have been air either entering or leaving the building, hearing a noise does not help you either way.  Was Elvis ever in the building at all?

 

Notes:

I had the brilliant Dr Blair Munford review a heap of the physiology here to make sure it matched up.

After that link to the LITFL bit on transpulmonary pressure again? Then go right here.

And John West’s masterpiece (well at least the page mentioned) is here.

That image of Nahni with the big ears was posted to the Creative Commons part of flickr by Allan Henderson and is unaltered here.

Oh, and in case you didn’t know the truly amazing John West, Adelaide boy made good, has recorded his whole lecture series for you to go and watch. Because when you’re in your 80s you’ll probably be contributing to medical education like that too, right?

I Wish I Knew Then What I Know Now (Edition 2 – Packs)

Continuing a theme started with a practical post on direct and indirect pressure for haemorrhage control, Greg Brown (Education Manager amongst other things) discusses the things he’s learned about how to figure out what you need in a kit. 

I remember the first time as a young Nursing Officer in the Australian Army I went on exercise (that’d be “manoeuvres” for you Americans, and “war games” for those that watch too many movies) and had to pack a medical kit. Not knowing what was required for the job (and not asking either) I had earlier visited the field pharmacy with a request that was essentially “one of everything you have, please Ma’am”.

The result? I spent three days being cold, wet, hungry and slow – the sheer size and weight of my medical kit meant that I had not enough room for “luxuries” such as a sleeping bag, raincoat or enough food.

Now what?

So, what has changed over the years? Well, I’d like to think that a lot has changed. Firstly, I now have the experience to know that if I cannot do my job (because of issues pertaining to cold / heat / hunger / thirst / ability to keep up etc) then I am a liability and not an asset. I have also learned that the greatest skill ANY prehospital care provider can possess is the ability to improvise. And finally, I’ve learned that big ticket “Hollywood” style medicine does not keep people alive but that, as a popular Australian breakfast cereal advertisement from the late 1980’s stated so eloquently, “the simple things in life are often the best”.

It is important to realise from the outset that there are arguably more variables in life when it comes to medical kits than there are medical conditions that need treating. Okay, that is a bit of an exaggeration, but hear me out. When creating a medical kit the individual must ask themselves a series of five questions that will guide the size, contents and capability of their kit.

Question 1: Who will be using the kit?

If the answer is simply yourself, then you can afford to consider taking items that are your favourite but not necessarily everybody else’s preferred option (caveat: they still need to be evidence based and supported by your clinical practice guidelines / protocols). An example is in regards to airways: you might be an avid supporter of the iGel whereas I sit firmly in the LMA Supreme camp whilst there also exist individuals who like the King-LT. One could argue that they all do similar things and possess commonalities (e.g. blind insertion, semi-secure airway etc) yet they each require necessary knowledge, skill and attitudes in order to make them work. The solution, in this case, is standardisation – not three separate but similar airway devices.

Question 2: What is the kit expected to be capable of doing?

Within CareFlight we have many different lines of operation; for ease lets call them Sydney, Darwin, International and Off-Shore. So, take our Sydney operation – CareFlight Rapid Response Helicopter (CRRH). CRRH works as part of a wider retrieval network to service the Sydney basin. The majority of its taskings are to traumas and near drownings, so its kit reflects this. CRRH is unlikely to be tasked to a ketoacidotic haemophiliac with sepsis on a background of COPD. Why? It services the Sydney basin where there are also around 50 ambulance stations, each staffed with well trained, well equipped and well-motivated paramedics who are standing by to deliver the patient to one of a dozen equally well staffed / trained / equipped / motivated hospitals, that are available 24/7. If CRRH is treating and transporting this patient then it is because they’ve been ejected off of their motorbike whilst completing stunts at the local motocross track (again, perhaps a slight exaggeration for this particular patient), so the activation is to a trauma. CRRH’s kit must reflect this, just as the Darwin, International and Off-Shore kits must (and do) reflect their demographics.

The same goes for medical kits of a more “tactical” nature. If your tactical kit (the one you wear on your rig when conducting a deliberate action / breach / clearance etc, or every day because you are clever and “that’s how you roll”) contains a laryngoscope then I’d respectfully suggest that you’ve got it all wrong. Interventions in this environment need to be high yield and rapidly applied whilst allowing for the maintenance of situational awareness. If you are head down / bum up intubating, you are not accounting for your own safety. Besides, is the expectation now that this patient will self-ventilate? Or does your tactical kit also contain a self-inflating bag or mechanical ventilator?

Question 3: How long does this kit need to last? 

This is a question of stock holdings. When I think back to that first Army exercise in a medical role of mine I now ask myself “it was only three days long, so why did I need seven days’ supply of three different oral antibiotics – especially when we were within two hours walk of a field hospital?” My stock holdings were all wrong. Chatting with many others over the years (both military and civilian) I have found that this can be a common theme amongst pre-hospital care providers.

If some is good, more must be better, right? Wrong – more just means bigger, heavier and slower. Besides, if you brought it – you’re carrying it.

But what if one fails, won’t I need a second / third / fourth? To this I offer that if your plans are built around multiple failures in equipment then it is time to revisit your equipment list and look for alternatives that are more robust and reliable.

An important consideration when assessing how long your kit needs to last is: what is your mission? If your mission is to conduct humanitarian assistance in the wake of a natural disaster for a period of seven days then you are going to need a LOT of stuff – trust me, having deployed to a few natural disasters in my time you will require a very robust supply chain. But if your mission is to treat and transport one victim of that natural disaster at a time with a resupply between each mission then you don’t need that much gear. Besides, generally speaking the less you carry the faster (and further) you can travel.

Stock holdings are a balancing act. It is reasonable to build some redundancy into your medical kits (ever had that one vial of morphine in your kit smash when someone decided to use your kit as a stepladder?) but it must be balanced with the knowledge that if you brought it, you’re carrying it.

Question 4: Is the kit a “stand alone” or designed to be augmented?

Capability should be viewed in terms of three things:

  1. people;
  2. equipment; and
  3. the ability to effectively combine the first two points.

I learned a long time ago that I was never going to be the only person in a group with medical training. Every “operator” (e.g. police officer, fire fighter, soldier, aircrew member, emergency service volunteer etc) has basic first aid training (and sometimes much more) and many will carry their own supply of essential items (i.e. arterial tourniquets, bandages, gloves etc). In situations where medical attention is required, medical personnel need to utilise the capabilities provided by others.

It is always worth considering this concept of capability when forming your plan; planning to combine medical kits in order to create improved capability is a useful concept. Most military and paramilitary units do just this; as an example, the Australian Army’s Parachute Surgical Team (PST; now superseded) built its equipment plans around the “what ifs” of war and how to ensure enough capability without carrying a whole hospital worth of equipment.

What do I mean by the “what ifs”? Well, I’m glad I asked myself this question.

What if the plane carrying the equipment got shot down before we could drop the stores? Well, each member of the PST parachuted with a medical kit that, when combined with those that others carried, formed an interim resuscitation and surgical suite. What if a paratrooper and his / her kit went missing? Well, there were just enough team members to space out on separate aircraft to create two identical suites. What if a paratrooper required more than first aid on the drop zone or during the advance? Well, each kit also contained the stores statistically required to treat a battle casualty.

Each kit creates a capability; but when combined they can provide so much more. This is an important concept to keep in mind when designing your medical kit.

power-rangers
It’s a bit like the Mighty Morphin Power Rangers. Individually they don’t necessarily get the job done but when combined they offer … Spandex. And also getting things done.

Question 5: Can you actually carry it? 

Size matters. I’ve said it a few times already, but size really does matter – if you brought it, you’re carrying it.

For a medical kit to be effective it needs to be capable of getting to and travelling with the patient. Therefore, if it is so big and cumbersome (because you packed one of everything…and some redundancy) that you cannot get to the patient then you need to ask yourself “what is the point?”.

Now, I will freely acknowledge that different sizes are required for different tasks – in fact, I have four different kits in my personal armoury for four different purposes. Similarly, CareFlight has different sized kits for different tasks within its separate lines of operation.

So some things to consider include:

  1. Is this kit staying in a vehicle (if so, what type of vehicle?) or does it need to be portable by an individual?
  2. If it is portable, what else is that person carrying (e.g. a tactical kit will likely sit between other pouches / holsters on a belt or chest rig whereas a bigger kit may come with shoulder straps or need to fit inside another pack)?
  3. When packing it, how many pouches will you need to open in order to perform one intervention? (Note: the answer should be one; if your IV cannula, sterile wipe, venous tourniquet, securing tapes, bung, giving set and fluids are not together then you’ve got it wrong.)
kits
OK I may have a bit of a kit fetish but each one has a specific purpose in life. Beyond just making me happy even.

Summary

So there you have it. Added to the list of “things I know now that I wish I knew then” is medical kits. I now start with an analysis of the mission, draw out the likely tasks, consider the need for redundancy, look at what else I need to carry and consider the overall capability. What I don’t do is request “one of everything please, Ma’am”.

 

Notes:

This one is much more of a recount of personal experience so there aren’t a heap of links to send you to. It would be great if people could give examples of how they think about their kits and what they carry though. It’s a good bet there are clever people out there who would point out things that haven’t come up here.

Oh, and don’t forget if you like the stuff on here there should be a spot somewhere on the page that lets you follow along so you’ll get an email when a post goes up.

Tactical Medicine in the Civilian Setting – Part 3

The third and final instalment of this series has been a while coming. Nothing to do with being tactical just because “reasons”. Here’s Mel Brown following from part 1 and part 2 with, yes you guessed it because of precedent and it was written at the top there, part 3. 

In part one of this series we looked at what tactical medicine is, some of the history of tactical medicine (both military and civilian) and the three preventable causes of death within the tactical environment. In part two we looked at some of the models of infiltration for medical teams, specifically the “whos, hows and whats” of this topic. Now in part three we will look at the three phases of care as set out by the Committee for Tactical Emergency Casualty Care (C-TECC).

Not just “what” but “when”

Medical intervention is vital to saving lives in the tactical environment as 90% of tactical deaths occur prior to the casualty reaching a medical treatment facility. However, these interventions must be performed at a tactically appropriate time otherwise more injuries may be sustained and potentially more lives potentially lost. This is why the three phases of care (as set out by C-TECC) guide when certain interventions should be attempted.

Conventional EMS protocols don’t account for unsecure or high threat scenes and are solely patient focused without any acknowledgement of the surrounding operational or tactical constraints other than to assess for danger during the primary survey. This is why the C-TECC guidelines were developed; they guide patient care whilst taking into account the operational requirements of a high threat environment.

C-TECC guidelines should be seen as “guiding principles”; they are not rigid or inflexible like some current civilian EMS protocols. The three phases of tactical care are dynamic, often overlap and rarely work in a linear or isolated fashion. This is why it is so important to have a clear understanding of each phase so that fluid movement between phases is possible.

The Three Phases 

There are three distinct phase of care within the tactical environment that guide which treatment should be applied when. The three phase of care are:

  • Direct Threat Care
  • Indirect Threat Care
  • Evacuation Care

For those of you with a military background you may be used to these three phases being called:

  • Care under Fire
  • Tactical Field Care
  • Combat Casualty Evacuation Care

C-TECC changed the titles of each phase to ensure that they could be easily used in all high threat situations within the civilian setting. A high threat situation is not just the kinetic one (active shooter, blast) but includes building collapse, multi-vehicle accidents, natural disasters or even the rapid advancement of fire.

Let’s dive in a little deeper.

1. Direct Threat Care

The direct threat care phase exists whilst there is a continued threat directed towards both casualties and other personnel and the risk of further injuries and / or deaths is very high. Treatment during this phase is focussed on minimising further harm, accomplishing the mission, neutralising the threat and stopping catastrophic haemorrhage. There are minimal medical interventions delivered to the casualty in this phase. This is a foreign concept to most medical personnel.

The medical care provided in this phase is limited to controlling extremity haemorrhage and removing the casualty from the point of injury. This care can either be delivered via self-aid or buddy-aid. If the casualty is able to self administer first-aid then this should be encouraged so that the medical responder can care for the casualties that are unable to treat themselves.

A big part of the care in this phase may be simply assisting the casualty to a point of cover; after all, the casualty should never (look maybe that should be in capitals because never, never, never) be treated in an exposed area. Don’t treat on the street.  It is important to think about the choice of cover….good concealment doesn’t always equal good cover.

concealment

Early haemorrhage control is critical in tactical medicine as it accounts for the largest statistical group of preventable deaths. The C-TECC guidelines recommend rapidly controlling extremity haemorrhage in this phase and this usually defaults to the application of an arterial tourniquet. It is important to remember that any medical interventions in this environment need to be balanced with operational risk. This means that sometimes we can’t provide all the care we would to our patient it we were in a non-tactical environment.

Applying a windlass arterial tourniquet can rapidly, easily and effectively treat extremity haemorrhage. There are two such arterial tourniquets widely used in Australia and approved by the TGA – the SOFFT-W and CAT (and remember that first post in the series had a bit on tourniquets). Be aware that the latest CAT is a generation 7 and has some differences to the generation 6 – equipment familiarity is a must.

The arterial tourniquet must be applied as high as possible on the limb and over clothing as it is tactically unsound and time consuming to remove clothing to look for all wounds on the extremity within the direct threat care phase. The aim of treatment within this phase is to keep the blood where it needs to be! In simple terms if you don’t keep the red stuff on the inside then you may as well not bother with anything else as the best blood for the casualty is their own. Don’t forget to mark your casualty’s forehead with the universal sign for an arterial tourniquet, that being a “T” and the time.

Direct pressure should be considered if the environment allows it or if the casualty can apply direct pressure by him or herself. Applying effective direct pressure is time consuming and reduces the medic’s ability to treat multiple casualties. Haemostatic dressings are not considered in this phase and are deferred to the indirect threat care phase, as they require time to work (3 – 5mins of continuous pressure). This is why arterial tourniquets are seen as the most effective and rapid intervention for extremity haemorrhage within the direct threat care phase of the tactical environment.

The only other brief consideration in this phase is to airway. Put simply, this means that you may place the casualty in the recovery position when moving them to a safer position but only if it is tactically appropriate to do so and can be rapidly achieved (this is not a formal assessment of airway – it is simply positioning).

2. Indirect Threat Care Phase

The indirect threat care phase evolves once the responder and the casualty / casualties have moved to an area of relative safety. This relative safety may be provided by structures such as a wall, building, car etc. or by the presence of a tactical security force. Either way the tactical medic must maintain situational awareness whilst treating the casualty / casualties as the environment is dynamic and can change back into a direct threat situation rapidly and at no notice. Always be prepared to move instantly…..this means do not open all of your pack up and spread it out!

In some situations consideration must be given to the disarming of casualties, both friend and foe. If the casualty is unable to sufficiently control or secure his or her own weapon then the medic needs to render the weapon safe and remove it from the casualty. This action is paramount if the casualty is showing signs of altered mental status or head injury. This helps ensure the safety of you, other personnel and the casualties.

If there are multiple casualties then the tactical medic needs to complete a rapid triage that will sort the casualties into three simple groups:

  • Uninjured and / or capable of self-extraction
  • Deceased / expectant
  • All others

The uninjured or capable of self-extrication group should be encouraged to self-aid. This group (if able) may also assist in applying first-aid to other injured casualties. The deceased / expectant group should (if tactically appropriate) be placed away from the core group of casualties that are receiving care.

The “all others” group should be assessed using the C-ABC acronym (Catastrophic haemorrhage – Airway, Breathing & Circulation). The casualty / casualties need(s) to be reassessed to ensure that all interventions performed in the direct threat phase are still effective and needed as well as assessing for any unrecognised haemorrhage.

Removal of clothing and protective equipment should be kept to a minimum. However, the tactical medic needs to ensure that life-threatening injuries are not missed. Therefore, they must check under clothing, body armour etc. and ensure they inspect the casualty’s back.

Because body armour and clothing should not be completely removed (it is required in order to provide continued protection for your casualty) the casualty should be assessed for further injuries by firmly raking the whole body. When assessing under body armour only unclip one side of the armour and lift up (don’t completely undo or remove). Raking allows for identification of unseen wounds as the fingers will fall into divots due to the firm pressure being applied.

Haemorrhage control within this phase may include:

  • Direct pressure methods (an emergency bandage is useful for this);
  • Tourniquets for undiagnosed extremity haemorrhage; and,
  • Haemostatic dressings for non-compressible haemorrhage.

The emergency bandage is a useful tool within the high threat environment as it can be applied rapidly and ensures direct pressure is applied to compressible haemorrhage (See the picture below). The combine found within the bandage has a rumoured capacity of 400mL (note: our experience is closer to 250mL – which is still a lot!) and the pressure device can apply up to 13.6kg (30lbs) of pressure onto a wound.

emergency-bandage
Probably a pretty effective way of soaking up spills around the house too.

If you don’t have such a device available or you run out of resources it is extremely simple to improvise this device by following the four steps below:

4-steps

For further information on direct pressure methods you could link at the post that is totally on that right here.

Haemostatic dressings are an effective method of controlling non-compressible haemorrhage, compressible haemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation times are anticipated to be prolonged). Currently there is only one haemostatic dressing approved by the TGA for use in Australia, this is called QuikClot Combat Gauze.

QuikClot Combat Gauze is impregnated with kaolin, an inert mineral found in some clay, specifically clays from tropical areas. Kaolin is a potent activator of contact (intrinsic) clotting pathways that accelerates the initial onset and speed of clot formation. Further information on QuikClot and its use will be available on the Collective as part of a future post of the ongoing series titled “I Wish I Knew Then What I Know Now!” If you want information sooner our Education team would be happy to share its one page handout – contact them by leaving a response to this blog.

What about the Airway?

Airway management in the high threat environment must be high yield and take minimal time to implement. That means the intervention might be as simple as applying a jaw-thrust or positioning the casualty to open the airway. The position chosen for the casualty (recovery or seated position) will depend on a few things, some of which include:

  • The current tactical situation (this has a massive impact on what position may be used for anyone as it may not be safe to sit your patient upright).
  • The conscious level of your casualty (unconscious vs conscious but with airway concerns).

The only piece of plastic that is considered in the high threat environment is a nasopharyngeal airway (NPA). NPA no longer has the contraindication of basal skull fracture…..believe it or not. It is now considered a relative consideration when basal skull fractures are suspected (or known). I put to you that the reason why one or two have been caught on CT or x-ray in the wrong spot is purely and simply due to poor technique. The best tip I can give you here is aim in the direction of the ears NOT the eyes!!!

NPAs are far more useful than Oropharyngeal Airways (OPA) in an overwhelming situation where you are unlikely to remain solely with one casualty. NPAs allow for airway support through all stages of unconsciousness to consciousness, unlike the OPA that will be spat out by the casualty as soon as their gag reflex returns (but not always with a return of complete airway control by the casualty).

And getting on to breathing …

Assessment of breathing cannot always (actually put it in the “rarely” category) be done through the traditional means most healthcare professionals are used to in the hospital setting. The ability to listen to breath sounds is diminished considerably due to noise, protective gear (body armour, clothing) etc. and the fact that an ongoing tactical situation is likely to be noisy. Therefore, it is important to remember to use your observation skills and sense of touch. Assess the quality of the chest wall movement – is it equal, does the left side look the same as the right side, is it moving as you would expect?

It is important to assess the casualty’s chest and back thoroughly. This is the only way you can be sure that there are no open chest wounds or obvious chest injuries. So make sure you lift up body armour then look, feel and rake firmly to ensure you don’t miss any injuries!

If during your assessment you find an open chest wound it is important to cover the wound with an occlusive dressing. The general rule of thumb is any wound between the umbilicus and the shoulder should be covered with an occlusive dressing. There are many commercially made chest seals on the market (e.g. Ashermans, Halo, Russel etc.) or you can used improvised ones – one improvised seal that is usually readily available is defibrillator pads. No matter what you use, just make sure it sticks and that you have cover both the entry and the exit (if there is one) wounds.

An important point to remember is that even if you use a vented seal, it is likely to clog up with blood or fluid quickly. This means it will lose its ability to allow air to escape from the casualty’s chest. Therefore, it is a useful to get into the habit of checking for signs of an increasing pneumothorax regularly even if you use a vented seal. If the casualty starts to display signs of an increasing pneumothorax it will be necessary to “burp” the biggest chest wound. This is achieved by manually forcing air out of the chest by compressing the rib cage (with the seal removed enough to expose the wound). Once the air has been manually expelled replace the seal whilst the downwards pressure is still being applied.

The only invasive intervention considered here for a breathing problem is that of needle thoracocentecis (or decompression). There is no time nor should there be any consideration given to more advanced interventions (e.g. finger / tube thoracostomy). Always remember the indirect threat phase can quickly and without warning return to a direct threat phase.

Casualties who fall victim to penetrating or blast injuries that do not exhibit signs of life are most likely to have exsanguinated, or “bled out”. In these cases commencing CPR is unlikely to revive the casualty as the most likely cause of their cardiac arrest is insufficient circulating blood volume – compressing the heart will not circulate blood if there is no blood left.

This is not a hard and fast rule though – if this casualty is your only casualty and the tactical environment permits then it may be in the best interests of your team and bystanders to be seen to be doing something for the casualty. Furthermore, if your medical team is immediately available and possesses appropriate resuscitative equipment (such as the ability to “plug the hole” and perform a blood transfusion) then the commencement of CPR may be warranted. Again, C-TECC produce guidelines, not rules.

Always remember to reassess your casualties as frequently as possible. It is important to rapidly acknowledge the deteriorating casualty and to ensure that all interventions performed remain both effective and necessary. Once the environment starts to settle it is important to consider documentation (this may be as simple as writing on the casualty in permanent marker) and packaging the casualty as they will require moving to an evacuation point at some stage.

Some Notes on Triage and Organisation

Triage in these overwhelming situations needs to be simple and understood. You will not have the cognitive ability to follow complicated processes in this environment. There are many systems of triage in existence. In the presence of a mass casualty situation the CareFlight triage system has been assessed as being a simple yet effective method (as it effectively triages both adults and children). This system has been adopted by many agencies around the world including certain militaries (who shall remain unnamed, you’ll just have to trust me there).

The CareFlight Triage system is a simple system that can be used by people with minimal training to determine whom should be treated when.  If casualties are able to walk (this is walk, hop or crawl) then it can be assumed their ABCs are all satisfactory (at least for the time being) and they can wait or even be transported in groups by simple means (e.g. bus) to a staging area / hospital. To put it bluntly, if you can walk then you have reasonable perfusion, irrespective of your injuries.

Casualties who do not obey commands and don’t breathe when their airway is opened are deemed unsalvageable in this setting.  However, remember that this only applies when resources are overwhelmed; if you have a single casualty then you may consider continuing full active treatment.

If the casualty is requiring airway manoeuvres for them to breathe or have no radial pulse, suggesting poor perfusion, then they have the highest priority for treatment (i.e. immediate). The other group of casualties that cannot walk, but can obey commands and have a radial pulse should be treated as soon as possible (i.e. urgent). See below for the CareFlight Triage – Mass Casualty Card.

triage

Experienced TEMS personnel have found that a lot of time is being spent on the re-triage of deceased casualties. Some injuries in the light of reflection are easily seen to be non-consistent with life, yet in the tactical environment people will re-triage these casualties many times. Therefore it is important to consider positioning the deceased casualty in a respectful yet distinctive position (that all personnel know as the sign for deceased) to indicate they have been assessed and are considered deceased.

The position recommended by Threat Suppression in the USA is to place the casualty on their back, legs crossed at the ankles, arms straight up (above head) with wrists crossed. This will help ensure the casualties that require treatment and that we can potentially save are assessed as quickly as possible.

If you are involved in setting up a Casualty Collection Point (CCP) then it is important to keep your casualties and equipment together. This minimises time wastage and allows for easy access to both the casualties and resources. It is important to ensure that you think about setting up in a protected area which gives you easy egress (escape) points as well as allowing you to maintain a good visual of any threat entry point. Here are two set-up examples:

setup-1

setup-2
There’s not a single solution but the principles stay the same

3. Evacuation Care Phase

This phase of care takes place in a safe location removed from the tactical environment. In theory, once the casualty is loaded onto the evacuation asset or moved to the pre-staged evacuation point they should be departing the scene of any threat.

Prior to commencing the evacuation all previously performed interventions should be reassessed and, where required, bolstered. Good packaging of the casualty here is vital to ensure all interventions remain insitu.

Spinal immobilisation is becoming more and more controversial as more reviews of the literature come out. Some services no longer place cervical collars as they don’t immobilise the neck effectively and make airway control difficult. However, consideration of spinal injuries should still occur and the casualty should be packaged appropriately (in accordance with local practice) for these injuries.

More resources should become available during this phase. There should be an increase in:

  • Personnel (medical, logistical, tactical)
  • Equipment
  • Medical supplies

Other considerations include: large bore venous access or intraosseous access; further assessment and administration of analgesia and fluid replacement; and if prolonged holding or transport times are expected then consideration may be given to the administration of antibiotics.

It is important to remember in this phase that only interventions that are needed should be performed. If the casualty does not need a chest tube then they should not receive one just in case. These unnecessary interventions will lead to a choke point within the flow of care and will delay casualties getting to where they need to go – the hospital!

The Summary

In broad terms, casualties in a tactical environment will fall into three categories:

  1. Casualties who will live regardless,
  2. Casualties who will die regardless, and
  3. Casualties who will die from preventable deaths unless proper life-saving steps are taken immediately.

The guiding principles of Tactical Emergency Casualty Care exist for the purpose of eliminating preventable deaths. Remember never “treat on the street” and that the right procedure performed at the wrong time or place might result in further casualties, injuries and death. If all we can do is treat extremity haemorrhage (tourniquets) and tension pneumothorax then up to 94% of preventable deaths may be avoided.

Notes and References:

Here’s a few of the more useful references you’ll find out there.

Tactical Emergency Casulaty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments, 2011, Callaway DW et al, Journal of Special Operations Medicine, vol. 11, Edition 3.

How to Develop Tactical EMS Protocols, 2014, Carhart E

Afghanistan Casualties: Military Forces and Civilians, Chesser SG, Congressional Research Service, 2012

Death on the battlefield (2001 – 2011): Implications for the future of combat casualty care, 2012, Eastridge BJ et al, Journal of Trauma Acute Care Surgery, vol. 73, no. 6

A Guide to U.S. Military Casualty Statistics: Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom, Fischer H, Congressional Research Service, 2014

Combat Casualty Care, 2010,Katoch BR. Medical Journal Armed Forces India, Vol. 66, no. 4

Introduction to Tactical Emergency Casualty Care, NAEMT.org

Resident Involvement in Civilian Tactical Emergency Medicine,2010, Ramirez ML et al, Journal of Emergency Medicine, vol. 39, no 1

A New Response supporting paradigm change in EMS’ operational medical response to active shooter events, December 2013, Smith ER (Jr) & Delaney JB, Journal of Emergency Medical Services

Lessons learnt and battlefield innovations from the Middle East Area of Operations, Stephenson J. 2008, Journal of Military and Veterans’ Health, vol. 16, no. 4

Learning from tragedy: Preventing officer deaths with medical interventions. Sztajnkrycer MD. 2010, The Tactical Edge, Winter 2010

Tactical Combat Casualty Care Handbook, Center for Army Lessons Learned Supporting the Warfighter.

And if you were interested enough to get this far, maybe it’s time to fill in your details so you’ll get an email update whenever there’s a new post.

 

Unexpected at 24,000 Feet

Contributors Dr Toby Shipway and Flight Nurse Jodie Martin return with a little about something that would make any retrievalist sweat – delivering babies in the air. 

A call came into the Logistics Coordination centre from a nurse in a remote health centre, worried about new contractions in a pregnant woman who was 31 weeks pregnant. We decided to take a full retrieval team for the ‘just in case’ scenario.  Afraid of getting caught out, we had a big discussion to make sure we had all the right gear on board the aircraft and what our plan of action would be should we be faced with the rare event of an inflight birth. Why worry though? They’re rare, right?

We retrieved the woman from a remote airstrip and it became evident just after takeoff that she was in established labour. Even after tocolytic therapy, the preterm baby was born at the start of descent into Darwin. No one on the plane will forget the midwife examining the patient, looking up wide-eyed and shouting calmly down the plane ‘its coming out now’.  Never has a pilot descended at such a pace. After initial resuscitation of the baby, both mum and baby did well and were transferred safely to the hospital. Phew.

After this, we started researching how many in-flight births had been registered during CareFlight’s tenure in the Northern Territory (NT). This became the basis for a recent case series publication in the Airmedical Journal.

img_4028
The sort of view you don’t get to enjoy when it starts getting imminent.

The Big and Little Numbers

Four cases were found on searching through the database over a four-year period from 2011 to 2015. Over that four-year period there were 1311 retrievals associated with Obstetrics and Gynecology, out of a total number of 15967 retrievals in the NT. This means obstetric and gynecology related retrievals account for approximately 8.2% in our aeromedical retrieval service.

Looking at the obstetric retrievals in more detail, there were 436 cases associated with pre-term labour of which 4 progressed to in-flight births. This equates to an incidence of 0.92% of all women transferred in preterm labour. It is not a common clinical situation.

These numbers are similar to a paper from Ontario, Canada1, which showed an incidence of 2.25% (11 in-flight births from 488 pre-term labour patients over a 5 year period). A paper from RFDS in Western Australia from 20122 showed no in-flight births over a 26-month period, with 500 cases of women at risk of pre-term birth included. Our four cases aren’t the only ones happening in Australia though. There was a preterm birth on an aeromedical aircraft over the Bass Strait recently.

What About Those Cases Then?

Here’s a brief description of each of those 4 cases.

Case one was a 37 year old woman of gestational age 36+5 weeks, gravida 5 para 2. The retrieval was tasked in the early hours at 0010. Take off was at 0050 and contact was made with the patient at 0145 at the airstrip. She was contracting 3:10 at this point. Tocolytics had been administered according to protocol, which was 3 separate doses of nifedipine 20 mg initially, at 30 mins and at 1 hour.  Return takeoff was at 0210 with progression to spontaneous vaginal delivery of the baby at 0245. 10 unit of syntocinon was administered intramuscularly with approximately 300 mL of blood loss measured with delivery of the placenta. Apgars of 61 and 95 were recorded. Both baby and mother were discharged at 3 days from hospital with routine follow-up from the community nurse.

Case two was a 25 year old woman of 31week’s gestation, G2P1 – this was the case from the top.  Again this was an early morning flight, tasking was at 0052 and take off was 0128.  Patient contact was made at 0250, where the patient walked onto the plane contracting 1:10. The clinic team had given nifedipine as per protocol. Return takeoff was at 0300 with progression to spontaneous vaginal delivery at 0400. Apgars were 61 and 85 with the baby needing some supportive ventilation. Mother and baby were transferred to hospital where on assessment in the neonatal unit positive pressure ventilation was stopped. Length of stay for this little one with intrauterine growth retardation was 22 days; there were no complications with the mother.

Case three was a 31 year old woman of 22 week’s gestation, G6P2. This one came up in a previous post as it involved a complicated resuscitation of mother and baby. The midwife was en-route back to home base on another task when the referral call to divert to this case was made. This again was in the early morning with the re-tasking occurring at 0330. On assessment at 0450 the patient was contracting 3:10, and the clinic reported a large clot was passed in clinic. Return takeoff was at 0500, with progression to spontaneous vaginal delivery at 0522. Apgars were recorded as 61 55 510 as neonatal resuscitation was ongoing. The mother delivered the placenta at 0548, which was accompanied by a PPH of 1 L dropping maternal BP to 42/38. Fundal massage and a blood transfusion were started. On landing the retrieval team was met by a ground crew – the neonate was transferred in a separate ambulance with ongoing resuscitation by the Medical Retrieval Consultant and a flight nurse. On reaching the Emergency Department the multi-disciplinary team decided to cease resuscitation of the baby at 0645. The mother received further blood products and stayed in hospital for 4 days.

Case four was a 26 year old woman of 28+5 week’s gestation, G2P1. This was the only retrieval in daytime hours with tasking at 1040 and take off recorded as 1135. The retrieval team went into clinic on arrival, making contact at 1245. On assessment the patient was contracting 1:10. Return takeoff was at 1345 and patient passed a large blood clot at 1410 with rapid progress to spontaneous vaginal delivery at 1418. Apgars recorded were 61 95 and some respiratory support with nasal high-flow was given. The placenta was passed at 1425 and the total blood loss was estimated to be 250 mL. The patient had no documented cardiovascular instability. The patient and baby were transferred to hospital with no further issues. However the baby stayed in hospital for 66 days needing long-term respiratory and feeding support. It was diagnosed with a dilated cardiomyopathy and on follow-up review was listed for a heart transplant.

 

What About the Treatment?

All women received the recommended preterm labour treatment, being intravenous antibiotics and steroid therapy. Three out of four patients received tocolysis – the fourth case did not as the blood clot passed in clinic was deemed a contraindication. It was reported vaginal examinations upon referral were conducted in 3 out of 4 of these cases. Interestingly, the reports of those examinations found the cervix to be closed or an undetermined dilation.  It goes to show that despite our best estimates from a physical examination we need to be prepared that inflight birth may in fact occur, even though it is a rare occurrence.

In transferring women in pre-term labour, the aim is to keep the baby in utero, as the evidence relevant to our setting indicates that in utero transfer is associated with much improved maternal and neonatal outcomes. The NT has a particularly high proportion (10.6%) of preterm births prior to hospital arrival and although multifactorial the large distances are likely to play a significant role.  Prompt retrieval and the involvement of a team with the right skill mix to make a detailed obstetric/midwifery risk assessment would hopefully lessen the chances of inflight birth. But very rare still doesn’t mean never.

Notes:

Here are those other papers again:

McCubbin K, Moore S, MacDonald R. Medical transfer of patients in preterm

labor: treatment and tocolytics. Prehosp Emerg Care. 2015;19:103e109.

and

Akl N, Coghlan EA, Nathan EA, Langford SA, Newnham JP. Aeromedical transfer

of women at risk of preterm delivery in remote and ruralWestern Australia: why

are there no births in flight? Aust N Z J Obstet Gynaecol. 2012;52:327e333.

and of course the trigger paper from our NT experience is here:

Shipway T, Johnson E, Bell S, Martin J, Clark P. A Case Review: In-Flight Births Over a 4-Year Period in the Northern Territory, Australia. Air Med Journal. 2016;315:317-20.