Tag Archives: i wish i knew then

Practical Things, Retrieval

I Wish I Knew Then What I Know Now – Holding the Line

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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”.

Simple Solutions

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.

Bandage Secure 1

Bandage Pull

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.

 

Notes:

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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Airway, Practical Things

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

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

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

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

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

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

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

Simple Is As Simple Does

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

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

Still here? Good then, on with the show.

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

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

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

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

Table

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

Putting It To Work

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

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

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

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

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

 

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

 

Notes:

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

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

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

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

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