Well everyone else is doing the “look back, look forward” thing, so why not us as well?
It’s that time of year. You know, the one where we just want a few more days to kick back and relax or enjoy a southern hemisphere summer. What better way to look busy than a review of the posts that got the hits in 2017? Ssshhh. There may well be better ways but this is what we’re going with.
First up, music for the ears
Podcasts. People do them and people listen to them. Clever people do them regularly. We are not that clever it seems. We did finally get around to putting up a couple this year though and the most recent one was very comfortably the most popular podcast we’ve done. OK, it’s a field of four but it’s not nothing.
The podcast features Dr Blair Munford. Blair has been in the retrieval and prehospital field since the mid ’80s. He has stories. Lots of stories. This story is his though and in it you get to hear a little about what it’s like on the day you’re getting picked up by the helicopter. So maybe have a listen. Lots of people obviously thought it was worth it.
The Not Very Final Countdown
We’re not packing up or anything so it’s nothing like a final countdown, but is there a theme amongst the posts that people seem to click on the most? Well let’s see. Here are the 10 top written posts through 2017:
9. Tactics for hostile places – Tactical Medicine still going strong
The series on tactical medicine dates from 2016 but still gets plenty of interest. The third instalment just keeps clocking up the hits (and provides an easy link to chapters 1 and 2). People just want to know about phases of care I guess. If you like that you might also find this conference update worth your time too.
8. An old classic – little kid RSI
A couple in the year’s top 10 were all about kids which is a pretty pleasing thing. The care of kids isn’t just about shrinking stuff from adults and there’s plenty to gain from being kid friendly. This post went over the reasons that the approach to RSI in kids has changed and what we should be trying to focus on.
7. Necessity and the mother of invention
As much as we like kits sometimes you have to be flexible. This post on how to use what you have when you just have no choice is designed for when you’re stuck in one of those moments that will make you thank your gods for your real equipment when you’re back on a real job. Tourniquets? Check. Pelvic binding? Check.
This practical post on putting cannulas in little people certainly grabbed some interest. Maybe it will help out next time you’re facing a procedure that can cause pain at both ends of the needle.
3. More physiology when you pick a person up
This post comes from 2016 as well but it just keeps people coming up. A topic not covered that much elsewhere, but the physiology of a patient being winched is certainly relevant to lots of people in the rescue space.
2. In a bind
What is it about pelvic binders that gets people coming back for more. Our long running series on pelvic binders got a boost with number 5 which covered a case where the binder really probably didn’t help. You could drop by and end up down the rabbit hole of the other 4 posts with those links at the start of it.
1. Back to basics
And the top spot for 2017 goes to one of those great posts that covers things we often think of as basic but which might just make the biggest difference to patients – “basic” airways and adjuncts. Maybe you’d like to drop by this edition of those things we wish we’d known way back when we started.
So that’s the list. And the theme is pretty clear. People like practical things. And physiology. And things about kids. And things that touch on the literature. And … actually people probably just like all things prehospital and retrieval. Better get back to it.
The image from unsplash.com was posted just like this by Neil Thomas.
First up is a big thank you to my co-author Pieter van den Berg from the Rotterdam School of Management in the Netherlands. Pieter is the real brain behind the study and the mathematician behind the advanced modelling techniques we utilised. Pieter has looked at HEMS base location optimisation previously in Norway and has done some modelling for Russel McDonald’s service Ornge in Ontario, Canada as well. Without him the study would not have been possible.
So what did we do and why?
As already noted Pieter had recently done a similar exercise in Norway where the government has a requirement that 90% of the population should be accessible by physician staffed ambulances within 45mins. Pieter and his co-authors were able to demonstrate that the network of 12 HEMS bases easily accomplishes this – indeed it could be done with just four optimally positioned bases. They also modelled adding and moving bases to determine if the coverage percentage could be optimised with some small adjustments.
As it happens New South Wales (NSW) and Norway have very similar population densities and both are developed, first world jurisdictions. Hence this previous study seemed a good place to start for a similar exercise in NSW. Both jurisdictions also have geographical challenges; Norway is long and thin with population concentrated at the southern end whereas NSW has almost all the population of the state along the eastern coastal fringe with high concentration along the Newcastle – Sydney – Wollongong axis.
We were interested in population coverage but we also wanted to look at response times as this also is a key performance indicator for EMS systems. It is certainly reported as a key indicator by NSW Ambulance. Response times were not modelled in the Norwegian system so we were interested in seeing how the optimum base locations varied depending on the question that was asked, particularly in a jurisdiction such as NSW where the population is so concentrated to a non-central part of the state.
If you look at the study you will note from Figure 1 the existing arrangements in NSW. You’ll be shocked to know these arrangements weren’t planned in advance with the aid of a Dutch maths guru. These things happen organically. Nevertheless it provides a reasonable balance of response times and coverage although the gap on the north coast is immediately evident.
If you start with a clean slate and optimally position bases for either population coverage or average response time, both models place bases to cover that part of the coast (see Figure 2). Hardly surprising. When we modelled to optimise the existing base structure by adding or moving one or two bases, the mid north coast was either first or second location chosen by either model too.
This seems an obvious outcome from even a glance at the population distribution and current coverage in Figure 1. What is surprising is that the 2012 review of the HEMS system in NSW (not publically released) which utilised the same census data in demand modelling did not come to the same conclusion when two previous reviews in the 1990s and 2000s had recommended just such a change. Certainly the Reform plan for helicopter services which was released the following year did not make any changes or additions to base locations leaving this significant gap still uncovered.
Wagga Wagga was the other location identified for a HEMS base in the 2004 review. Interestingly it is favoured as the first relocated base when the existing structure is optimised for average response time by moving Canberra to this location. But a Wagga Wagga base also was not mentioned in the reform plan.
What about the green fields?
When the green field modelling was done it is clear that the current NSW system mostly closely resembles the model optimised for average response time, rather than coverage. The Wollongong base really justifies its location on this basis as it contributes to a better overall average response time. Its population coverage falls entirely within the overlapping circles of the Sydney and Canberra bases so it makes no contribution here, at least if a 45min response time is used as the standard.
There was another aspect that interested us compared with Norway. In Norway all aircraft have the same capability and this is also true for the recently tendered services in NSW. The unusual feature in NSW though (unique to Australia although common in Europe in particular) is a dedicated urban prehospital service operating from a base near to the demographic centre of the largest population density – Sydney. The performance characteristics of this service have been well described (by us, because I’m talking about the CareFlight service which I think does serve a useful function) previously and when it was operating with its own dispatch system was the fastest service of its kind in the world to our knowledge.
Like the Wollongong service it operates entirely within the population coverage circles of other bases, but it makes an enormous contribution to average response time. When this rapid response urban service is added to the network of large multirole helicopters in NSW the average response time across the entire state falls by more than 3.5mins because that service is able to access more than 70% of the state population within its catchment zone, and significantly faster than the multirole machines.
This modelling only takes into account the response time benefit of the specialisation afforded by such as service. We have previously been able to demonstrate that the service is also much faster in almost every other aspect of care delivering patients to the major trauma services in Sydney only a few minutes slower than the road paramedic system but with much higher rates of intervention and ultimately passage through the ED to CT scan faster than either the road paramedic or multirole retrieval systems in NSW. At least this was the case when it had its own specialised dispatch system but that is a story we have discussed previously too.
There are recurrent themes here. The Rapid Response Helicopter service adds significantly to the response capability in NSW whether you model it using advanced mathematical techniques or whether look at the actual response data compared with the alternative models of care. Indeed the real data is much stronger than the modelling. It seems that at least in large population centres in Australia there is a role for European style HEMS in parallel with the more traditional multirole Australian HEMS models that service the great distances of rural and remote Australia. Different options can work alongside one another to strengthen the whole system and better deliver stuff that is good for patients – timely responses when they really need them. The capability differences however need to be reflected in dispatch systems that maximise the benefits which come with specialisation rather than a one size fits all tasking model that takes no account of those significant differences.
Every version of the numbers I look at tell the same story.
Notes and References:
While this post covers a few ways of looking at a tricky sort of problem, there are lots of clever people out there with insights into how these things work. If you have ideas or examples from your own area, drop into the comments and help people learn.
Now, the paper that’s just been published is this one:
OK it’s a few weeks back, but here’s Greg Brown with the lowdown on a conference about tactical matters.
Conferences: a formal meeting of people with a shared interest, typically one that takes place over several days; the means by which professionals from around the globe congregate with a view to learning from each other. Sometimes also referred to as junkets, jollies, paid holidays and tax write-offs.
But in all honesty, oftentimes the only way one can be afforded the chance to be surrounded by like-minded professionals with a view to learning from the experience of others, benchmarking your intellectual property against that of other organisations operating in the same “space” and refining your knowledge thanks to the latest in international research is to travel to the other side of the world and attend a conference. So, as one of the few non-government providers of tactical medicine training in Australia, that’s precisely what we did.
In mid-October 2017 two of CareFlight Education’s staff travelled to sunny (well, we assume there was sun above the pouring rain) Sundsvall, Sweden, to attend the inaugural Tactical Trauma conference. If you are on Twitter, you can search for it using #TacT17. If you are not on Twitter, then join Twitter and search for it using #TacT17….
This post provides a summary of what we found, what we liked, what we didn’t like and some takeaway points.
This was truly an international event. Presenters came from across Europe (with a strong Scandinavian presence, as expected), North America, the Middle East and even Australia. Participants included both hospital and pre-hospital doctors, nurses, paramedics, police medics, retrieval (road and air) clinicians and military folk.
The Stuff to Chew On
As the name “Tactical Trauma” suggests, the conference was focussed on the medical management of trauma with a tactical twist. It should be noted that discussions regarding any tactical imperatives were limited by the realities of operational security. For obvious reasons, nobody wished to describe their unit’s tactics in great detail. They were enough to paint the scene though.
Therefore, if you were looking to learn how to become the next big thing in SWAT team medicine then this conference probably wasn’t for you – and there certainly were no skill sessions on how to kick in doors, breach a terrorist stronghold or fast rope from a helicopter (although these might be popular sessions next time).
Rather, focus was placed on the provision of “good medicine in bad places”. There were sessions by military doctors discussing what worked (and what didn’t) on recent deployments (including topics such as blast injuries, penetrating chest injuries and rates of injuries in dynamic events), the usefulness (or otherwise) of helicopter emergency medical services in hostile mass casualty events, comparisons of contemporary haemostatic agents versus conventional bandages in wound packing, the perils of acute traumatic coagulopathy, discussions on vascular access options, and the progress over the years in the application of clinical management strategies. It is also worth noting that since this is in fact 2017 no medical conference would be complete without at least one presentation on POCUS (that’s Point Of Care UltraSound – and yes, it is very useful) and one on REBOA (or Resuscitative Endovascular Balloon Occlusion of the Aorta – and no, there is not enough evidence to definitively support it); these were dutifully attended to.
Case studies are always useful; in this instance we were treated to reviews by the Finnish and Norwegians of their tactical emergency medical support systems, the Israelis and their medical response to contemporary domestic contingencies and both the French and Swedish on their responses to recent mass casualty events. There were also a few “closed door” sessions for police medics regarding recent mass casualty events in the USA.
But finally, as most of us already appreciate, being outstanding at your trade is only part of the job; the ability to communicate effectively with your team members whilst managing your own stress levels are also vital in providing optimal patient care. As such, sessions on crew resource management skills, the cognitive revolution, tips for centring one’s self prior to and during a job, and how to get the rollout of good ideas actually rolling were welcome additions to the program.
Things We Liked
Firstly, whilst it is obvious that military experiences inform civilian practices, we appreciated the fact that this conference was focussed on civilian (not military) practice. Other conferences of the type claim to do this yet the majority of the auditorium is filled with uniforms of various militaries.
Secondly, sessions were kept at a length that were short enough to retain audience attention but long enough to cover the required level of detail for the given topic. If a topic was not floating your boat, a new topic would commence in 20 minutes.
Thirdly, at no point did we hear “you must do it this way – if not, you are wrong”. The overall feel of the conference was that no single entity had all the answers but that through collaboration we can all improve. Participants were encouraged to seek out presenters (who were all easy to find) and undertake collaboration.
Finally, the focus was on “good medicine in bad places” and not cool Velcro patches, the latest fashion in tactical gear (which would obviously only come in black and be stamped with a label consisting only of numbers) and the liberal application of mutual back-slapping.
Things That Were Not the Business For Us
Despite the fact that the conference was aimed at civilian practice, the majority of presenters referred to TCCC (Tactical Combat Casualty Care) and not TECC (Tactical Emergency Casualty Care). It is possible that the presenters were using the term TCCC out of habit, but when one considers that the latest review of TCCC by the Committee has lead to their terms coming closer into line with that of TECC (and not vice versa), it is time that the world started embracing the correct terminology.
Having a single track makes it hard to keep everybody interested, and at times we felt sorry for certain members in the room. These folks included frontline police officers who have a secondary role of medical response – whilst the clinicians were riveted by the maps of clotting cascades and stories of roadside REBOA, the Police Medics just wanted to know (a) how best to plug the hole, and (b) how fast to drive.
[Note: we got the impression that the conference convenors were victims of their own success – we are not sure they realised just how popular it might be when they originally floated the idea on social media. We are confident that this issue will be alleviated next time.]
If you had to sum up the content of a jam-packed two-day conference in just a handful of points then these would be them [note: these are more paraphrases than quotes]:
“Learn from the experiences of others. Recognise that no single agency has all the answers, so work with and not against each other.” Matt Libby, flight paramedic with Boston Med Flight, USA
“In resuscitation, the most effective therapies are those that can be applied quickly. Time is blood.” Dr Richard Dutton, trauma anaesthetist, USA
“You can possess all the best haemorrhage control devices in the world, but if you are not using them properly then they are worthless. Training is key.” Dr Mark Forrest, medical director of ATACC, UK
“Battlefield medicine is like plumbing: if it’s blocked, clear it; if it’s leaking, plug it.” Gary Grossman, CSAR paramedic, Israel
“In a high risk or major incident, it makes sense to have all rescue agencies working together under a common SOP that has been tested prior.” Dr Stephen Sollid, medical director and retrievalist, Norway
“REBOA has a place in pre-hospital care; we are just not quite sure what that place is. Blood will still be lost from backflow.” Dr Tal Hörer, vascular surgeon, Sweden
“Medics in the hot zone should focus on not getting themselves killed and not endangering the mission. Cross training is vital.” Dr (LTCOL) Ishay Ostfeld, IDF and cardiothoracic surgeon, Israel
“In a critical patient, performance of life saving interventions should take precedence over applying rigid protocols around immobilisation.” Dr Thomas Dolven, intensivist and retrievalist, Norway
“People only improve if they actually want to. You cannot force improvement.” Michael Lauria, former USAF PJ and current medical student, USA
“When it comes to vascular access, there should not be different hospital standards and prehospital standards. There should just be standards.” Dr Knut Taxbro, anaesthetist and retrievalist, Sweden.
So I guess the big question that remains for everyone is “was 50+ hours of travel from Australia to central Sweden for a 17 hour conference really worth it?” Given that we were able to assess the content of our training against that which other like-minded organisations from around the world provide in an open and non-threatening forum, tweak our content in line with the latest evidence, build contacts with groups and individuals that have the same struggles as we do in Australia, and provide some guidance to participants who were looking to develop their own tactical medicine training – the answer is obvious.
Wait, I almost forgot the really vital lessons
The Swedish love speed cameras. I mean, seriously, they are everywhere!
Reindeer is actually quite tasty.
Moose is a bit, well, meh….
When it comes to rivalries, Norway is to Sweden what New Zealand is to Australia.
The Australian TV shows “Prisoner” and “Flying Doctors” are compulsory viewing for Swedes.
And 50+ hours of travel by air is in fact a very long way – but it beats driving.
Hey, are you interested in this stuff?
Well you could choose to read our previous posts about TECC here, here, or here. If you do you’ll find heaps of references and further reading on all things tactical.
CareFlight does have courses on that sort of stuff (it’s one of the bits you can find here) so you might find a bit of interest in that or, [looks shy, kicks dirt] y’know, do whatever. If you were interested (but no pressure) it runs pretty regularly (like in 2018 it’s happening on 12 February, 26 May, 20 August and 24 November).
Meanwhile if you like the stuff on the site you could always share it around. Or even sign up to get the emails whenever things hit.
There’s a chance that something about Blair’s story might make you want to help someone, somehow. If that’s the case either drop a message in the comments or email at firstname.lastname@example.org and we’ll follow up.
In this episode all the music is by Broke for Free and available via Creative Commons at the Free Music Archive.
The image is by Justin Luebke and was uncovered at unsplash.com
Finally, we decided to record someone. Dr Andrew Weatherall with a new contributor, Dr Blair Munford.
So we always meant to include the occasional podcast. Finally it might happen. This episode features Dr Blair Munford, whose career in prehospital and retrieval medicine started back in the mid-80s when flight suits probably required shoulder pads and big hair. Blair should be dropping by pretty regularly but this is an introduction with a reflection on a bit of history and a few tales of a life in retrieval (all de-identified and with clearance previously provided).
Anyway, it’s a long history (if you want to get some sense of it if you drop by CareFlight’s publications page you can see him way back at the start, around the time he was kicking off with descriptions of the CareFlight stretcher bridge in 1990).
Anyway, here’s the various ways to get the podcast.
Right click and choose save as to download the podcast. (That’s control-click if you’re on a trusty Mac.)
Of course you could just find the podcast over at iTunes here.
Well this time around we welcome a new contributor. Dr Shane Trevithick is a retrieval doctor with many years experience covering prehospital, interhospital and coordination work when he’s not being an emergency doctor. He’s got a bit on simple systematic approaches that get the job done.
One of the exciting things that practicing medicine out of a helicopter does is make you a “Rock Star” of the medical world. Your colleagues and the general public are amazed by your method of arrival on scene, the ensuing dramatic interventions, the sexy uniform, your appearance on the evening news and your general confidence back in the hospital when you can manage dramatic medical problems which seem much easier when they are not trapped upside down in wreckage.
The problem with being a Rock Star performing in a band is that to continue being the Rolling Stones of Medicine [Ed: we would not suggest this reference is in any way a sign of author age] you feel compelled to keep releasing new albums regularly. This can be a problem, especially with social media, as developments in medicine do not keep pace with the need to tweet and podcast and you are at risk of grabbing the latest study or technique involving patient plumbing and announcing this to the world as the next big thing in the world of Helicopter Rock Band Medicine.
This does tend to mean that you can gloss over some of the basic things which really make a difference to your medicine and your patients. Just like a Rock Star will be completely familiar with the basic things that makes playing their instrument possible, it helps if you can really nail the basics.
So here are a few tips that work for me to do a better job as a retrievalist in whichever team I’m working in. Have a Plan
A good plan when you approach a patient makes a big difference, especially for an interhospital retrieval. This makes a huge difference to the smoothness of how your retrieval will flow and reduces your risk of making an error by omitting something. This is a bit like having a checklist but I don’t quite use it like that because really a checklist involves a bit of call and response. It’s not quite a strict list, more like having a systematic approach to reduce the risk of error. If you have the same pattern to how you do things you get much quicker and slicker and you are much less likely to miss something.
It took me a lot of years to work out I didn’t have a consistent system. And when I analysed some the mistakes and complications I had I realised they came about because, like a good anaesthetic registrar would, I modified what I did to fit the Paramedic I was working with, rather than communicating a system that would ensure I didn’t miss things. If I had actually had any system to do the job myself then I would have avoided a lot of problems.
So here’s the system I created for myself. It might work for you, or might just prompt you to think through what system would work best for your brain.
Check ETT Size and measurement at a fixed point (e.g. teeth).
Check ETT Security – that means connections and how well it is tied/taped. I almost always find myself fixing something about security.
Check ETT Site – on an X-ray.
How well is the patient breathing? It’s a seemingly simple step but yes, I still remind myself.
What are the ventilator settings? Got it, now match them (with the transport ventilator). I tend to work with paramedics who make logistics and practicalities in a brilliant fashion. It always seems that just as I get this step done they are ready with a patient slide to transfer the patient onto the stretcher.
What’s the IV access? Secure that well too.
What about the arterial line? Critically ill patients being moved should have this so now is the moment to make sure it’s connected, working and zeroed. This usually matches up with when my friendly paramedic is miraculously also up to the exact bit where I should be helping with the monitoring.
Think “I need enough sedation for 3 times the anticipated length of transfer” and make sure you’re ready (plus see the bit below).
Also have a think about what things you have handy as downers (mostly sedation and analgesia) and uppers (like metaraminol) which might just come in handy if you get the downers bit not quite right (or for other reasons of course).
E: Everything Else
Do you have all the equipment you brought with you?
Do you have the notes?
Do you have any scans?
Do you have ALL the equipment you brought with you?
Do you have any patient belongings, either the material ones or the relatives that also belong to them that you might be bringing?
No, really, do you have ALL the equipment?
Now, about that sedation
Yes, I gave this its own bit because it is really important. Let’s assume you’re highly skilled at drug-assisted intubation. After that there is the post intubation phase, whether you have intubated the patient yourself or whether the patient comes already intubated.
I think it is really important to make a couple of distinctions in retrieval. One is you are giving “a Retrieval” and NOT “an Anaesthetic” or “a Sedation”. An Anaesthetic is an art form so important there is an entire medical specialty devoted to it. But it is basically focussed on having someone pain free, unconscious of what item number is being performed on them, and then woken to a state of bliss in a a calm quiet environment surrounded by nurses fussing over you. Usually woken relatively quickly after the item number as well.
This does not apply to retrieval. In a retrieval you do not want your patient to wake up. Especially over that last speed hump on the roads leading to the hospital. With apologies to ICU that your retrieval patient will take a day longer to wake up than someone they lightly sedated you have to remember it is not a “sedation” it is a “retrieval”.
There is very little fussing (doctor dependant) and a lot of shaking up/moving/noise/vibration/stimulation. When I was a retrieval registrar no one discussed this with me and since I was very comfortable to treat people with morphine and midazolam either together or separately, with propofol, (ketamine hadn’t come into use again when I was a registrar) and with fentanyl I just kept running whatever the hospital had chosen assuming that since they were a hospital they had correctly chosen the right sedation for the right patient. It was also quicker and easier to just keep running whatever they started as we didn’t have to go through the entire fuss of drawing up new drugs.
I am now, with experience, absolutely sure that this is not best practice. Now I don’t use propofol at all for a retrieval – it is an ideal anaesthetic drug which makes it very poor for A Retrieval. Of course that is only my opinion born of experience with no published data I am aware of (there is a study for someone) however I can promise you that performing a “retrieval” after intubation requires only two drugs for maximum benefit: Separate infusions of fentanyl and midazolam. If you are running two inotropes and only have one pump left I will allow you to mix them together but the ideal concentrations are 1000mcg fentanyl in 50mL and 50mg of midazolam in 50mL. Run them at 10x higher doses than you would use in ICU so you need to think about starting at 200-400mcg/hr fentanyl and heading north and 5-10mg/hr of midazolam.
And if you arrive and your patient is light and coughing on the tube, if their haemodynamics will tolerate it just give them substantial loading doses of these drugs, say 0.1mg/kg midaz and 2mcg/kg fentanyl and then start your high dose infusion. I can promise you this will be the best tolerated, most cardiostable way of performing “A Retrieval”.
Just remember the gotcha – as your helicopter starts to land at the hospital it will shake violently for 30 seconds or so. This will cause your patient to wake up and extubate themselves at the one time you can’t go out of your seatbelt to fix the problem. Remember to bolus before landing.
So there you go. Some of the basics that can help you be the Rock Star you want to be.
All the images here are via Creative Commons on flickr and are unchanged here and put up by Izzy by the Sea, Duncan C, ThoreauDown and Bart Everson.
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Putting a cannula in kids can be… well, an experience. Dr Andrew Weatherall has a collection of tips and tricks that might just be useful.
Cannulas. Little people. Not always a match made in heaven. At the joint I work doing kids’ anaesthesia, we often note that they are the great leveller because it doesn’t matter how special you’re feeling, you’re just one lousy cannulation day away from feeling very, very mortal.
They are sort of essential for prehospital and retrieval work though. The thing is that we know that if you’re not working in a designated paediatrics job, the chances are that the little sprocket end of the market is by far the group you see the least. Which is not ideal for gaining and retaining skills.
So short of approaching random families in the street to see if the kids have always felt like their life was missing a cannula and would they like you to help with that (and that is a terrible start-up idea, don’t do that), you have to make your best of the opportunities you have and draw on thoughts from other people.
So collected here are a bunch of things that help me get those little cannulas in. It’s not an exhaustive list of everything everyone has ever come up with of course. It’s just stuff that works in my hands that I’m sharing, partly in the hope that other clever people will chip in with suggestions in response. There must be some experts out there that we just need to poke enough to make them vomit up their wisdom.
I’m even going to leave out the “give them an anaesthetic and get them to sleep” one because it feels a little like cheating for this scenario. And for the purposes of this post I’m not going into ultrasound stuff because that’s a whole extra thing. Let’s just put on record that if you’re cannulating for retrieval give it a strong thought.
So in a “not necessarily the most sensible order” kind of way, here’s how I’d think through that whole cannulation palaver:
1. What’s my aim here?
Knowing why you’re bothering with that cannula might seem like a dopey place to start but it sort of determines a bunch of decisions that follow. If you’re in a prehospital setting and you’re thinking of the cannula to get analgesia happening, do you have options you can start with first (intranasal or methoxyflurane etc) that will treat the clinical problem in the short-term and buy you time (plus help the kid, family and you) before getting to the cannula you might need long-term?
Are you adding one as a precaution for transfer? Is that the best choice for the patient and you? If it’s not time-critical do you have time for local anaesthetic options to do their thing?
Do you need the sort of urgent access that might befit an intraosseous option, then quick resuscitation and then an attempt at an IV once there are actually veins that have actual circulating volume in them to work with?
In this setting, it might well be that the IV is exactly what you need of course. But making that an explicit step in your thinking is a good thing. It makes you really prioritise the vital steps for management of the patient.
2. What’s my limit?
This flows from point 1. How many attempts would you consider before you try something new (like a different form of access, or asking someone else to have a go)? If it’s a cannula that must be done, your limits are going to be different than if you have nothing to start with. If you’re in a retrieval, rather than prehospital setting through there might be lots of clever people who can help (or who could do it while you do things that only you can do).
Setting some sort of soft limit where you will stop and reassess does stop you getting into the hole that comes with “I have to get this in” to the point where you forget the primary needs of the patient and it becomes mostly about pride. I’ve been there. A pride hole helps no one.
I don’t think you run the risk of mentally setting up with an assumption that your attempt will go wrong by having that limit either. It’s just about keeping whatever the primary goal of care (which is almost never the cannula itself, but what you can provide with the cannula) foremost in your mind.
3. Super prep
Preparation is pretty much everything here.
And whoever is helping them obviously but mainly the patient. If you’re with an awake patient, then telling them what you’re going to do and why is a pretty important place to start. The style that people employ for this can vary but one thing I’d be pretty firm on is that you can’t win by being dishonest. If it’s likely to hurt, don’t promise it won’t. If they’ll still feel pushing (like when you’ve used local anaesthetic cream), probably warn them. Let them know if you’re going to get someone to do the work of keeping a limb still. Explain steps as you go.
If you can, choose to work in a position you find comfortable. Removing any degree of strain from your own posture just makes it easier to keep your later movements refined and precise. Not always possible, but working at the right height or even sitting down can make all the difference.
Way too often over my career I’ve gone to put a cannula in a spot because it seems convenient and later realised there was a much more accommodating vein somewhere else. There is something even more convenient than a vein that is close to where you’re standing. The vein that will actually help you out that’s all the way over there. Over that other side.
Check all 4 limbs, every time you can.
Stuff for cleaning, stuff for doing, stuff for securing. Have it all ready to go (and that includes a back-up cannula ready in case you need to move on to another attempt). Once it’s in you want to be able to have it secured as quickly as possible. And once you’re under way you don’t want to be distracted by needing to reach for anything else.
A really good clean with an alcohol swab has an additional purpose. Sometimes it highlights a change in contour of the skin as the light picks it up and this reveals a vein. Sneaky and appropriate infection control.
4. The Actual Doing
Right. The pointy end. So to speak. Not so certain about this bit? Well these are all things I do or have seen others do. Comprehensive? Probably not. For everyone? Maybe not but worth a think I reckon.
Choose your cannula
First up, examine that vein and decide which cannula you think will actually go in it. We all love a cannula big enough to rehydrate a woolly mammoth (and think how dried out those codgers would be now), but the truth of paediatric patients is that you don’t need a massive cannula to achieve good fluid loading. And you can definitely resuscitate more effectively with a smaller cannula in the vein than a bigger one in the subcutaneous tissues.
I’d even cope with a not-super-huge cannula in the cubital fossa if that’s what you need to get things rolling. At the hospital we regularly resuscitate kids without a huge cannula. It just needs a syringe and a 3 way tap (and you can actually do with most lines without a 3-way tap). Mostly it’s actually about paying attention and doing it, rather than letting it run.
Line it up
Absolutely the commonest thing I see trainees do when they are struggling is not actually lining up the cannula with the vein it is supposed to slide into. The entry point is somewhere near, but if you look at the barrel of the cannula, it doesn’t line up with the direction of the vein. Good luck with that.
Don’t focus so much on the entry point you forget the rest of the thing.
Make a hole
OK this one is probably more for the retrieval setting (and particularly for tiny ones) though I guess in principle as long as you have good sharps management you could maybe consider it for prehospital work (I’ve never done it there though). Not sure I’d try it in an awake child without some local numbing happen either.
After you choose your cannula, get a needle bigger than the gauge of the cannula. Make a hole in the skin at your entry point. Now when your smaller cannula passes through the hole you shouldn’t have the skin dragged in with it at all. You should lose all resistance at that level actually. Do it right and pretty often you’ll feel the end of the cannula pop into the vein before any visual clue like a flashback tells you that you’ve made it.
Note that having gauze handy for any small amount of blood ooze that would obscure the entry point is helpful here.
The saline trick
I think this only works with non-safety cannulae. Basically you fill the hub with saline and when you hit a small vein you’ll see a super quick flashback (even just starting with a quick change in the light in the saline). This one’s particularly useful for getting early warning in tiny veins to avoid going straight through.
Short and sharp
You probably understand that you need to come really flat to the vein with your angle of approach (by all means be at a more acute angle to get through the skin, but approaching the vein should be pretty flat).
The other key bit though is short, sharp movements forward followed by a pause. I tend to find slow advancing just doesn’t do the job in little people’s veins. It’s like the slow distortion of the tissues encourages them to roll out of the way (you can even see it on ultrasound). A sharp move forward, then a pause, then repeat just seems to work better.
You get the flashback. Victory! Except you still need to advance and you’re worried it’s a bit small that there vein. So do a really small advance. Then rotate the whole cannula (as in the needle bit as well) 180 degrees. The leading edge of the needle is now closest to the skin, and the pointy bit isn’t going to go ahead and spear the back wall. Advance a little more. Now feed off the cannula.
This trick is more well known. Once you think you’re in that vein, twist the cannula off into the vein. In bigger kids it’s probably no help but in smaller veins it does seem to sometimes help get it not to catch up on the wall of the vessel.
Wired for Not Sound
This one is not really a prehospital thing but if in a retrieval-type situation you could consider this one. Have a think about getting familiar with wires for Seldinger options. There are manufacturers out there making short wires that will feed down a 24 gauge cannula. Arrow make one that is 0.018 inches (diameter) and Cook make one even smaller (at 0.015″). When you have one of those cannulae you really want but after you feed it off it’s all gloom, a wire can rescue you.
The technique (with appropriate cleanliness and wire precautions to ensure you don’t lose it in the vein all in place) is to gently start pulling back just the cannula until you have blood freely flowing back. If you gently advance the wire up the cannula at this point it will sometimes find its way perfectly up the vein. If so, you now have an introducer to place a cannula (maybe even one larger than the one used for access).
Not a technique to try in anger for the first time without someone who has done it nearby I’d say.
It’s also worth noting that not all wire/cannula relationships are without challenges. For whatever reason a Surflo 24 gauge cannula will absolutely not allow a 0.018 inch wire through. A 24 gauge Insyte? Well they were made for each other. Go figure.
4. The Strapping
Well that’s a completely different post. I only wish someone had good tips for things like that (like say, here).
For kids cannulas there are a lot of techniques out there and lots of strong opinions about tape. My main thoughts would be:
The tape has to be in contact with the actual thing it is supposed to hold. Sometimes I see people holding tapes tight as they put it across the cannula, thereby guaranteeing the tape only contacts the top surface and is then stretched onto the skin. Form the tape closely to the cannula itself. Squeeze it right on there to get maximum tape-to-cannula contact. Then lay it across the skin (no stretching) and put some pressure on it to get adherence happening.
Really think hard about things like boards. If they are not adding security for that cannula, you can almost guarantee they are adding annoyance for the patient.
So there’s a start. I bet people have more I’ve forgotten or don’t even know about.
You might just find some of these tips help though. And if that’s the case you will hopefully end up not being the big prick finding it a bit of a prick to get a little prick done for a little kid.
Little kid. What did you think I was going to say?
I am not kidding about hoping people will have better tips. That’s what the comments bit is for. Go nuts. Or share the post and see if someone else has one.
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The images here were from vandys (the speed limit one) and Petras Gagilas (the tunnel thing) and used unchanged from their spot on flickr under Creative Commons.
Back with another instalment in the popular series “I wish I knew then what I know now” is Greg Brown, current Education Manager / Clinical Nurse Consultant with CareFlight and former Australian Army officer.
Intravenous cannulation: the art of finding the biggest tube with a sharp point in your kit and placing it in the most proximal vein you can find so you can deliver various fluids or medications that may or may not make the patient feel better but certainly help you feel as though you have achieved something.
Okay, this might be a bit of a stretch – but in all seriousness the ability to gain and maintain dedicated vascular access in your sick patient is a vital component of medical care for nurses, paramedics and doctors alike. For many (both in and out of hospitals), the ability to find that elusive vein is a point of pride, and getting that solid red flashback in the chamber of the cannula is at times the cue for the treating team to stop holding their breath.
But the IV cannulation process is not complete once the [insert name of your service’s approved form of IV dressing] is applied. In the retrieval world, an IV cannula is almost always going to have fluids flowing through it (or at least attached to it). Having fluids attached gives the healthcare provider a ready-made flush for those medications that are used in treating the patient. Want to give a bolus of IV ketamine? You are going to need an IV flush. IV fentanyl? Flush. IV anything? Flush. You are going to be flushing everything, so you might as well attach a 1000mL bag of “flush” via a giving set and have it ready at all times.
Herein lies the problem. For anybody who has ever had to move a patient with an IV line attached, you know just how easy it is for that line to get snagged – and before you know it, your precious cannula is now no longer in a vein and instead is irrigating the helicopter floor / CT machine / footwell of the crashed car etc. Your service’s approved form of IV dressing might be awesome at holding an IV cannula in place, but it is no match for the body weight of that burly rescue technician with the IV line inadvertently wrapped around his leg who is moving in the opposite direction to the patient.
Laws to Live By
Many years ago at CareFlight, one of our “grey beards” (Dr Blair Munford, anaesthetist extraordinaire), came up with what we now call ‘Munford’s Law of Taping’ which states:
“The length of tape used on the patient should not exceed the distance between the point of injury and the receiving hospital, but anything less is acceptable.”
Taping IV lines is a good thing, but tape doesn’t work great on wet, hairy or dusty patients. Sure, you can circumferentially tape the IV line to the arm such that the tape sticks to itself and not the patient, but that is a lot of non-stretchy tape.
Story time. Many years ago, whilst on deployment with the Army, I was tasked with transferring a civilian casualty from the scene of a vehicle accident to a landing point whereupon she was to be whisked away to a United Nations hospital by helicopter. The accident involved an overcrowded minivan which failed to negotiate a corner resulting in it rolling. The knock-on effect was a mass casualty incident halfway between two forward operating bases. Medical and security assets were despatched to the scene, including myself as a young (ish) nursing officer.
After the usual initial chaos that results when medicine and tactics collide, we dutifully set about the triage and treatment of casualties in accordance with priorities and started stacking inbound AME assets. Unfortunately, given the topography, the AME teams could not land on site; therefore, we were required to ferry the casualties from the scene to a landing point about 2km away.
One particular casualty of mine was a lady with a mid-shaft femur fracture and a handful of broken ribs. I had applied a Donway Traction Splint to the leg, some oxygen and was trying to bump up her blood pressure with crystalloids whilst controlling her pain with increments of IV morphine. I had placed an IV in her antecubital fossa and had “secured” the giving set with some tape. However, despite the accumulative administration of a lot of morphine (the exact dose escapes my memory), she was still very obviously in pain. The problem? As we loaded her into the vehicle, the IV line became looped around the stretcher handle and the cannula had dislodged.
Ordinarily I’d have just placed another IV and started again; but in this case I had two problems: (1) being a mass casualty incident my stores had been pillaged leaving me unable to place another IV, and (2) the Blackhawk was already flaring (meaning it was about to land), so I didn’t have time to go back to the scene to grab more stuff. This was a major fail when it came to managing this patient. And in addition, the woman’s pain and lack of analgesia were about to become the AME team’s problem, but the embarrassment of losing the ONLY IV access this patient possessed was mine alone.
But, in the words of S.E. Hinton, “that was then, this is now”.
There exists a remarkably simple solution to this problem, and it involves a bandage. We now teach this technique to anybody who will listen because, quite simply, there is no good reason for losing an IV. It works on the side of the road; it works in an ambulance; it works in Emergency Departments; and interestingly, it works really well in those dementia patients that occupy their time by trying to undo every single medical intervention you’ve applied during your 12 hour night duty!
Step 1: Place an IV cannula in your patient in accordance the patient’s need and your ability / scope of practice. Apply whatever dressing your service says you should.
Step 2: Attach your primed IV line as per the application of common sense. Ensure that the roller clamp on the line is as close to the bag as possible – you will need to be able to access it.
Step 3: Run the IV line down the limb around 10cm / 4in and cover in a bandage (the broader the bandage, the faster the technique), leave a loop then bandage the IV line back up the limb.
Step 4: Repeat step 3 ending with the free running end of the IV line heading towards the head of the patient (this is where you will be located; if you need to replace the IV bag it’s best if the bag is close to you).
Step 5: Secure the end of the bandage with some tape. Ensure that you leave the side injection ports of the IV line accessible. You may even wish to mark these with tape so that you can find them quickly when under stress.
When you secure the IV line with these superimposed S bends you create 40cm of dead space that will take up the strain on the line if the line is pulled. Once tension is applied to the line the loops cinch together to take up the strain. More of a visual learner? Yeah, me too. See the images below.
What I now know that I wish I knew then is that performing this technique takes no longer than trying to apply copious lengths of tape to a patient’s arm, especially when that arm belongs to a sweaty, hairy person. I also know that I never again want to be the clinician whose handover includes “well, there was an IV in the arm but I kinda lost it in transit…” If it is worth doing, it’s worth securing.
We bet this isn’t the only way to secure a line. Got tips for us to learn? Then put them in the comments. We like learning.
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Respect for the classics doesn’t mean being stuck with them. Here’s a refresher on why you might not want to do RSI like they used to by Dr Andrew Weatherall. This one is a cross post picked up from the paeds anaesthesia site he chips in on, www.songsorstories.com
Everything in medicine needs the occasional reboot. I mean not as often as Hollywood thinks we need to reinvogorate a superhero franchise but at least every now and then. Sometime that’s because we learn new things (cross reference here). Sometimes it’s because our perception of what is the biggest risk changes (more on that in a second). And sometimes we suddenly realise that the original reason something became fixed practice might not have been a thing in the first place.
Which brings us to RSI, a classic so many of us have grown up with.
What is this thing?
The story of RSI starts with excellent intentions (and for this version of events I’m leaning heavily on this review by the excellent Thomas Engelhardt). In this case the idea was to come up with a safer way to get the snorkel in the all important windpipe as quickly as possible to try and minimise the risk of things that should stay nestled in the gastrointestinal tract might find their way to the lungs.
And you can understand why. Serious aspiration can, sometimes, be deadly. The first piece of the puzzle was written up by Morton and Wylie way back in 1951 who described where with the patient sitting up the anaesthetist would give intravenous barbiturate then muscle relaxant and rapidly intubate them. A rapid sequence of induction and intubation. So really it’s RSII.
8 years later a description emerged of a thiopental/relaxant/40-degree head-up tilt foot-down tilt. It wasn’t for another 2 years that cricoid pressure popped up (thanks Sellick) although interestingly it included not just a bit of pre-oxygenation but also some bag-mask ventilation prior to putting the tube in.
It was another 2 years before the other classic bit of RSII became popular, with an exhortation to avoid bag-masking because of the perceived risk for gastric insufflation and hence regurgitation.
A classic technique derived from a series of “what abouts” and “I reckons”. I mean, you wouldn’t read about it. Except you just did.
That’s not to say that medicine doesn’t have space for a bit of logical derivation of good ways forward. It might just suggest that the whole approach is open to a refresh.
Re-evaluating the Likely
If the technique was designed to prevent aspiration, maybe we should start with looking at how likely this event is in a setting a bit more modern than 1951. In 1999 the epic writing team of Warner, Warner, Warner, Warner and Warner looked at 56138 patients under 18 having procedures (elective or emergency) over 12 years to see just how big this problem was. This covered 63180 procedures.
The time frame for defining aspiration was entry into the operating room until 2 hours post-anaesthetic. To score the label there had to be direct identification of bilious secretions or particulate matter in the tracheobronchial tree or new X-ray findings after an episode of regurgitation. A total of 24 patients met the criteria.
11 of those were emergency cases so the rate in that group was 1 in 373 compared to 1 in 4544 in the elective cases. 21 of the 24 were around induction. 15 of the 24 had no symptoms develop despite the aspiration. 5 of the other 9 did need respiratory support of some kind and 3 of them needed ventilation for more than 48 hours. Well the paper says that but actually describes ventilation for 18 days, 14 days and 33 days in those cases.
And there’s the rub. It’s really very impressively rare. But then when it goes bad, the downside can be very, very down.
So fine, let’s prevent the bad thing. We’d better get on with the classic old RSII, right?
Remembering the Even More Likely
The problem with being so rigorously focussed on avoiding pulmonary aspiration that you do things like not help the patient breathe, is there are other basic functions that don’t get looked after so well. Like oxygenating.
Gencorelli et al looked at episodes of desaturation during RSI while describing the classic drugs/cricoid/no ventilation technique. Across 1070 children included they reported a 3.6% rate of desaturation to 89% or below (1.7% of the patients being in the under 80% group). Not surprisingly the under 2s were more likely to have a desaturation.
These rates are low of course and certainly lower than in some other areas of practice. Reports from emergency departments have indicated desaturation rates anywhere from 14% to 33% (with the latter reporting rates of desaturation of up to 59% in the under 2s).
So amongst the various things we’re trying to do to prevent the 1 in 400+ event are we at risk of failing on another key thing. You know? The oxygen provision thing.
What’s the alternative?
Neuhaus and team subsequently described very well their approach to RSII, which they badged as cRSII (where the “c” is for “controlled” not some other “c” word like “cheese” which wouldn’t make sense anyway but would be a good reminder that cheese is great).
They key features for them (putting to the side “lots of preparation”):
20 degrees of head up (though they say only for the over 2s)
Suction any NG in situ.
Give the drugs.
Avoid cricoid pressure (with a few exceptions).
Provide gentle facemark ventilation with peak pressures of 12cmH2O.
Neuromuscular monitoring to ensure the muscle relaxant has really, really worked.
This last point makes a heap of sense as active regurgitation is a problem created by airway instrumentation when you don’t have adequate anaesthesia and paralysis.
Talk is cheap though, what were their results?
They report on 1001 patients They had a moderate hypoxaemia (89-80%) rate of 0.5% and a severe hypoxaemia (< 80%) rate of 0.3% and the 8 patients this represents had a median age of 0.8 years. They had 1 patient with regurgitation but no evidence of aspiration.
That’s pretty impressive.
Putting it Together
So if we accept that we should really try and optimise oxygenation, and that the risk of this is higher than the risk of aspiration then we have to accept that modifications to that original technique are reasonable. What are a few steps for practically putting it together?
1. Assess that risk of a full stomach
It might well be that we’re going to avoid cricoid most times, but there are still a few situations where that risk of aspiration is probably higher. In the Neuhaus paper they suggested achalasia, Zenker diverticulum or post-colonic interposition patients (done for oesophageal replacement) always need cricoid.
It certainly seems worth having heightened concerns in the patient with significant increases in intra-abdominal pressure.
2. Everyone sits up
Why wouldn’t you have a bit of head up? It makes sense if you’re avoiding passive regurgitation and is a good position for pre-oxygenation, facemark ventilation and intubation. I’m not quite sure why some authors have suggested the under 2s shouldn’t be head up. This is a routine option.
3. Have that suction handy
Goes without saying maybe, but I’m saying it.
4. Pre-oxygenation, but not with distress
Yes you want to pre-oxygenate. And most times you can talk kids through that and get a full 3 minutes in. Some kids will only get more distressed with oxygenation though, and insisting on pre-oxygenation only guarantees distress. Given that you’re going to apply gentle face-mask ventilation, it’s rare you need to go to the wall on this one.
And while I’m there what about apnoeic oxygenation? Well, as discussed in this post, the evidence that’s available in kids isn’t so persuasive as to suggest it should be routine. The stuff that has been done showing extended apnoeic time actually followed effective pre-oxygenation with face-mask ventilation. So as we’re going to put that tube in quickly after the same sort of effective face-mask ventilation, extending apnoeic time for minutes seems not that clinically relevant.
5. Cricoid yes or cricoid no?
Again this is a judgment call. I know plenty of anaesthetists who still prefer to start with it but with a low threshold to remove it. I’m more likely to mostly err on the side of not using it, except for those high risk of aspiration patients.
If you are going to use it, it is worth noting that, particularly in infants, the trachea is quite often more prone to distortion by cricoid pressure than you realise. Doing flexible bronchoscopy work you’re sometimes asked to manipulate the airway and I’ve seen the whole trachea get substantially compressed and distorted by seemingly innocuous manipulation. Distort it enough and you can increase the resistance to air going in and out enough to make it easier to get down to that stomach.
In addition, as covered very nicely in this review, cricoid relies on the alignment of trachea and oesophagus and the evidence is that in kids < 8 years old 45% had displacement of the oesophagus so you’d be unlikely to get compression of the oesophagus even with perfectly delivered cricoid (at least on the CT scanning mentioned).
So for the very high risk ones I’d tend to start with it (well start with it once I’m sure the kids won’t react to it going on), but that leaves almost everyone where I would’t be too concerned. And if it is on, I’d be quick to take it off if it was impeding either view or tube passage.
We’re going to take our time with face-mask ventilation and maintain oxygenation. So where’s the extreme rush getting the tube in? Being too obsessed with that step, even though you’re achieving oxygenation, is a way to end up instrumenting the airway while the patient is only lightly anaesthetised or inadequately provided with paralysis. What was that thing we’re preventing again? The regurgitation thing that’s worse if we get going while the kid is lightly anaesthetised? Oh, right. Slow down.
The description suggests using a nerve monitor. I can’t say this is routine myself, but once the muscle relaxant is onboard I do publicly note for the team I’m working with how long we’ll be waiting on the clock before we start trying to intubate. (“The clock says 09:30 now. Once it ticks over to 09:32, we’ll start with the intubation.”)
I then remind everyone that this will take an unnervingly boring period of time and they might want to come up with a good joke to fill the time.
Yes, this is a thing that’s necessary because kids desaturate quickly. Particularly the younger ones. Achieving gentle face-mask ventilation relies on really good technique with the bag in hand. Plus it’s very therapeutic to gently squeeze that bag.
7. What about parents?
This one also needs an assessment of what might help and what won’t. For lower risk kids, as a paediatric anaesthetist doing it regularly, I’d be comfortable having them along. But if it was the sort of case that was likely to be difficult, or if I was back at the training junior doctor stage, there’d be no dilemma for me. I’d tell the parents that they wouldn’t be coming in. Having them alone to help their child relax (not always a guaranteed result of having parents in) has some advantages. But the prime job is safe management of the peri-induction period. And that might mean less people around.
So those are the simple things that have shifted over the course of my time in the big wide medical world. It’s a realignment of the priorities in a way that makes the ‘R’ in ‘RSII’ look smaller and smaller so that the oxygenation is placed at the top of the tree.
Put together though it’s a reboot worth endorsing. I mean the 60s just weren’t that great, surely?
How many bits that are really important aren’t covered here? There must be some. So leave a comment. We’ll all learn.
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This post is a cross-post from another site that this Weatherall bloke works on called Songs or Stories. It’s about paediatric anaesthesia.
That echidna pic came from flickr’s Creative Commons area and is unchanged from Duncan McCaskills’s post.
Now to the literature, because going to the direct papers is always rewarding.
That review by Engelhardt where he makes it clear what he thinks is this one:
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).
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.
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.
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.
Yes. That’s a real elephant and the photo is via @AndyDW_