Tag Archives: elephant

Just because you can …

With a couple of new papers landing that touch on the issue of how you provide and measure quality care around airway management, Dr Alan Garner returns to point at big animals that are bad at hiding.

Two new airway papers have come across my desk in the last couple of weeks and I now wish I had waited a bit longer before putting up the last post on first look intubation as a quality measure.

So where to start? Well how about a place where everything is apparently big? Yes, there’s a bit of work just out of Texas which sheds further light on that first look intubation story so that’s where we’ll land.

Chasing Quality

It sounds like they have used RSI for a while but undertook a quality improvement project to try and reduce their peri-intubation hypoxia rate.  The project involved introducing a bundle of interventions described in the paper as “patient positioning, apn[o]eic oxygenation, delayed sequence intubation, and goal-directed preoxygenation”.

The paper provides copies of the protocol for intubation pre- and post-bundle intervention in the on-line appendices so I might just go through them here to see what they did differently.

The first thing is there was an emphasis on positioning in the bundle, specifically head up a bit and ear-sternum positioning.  Lots of goodness here that I strongly support.

The second measure they mention was apnoeic oxygenation.  However looking at the pre- and post-bundle policies it is evident that they used it in both time periods.  In the before period it ran at 6L/min till the sedation was given then it was turned up to 15L/min.  In the post period however it was run at “MAX regulator flow” after the ketamine was administered.  I don’t know about the O2 regulators in Texas but to me this does not sound like they changed anything significant.  I will come back to apnoeic oxygenation later.

For pre-oxygenation in the pre- bundle period they used a NRB mask (with nasal prong O2 as above) in spontaneously ventilating patients (and arrested patients were excluded) but in the post- period the pre-oxygenation had to be by BVM with two handed technique to ensure a tight seal plus PEEP.  More goodness here that warms my heart.

Delayed sequence intubation in this study refers to administering 2mg/kg of ketamine then maximising preoxygenation for at least 3mins prior to administration of the muscle relaxant.  I don’t think this is necessary in all patients but this was the policy in the bundle.

The last thing they did was “goal-directed preoxygenation”.  This refers to having a SpO2 target >93% for at least 3 minutes during the pre-oxygenation phase after the ketamine had been administered.  If they could not achieve >93% the patient was managed with an LMA or BVM and transported.  I think this represents sensible patient selection in that it removes the high risk of desaturation patients from the process.  When you look at the results you need to keep this patient selection in mind. However I agree that in their system this is a reasonable approach to ensure patient safety for which the managers should be applauded.

Show Me The Money

Yes let’s get to that money shot:


I have been banging on about peri-intubation hypoxia being far more important than first look intubation rate for a while now and this data shows really clearly why.

There is no significant difference in this study in either first look or overall success rates pre and post the bundle but the hypoxia rate fell by a massive absolute 41%!  The 16% decrease in bradycardia emphasises just how much difference they made.  The managers of this system and their staff alike both need to be congratulated for this achievement as this is something that really matters.  And the first pass and overall success rates give no clue!

It really is time to drop first look as a quality measure and move on.  You could look at this paper and start wondering if it might even be worth dropping overall success rate too, which is an interesting thought.  Their policy favoured patient safety over procedural success rates by abandoning the attempt if the pre-oxygenation saturations could not be raised above 93%. It looks like it is working out well for the patients.

Oh, Back to Oxygenation

I promised I would come back to the apnoeic oxygenation issue.  I know the authors state that it was part of their bundle, but it was used in the pre- bundle period as well.  Hence there is no data here to support it’s use.

All three randomised controlled trials of apoeic oxygenation in the ED and ICU contexts (see the notes at the end) have now failed to find even a suggestion that it helps (check those notes at the end for links) and there are no prehospital RCTs.  My take is that it is time to move on from this one too and simply emphasise good pre-oxygenation and good process when the sats start to fall – or never rise in the first place like this group did so well.

Overall a big well done to the Williamson County EMS folks and thanks for sharing your journey with us.

Moving Right Along

The other paper comes out of London, where the ever-industrious HEMS group have published a retrospective review of their database over a 5 year period (from 2009-2014). They were looking for adult trauma patients they reached with an initial noninvasive systolic blood pressure of 90 mmHg or less (or where a definite reading wasn’t there, those with a central pulse only) and with a GCS of 13-15.

This gave them a total of 265 patients (out of a potential 9480 they attended). 118 of those underwent induction of anaesthesia out there beyond the hospital doors (though with exclusions in analysis they end up with 101 to look at) and the other 147 (that number dropped to 135 on the analysis) got to hospital without that happening.

Now the stated indications for anaesthesia listed are actual or impending airway compromise, ventilatory failure, unconsciousness, humanitarian need, patients unmanageable or severely agitated after head injury, and anticipated clinical course.

Now given that the inclusion criteria includes patients having a GCS of 13-15, it seems like both unconsciousness and those really impossible to handle after head injury are likely to be pretty small numbers in that 101. Even airway compromise, ventilatory failure and humanitarian need seem like they’d be not the commonest indications in that list that would apply to this patient group, though they’d account for some.

I guess it’s possible the patients were all initially GCS 13-15 on the team’s arrival but deteriorated en route, though I just can’t sift that out from the paper. Plus if that was the case it seems like you’d say that.

The Outcomes

In their 236 study patients, 21 died and 15 of those were in the ‘received an anaesthetic’ group. The unadjusted odds ratio for death was 3.73 (1.3-12.21; P = 0.01). When adjusted for age, injury mechanics, heart rate and hypovolaemia the odds ratio remained at 3.07 (1.03-9.14; p = 0.04).

Yikes, sort of.

What To Make of That? 

I guess we should make of it that … things you’d expect to happen, happen? Intubating hypotensive patients and then adding positive pressure ventilation in the prehospital setting is potentially risky for patients for a variety of known pharmacological and physiological reasons that the authors actually go into.

So the question is why embark on such a procedure where you know the dangers in detail? You’ve have to really believe in it to end up wiht 101 cases to follow up.

It feels like there’s an elephant in the room to try and address by name. I wonder if it has something to do with a practice I observed while working in the south-east of England 8 years ago. It relates to that last category “anticipated clinical course”.

Hovering elephant heads. They’re real.

The concept here is that if you figure the patient is going to be intubated later on in the hospital, you might as well get on and do it. Except the data here suggests that, much like you’d expect, you probably shouldn’t get on and channel your inner Nike marketing script.

Just because you can does not mean you should.  This paper really drives this home though it doesn’t really seem to come straight out and say it. It does pass the comment that “Emergency anaesthesia performed in-hospital for patients with cardiovascular compromise is often delayed until the patient is in theatre and the surgeon is ready to proceed.” Perhaps the problem isn’t using the phrase “anticipated clinical course”. It might be that you just have to remember that the anticipated course might best contain ‘risky things should probably happen in the safest spot’ in the script.

Compare and Contrast

The process of undertaking emergency anaesthesia because later the patient might require emergency anaesthesia is pretty much the complete opposite of the approach from the Williamson County EMS folks. They erred on the side of patient safety and withheld intubation if it was associated with unacceptable risk.

This paper demonstrates that emergency anaesthesia in patients with a high GCS but haemodynamic instability is associated with higher mortality.  We should probably be glad the authors have made this so apparent, because this is probably as good as we’re going to get. We’re not going to get a randomised controlled trial to compare groups. No one is allowing that randomisation any time soon making this another example of needing to accept non-RCT research as the best we’ll get to inform our thinking.

Patients with hypovolaemia due to bleeding need haemorrhage control. The highest priority in patients with that sort of hypovolaemia would seem to be getting them to the point of haemorrhage control quicker. And delaying access to haemorrhage control (because the prehospital anaesthesia bit does add time in the prehospital setting) when the patient has a GCS of 13-15 doesn’t seem to prioritise patient safety enough. Patients probably need us to adjust our thinking on this one.

That seems like common sense. The retrospective look back tells us pretty conclusively it’s a worse option for patients. And now it’s up to us to look forwards to how we’ll view those indications for our next patients. And “anticipated clinical course” probably just doesn’t cut it.



That hovering elephant head was posted by James Hammond in a Creative Commons-like fashion on unsplash.com and is unchanged here.

How about all those things that got a mention above that you should really go and read for yourself?

Here’s that whole bundle of care paper out of Texas:

Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med. 2018;doi:10.116/j.annemergmed.2018.01.044 [Epub ahead of print]

Those RCTs of apnoeic oxygenation in critical care environments mentioned are these ones:

Caputo N, Azan B, Domingues R, et al. Emergency Department use of Apnoeic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med. 2017;24:1387-1394.

Semler MW, Janz DR, Lentz RJ, et al. Randomized Trial of Apnoeic Oxygenation during Endotracheal Intubation of the Critically Ill. Am J Respir Crit Care Care Med. 2016;193:273-80.  

Vourc’h M, Asfar P, Volteau C, et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomised clinical trial. Intensive Care Med. 2015;41:1538-48.

And that paper on the hypotensive, awake prehospital patients scoring an anaesthetic is this one:

Crewdson K, Rehn M, Brohi K, Lockey DJ. Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental? Acta Anaesthesiol. Scand. 2018;62:504-14.










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.

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.



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.