by Mike Steuerwald,

Not much gets me as fired-up anymore as trying to optimize them. While I like to think that it’s because they are integral to our mission and are the ultimate weapon in our quest to go from “good to best”, it’s really just my borderline OCPD (just kidding…sort of).

Long story short, I spend a lot of time thinking about clinical and operational logistics in HEMS – it’s become my thing. My goal with this post is to share some of that thinking with others who might want to build off of our ideas in hopes that those colleagues (i.e. you) will share their ideas that they are really excited about with us at some point.

So in that stead, let me share our procedure kit idea with you…about 2 years ago we were fortunate to make the jump from BK-117 helos to EC-145s. During that transition, we completely revamped the way we carry and store our materials (i.e. our operational logistics). Part of this revamp included creation of procedure kits to store supplies needed to accomplish our core HEMS procedures. The ground rules were thus: (1) they had to be robust (2) they had to be uniform (3) they had to have everything you needed to do a procedure and nothing more (i.e. they had to reduce the cognitive load, not add to it).

So here is what we came up with. We built five kits that we vacuumed sealed using a food packaging system – goal #1 accomplished. The idea for doing this came from Jason Peng, one of our flight NPs. He was inspired by some observations he made while he was serving in the US Navy regarding how their materials came packaged.

Each kit has its own placard listing its purpose and all materials within (see goal #2). The placard also has a spot where the kit assembler can put their name and the kit’s expiration date (based on the soonest to expire component part).

The original five included: surgical cric (see video by Bill Hinckley posted a few months ago for much more on this), needle cric (see video posted by me a few months back for much more on this), finger thoracostomy, pericardiocentisis, and blind nasal intubation. If you take a look at my post on needle cric or Bill’s post on surg cric you will see what I mean regarding goal #3.

We have learned that these kits aren’t perfect in the couple years we have been making them. The names on the kits were a bit small to read and the placards were not color-coded…something newer iterations will fix. This tenant of operational hems logistics should not be overlooked – any system that cannot accept changes and evolve when improvements are concepted is doomed to fail.

In summary, if you think this is cool and you might want to make similar kits for your shop, I’m glad I was able to share this information with you. I hope to share more similar information soon.

Steuerwald Author Tag

Oral Boards Case with Dr. Blomkalns
The pt is a 70 yo M who presents with AMS, weakness and nausea for 1-2 days. He complains of diffuse weakness and feeling “sick”. His hx is significant for HTN, HLD, CHF and he takes digoxin. Vital signs on arrival are BP 90/60 with HR 47. There is concern for digoxin toxicity, so dig level is obtained and is 2.4 (normal is less than 1.2). His K is 6 and Cr is 1.9. EKG shows LBBB.
Learning points on dig toxicity:
  • Can be acute or chronic
  • Acute presentation: unstable hypotension and bradycardia. PAT with slow ventricular rate is a common EKG finding.
  • Chronic presentation: AMS, fatigue, nausea
  • Common lab abnormalities: hyperkalemia, AKI
  • Treatment is digibind
  • Not all digoxin toxic patients get digibind. Be careful giving digibind to A.fib patients as this may put them in A.fib with RVR and make their hemodynamics worse.
  • Patients should be treated based on their K (> 5.5), EKG and symptoms. Do not treat based on dig level alone.
  • Stone heart phenomenon: in the past, folks used to be afraid of giving Ca to dig-toxic patients. This has been disproved and Ca is safe in these patients, though it will not work as digoxin binds to Na/K ATPase and does not work on Ca channels.
  • Dose of digibind (given in vials): 100/weight in kg
  • Dialysis does not work, however it does clear digoxin-digibind complex and is helpful in pt’s with renal failure
  • Do not get repeat digoxin level after giving digibind as it is useless.
Tox to know for oral boards:
  • Tylenol and NAC
  • Aspirin and alkalization
  • Toxic alcohols: ethylene glycol, methanol
  • Digoxin
  • Pediatric Fe ingestion
  • TCA
  • Beta blockers and Ca channel blockers
General tips for oral boards:
  • Updating family and calling PCP gives you extra points!
Oral Boards Case with Dr. Stettler
84 yo F with AMS. Presents hypotensive, tachycardic, febrile. Has a sacral decubitus with crepitus. Concern for necrotizing fasciitis. Pt should get aggressive fluid rescuscitation, at least 2 L. She then requires pressors for management of her septic shock, NE and vasopressin. Needs a surgery consult for debridement.
27 day old F that is “not acting right”. Has had decreased PO, lethargy for 1 day. Presents hypotensive, tachycardic, tachypneic, with temp 100.2. Has 2 seizures in the ED. Has hypoglycemia on labs as well as leukocytosis in CSF concerning for sepsis. Treat hypoglycemia and seizure aggresively as well as give antibiotics early. Do not delay for LP. Always consider nonaccidental trauma.
Sim Cases with Drs. Fernandez and Hill
Male with chest pain, shortness of breath and fatigue. Presents with HR in the 30s and BP 95/62. Has 3rd degree heart block on EKG. Troponin is 0.89 and BNP is 1008. You can give atropine, but this will not work. DDx is likely ischemia, so the pt likely needs the cath lab. The pt gets put on transcutaneous pacer, but that does not capture, so he needs a transvenous pacer. The line for this is similar to a trauma cath (dilator is already in the line) and then the pacer threads through the line. The control box for the pacer is precet for HR at 80 and current of 10. If you forget what settings to use, hit the red button and it gives you automatic settings. Thread the pacer to 15 cm and then inflate the balloon until you get capture. Deflate the balloon and then decrease current to the lowest value that gets capture.
Check out the following posts for more info on transvenous pacemaker placement:
Young male with racing heart rate. He drinks a lot of caffeine and has HR in 170s-180s on presentation with normal BP and mental status. EKG shows SVT. Try vagal maneuvers, which have success rate of 25%. If this doesn’t work, give adenosine 6 mg, followed by 12 mg x2 prn. Adenosine has to be given fast as it has a very short half life – consider stopcock method for administration or drawing the med up in the flush (ala ALIEM and Bryan Haynes). If adenosine doesn’t work, consider synchronized cardioversion or other medications: verapamil, BB, procainamide. It is ok to discharge these patients if they are healthy and remain in NSR.
Update on Drugs of Abuse with Dr. Mel Otten
  • Overdoses kill more people than MVCs
  • Heroin overdoses are increasing in number while cocaine overdoses are decreasing
  • Prescription drug abuse: clonazepam is the most abused, followed by xanax/oxycodone/hydrocodone.
  • Cocaine is very frequently adulterated
    • Levamisole: antihelminth used in horses and used to adulterate cocaine
      • Metabolized to a stimulant (Aminorex)
      • Causes agranulocytosis (low WBC and increased infection risk) and necrotozing vasculitis
  • Synthetic Drugs
    • Most act on cannabinoid and/or amphetamine receptors
    • Bath salts: synthetic KHAT, mephedrone
      • Addictive, easily available
      • Aka “plant food”
      • Similar in structure to methamphetamine
      • Stimulant with serotonin and NE activity
      • Toxicity: tissue injury if injected, tachyarrhythmia, MI, stroke, myocarditis
    • NBOME: causes hallucinations, seizures, AKI
    • Geranium: stimulant that causes HTN, MI, cerebral hemorrhage
    • Spice: super THC that acts on cannabinoid receptors
      • Desired effects: euphoria, anxiolysis, antidepressant
      • Side effects: paranoia, seizures, HA, agitation, hyperthermia, arrhythmia
  • Inhalants: can cause sudden death due to V.Fib
  • Krokodil: desomorphine – causes skin and soft tissue damage
Intralipid with Dr. Mel Otten
  • Is this the tox magic bullet?
  • First used in anesthesia to reverse local anesthetic cardiotoxicity
  • Reported in animal studies to reverse lipid soluble drugs
  • Mechanism of action: no one knows but there are a few theories:
    • Lipid sink: sequestration of toxins from tissue
    • Hemodilution
    • Cardiotonic: rapid inotropic effects
    • Metabolic: provides lipid substrate for metabolism
  • If it is going to work, it works very fast, within minutes
  • Adult dosing: 200 mL bolus of 20% lipid emulsion followed by infusion of 0.25 ml/kg/min
  • Current indications: overdose of local anesthetic, haldol, TCA, beta blocker, Ca channel blocker
Financial Planning with Dr. Shaw
“The power of compound interest the most powerful force in the universe”
- Albert Einstein (supposedly)
Investment options for college: education IRA, 529 plan, UGM640px-Piggybank
  • Education IRA
    • 2000/year with income qualifications
    • No restrictions on investments
    • Must be used by age 30
    • Only educational expenses allowed
    • Not tax deductible, so funded with post-tax dollars
  • 529 plan: prepaid tuition/savings
    • Educational expenses only
    • Can be transferrable
    • Contribution considered as gift, so there is an overall dollar limit
    • Tax treatment: investment earnings are not subject to tax but contribution is taxed
  • UGMA = trust
    • Legally belongs to the child
    • No tax advantage to the contributor
    • No restrictions on investments or spending
    • Child gets control at 21 years of age
    • Tax treatment: can count against your child for FAFSA purposes
    • Can’t be accessed if you get sued as it is in your child’s name
Retirement options: pension, social security, IRA, Roth IRA, 401k/403B
  • Pensions: these are exceedingly rare
    • You receive X dollars/years worked
    • Now you can have a defined contribution, meaning that you and your company put in X/year and get it when you retire
  • Social security: 2642/mo maximal benefit if you retire at full retirement age
  • IRA: can contribute up to 5500/year
    • Set up with variety of institutions
    • If retirement option available at work, can only tax deduct if AGI < 69,000
  • Roth IRA: 5500/year max
    • Eligible only if income is less than 129,000
    • Contribution is not tax deductible but there is no tax on investment EVER
  • 401k/403B
    • Set up by employer
    • You pick contribution amount and investment
    • Employer can match contribution
    • Contribution is tax deferred
    • Current limit is 17,500/year

Investment options: stocks vs bonds

  • Stocks: unit of ownership in a company
    • Make money from appreciation and/or dividends
    • Foreign stocks are useful as their market does not always correlate with US market
    • Over long haul, usually increase in value
  • Bonds = IOUs
    • You lend me 100,000 over 10 years and I will pay you 400/month and then return 100,000 at the end of 10 years
    • Safer than stocks
    • Sources of risk
      • Inflation
      • Interest rate
      • Credit risk: issuer goes bankrupt
How to buy stocks/bonds: individually through a broker or through a mutual fund
  • 2 types of mutual funds:
    • Actively managed: fund hires a manager
      • Costly, 1-2%/year
    • Passively managed: index fund
      • Fund duplicates return on index
      • Index fund outperforms actively managed fund 75% of the time
  • Market crashes are terrifying. Do not sell your stocks. Sit and do nothing and stick to your plan
    • Upside of market crash is that stocks are on sale!
Alternative minimum tax: applies if you have lots of kids, high medical/dental expenses and high state and federal tax
     – not indexed for inflation
     – if you make > 100 K/year, you need to check if you have to do this
Bottom line: start investing now as every dollar you invest will compound over 20-30 years
MDM

by Tim Loftus, MD

Heilman, J.   http://upload.wikimedia.org/wikipedia/commons/c/c1/SubarachnoidP.png http://creativecommons.org/licenses/by-sa/3.0/deed.en

Heilman, J.

http://upload.wikimedia.org/wikipedia/commons/c/c1/SubarachnoidP.png

http://creativecommons.org/licenses/by-sa/3.0/deed.en

Perry et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid hemorrhage: prospective cohort study. BMJ 2011; 343:d4277.                                                                                                               

Study Objective: To determine sensitivity of head CT within 6 hours in ED patients presenting for possible SAH

Design: Multicenter prospective cohort study at 11 tertiary care centers in Canada from 2000-2009

Main Results:

  • 3132 patients enrolled
  • 240 total cases of SAH (7.7% study prevalence)
  • Overall sensitivity of CT for SAH was 92.9%
  • Overall specificity was 100%
  • Negative Predictive Value was 99.4%
  • Positive Predictive Value was 100%
  • 953 patients (30.4%) were scanned within 6 hours

o   121 (12.7%) found to have SAH

o   All cases identified by head CT (100% sensitivity + 100% specificity) 

Table 3: Sensitivity of Computed Tomography for SAH in patients with acute headache (recreated from original text)
LR (95% CI) Predictive Value (95% CI)
Time from HA onset to Scan # of Pts % Sens % Spec Positive Negative Positive Negative
All patients 3132 92.9 (89-95.5) 100 Infinity 0.07 (0.05 – 0.11) 100 99.4
≤ 6 hours 953 100 100 Infinity 0.00 (0.00 – 0.02) 100 100
> 6 hours 2179 85.7 (78.3 – 90.9) 100 Infinity 0.14 (0.14 – 0.17) 100 99.2

 

Authors’ Conclusions

Modern multi-detector thin slice head CT is highly sensitive for detecting SAH if performed within 6 hours of headache onset and interpreted by qualified radiologist.

“These findings are robust enough to inform the clinical decision […] whether to perform lumbar puncture after negative results on CT.”

Why Should You Care?
  • Headache approximates 2% of presenting complaints to the ED, and SAH is identified in approximately 1% of those patients with headache in the ED.
  • Overall mortality of SAH is high, estimated at 25-50% of patients dying within 6 months
  • If not fatal, SAH leaves approximately 33% of survivors with some appreciable neurological deficit affecting their ADLs.
Summary of the Discussion:

Many thanks to Dr’s Knight, McDonough, Hooker, and Adeoye who actively participated in the discussion and provided valuable insight. Many excellent points were raised, and although a verbatim post might do the contributors justice, it will not benefit those of us wary of the scroll feature.

Although this study raised some interesting points, as of right now the ASA/AHA currently recommend the CT/LP approach to diagnosing aSAH (Class 1 Recommendation, Level B Evidence, Stroke 2012). Heck, if Ope and his cronies cannot diagnose what may or may not be an aneurysm, then what is left for the rest of us? As was stated, if SAH is suspected clinically, then those patients should probably continue to get LP’s to assist in diagnosis or exclusion.

An interesting discussion ensued about the acceptable miss rate for SAH – and other neurologic catastrophes – being essentially zero. Thus, although a “bad” test might still look good for a disease of such low prevalence, it remains essentially indefensible not to complete the currently recommended evaluation if the head CT was non-diagnostic.

Also, to satisfy you methodology wonks, thanks to Dr. Benoit for pointing out that this was indeed a prospective study with the time cut-off decided a priori!

References:

  • Perry et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid hemorrhage: prospective cohort study. BMJ 2011; 343:d4277.
  • Connolly, et al. AHA/ASA Guideline.  Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. Stroke.  43. 1711-1737. doi: 10.1161/​STR.0b013e3182587839
Central Line Complications w/ Dr. Bill Knight
  • Rate of adverse events during central line placement is 2-26%.
  • Common complications
    • Early: mechanical, ie misplacement, pneumothorax
    • Late: infection, thrombosis, occlusion
  • 50% of femoral lines are misplaced during cardiac arrest
  • 20% DVT risk with femoral vein puncture
  • CLABSI (Central Line Associated Blood Stream Infection): 250,000/year
    • 3rd most common cause of nosocomial infection
    • related to duration of catheterization
    • mortality 12-25%
    • increases morbidity, mortality and prolongs length of stay
    • The most important thing you can do to prevent CLABSI is sterile technique
  • Arterial vs Venous placement
    • Confirm with Ultrasound
    • agitated saline under US
    • transduce waveform
    • send a blood gas
    • if in doubt, do not dilate
  • ALWAYS check your own x-ray and if you feel resistance, do not push but start over
  • Operator factors:
    • Failure more than 3 times increases risk of complications by 6 times
    • If you have > 50 insertions, your risk of complications is reduced by 50%
    • 3 unsuccessful attempts = new operator
Health Care Associated Pneumonia (HCAP) Update with Dr. Justin Benoit*
  • Criteria for HCAP
    • Hospitalization for 2+ days within 90 day period
    • SNF resident
    • Receives home IV therapy, chemotherapy or is a hemodialysis patient
  • HCAP treatment
    • Cefepime 2 g or zosyn (weight based dosing)  AND
    • Tobramycin (Cr based dosing)   AND
    • Vancomycin 20 mg/kg or linezolid 600 mg IV
  • Outpatient CAP treatment: monotherapy with azithromycin not recommended due to high resistance
    • levofloxacin 750 mg x 5 days: do not give in pregnancy, adolescents, CKD, pts on chronic steroids  OR
    • Z-pak + amoxicillin 1 g TID x7 days
  • CAP with admission
    • Floor: azithromycin + Rocephin/ampicillin  OR levofloxacin IV
    • ICU/stepdown: azithromycin + Rocephin/Augmentin OR aztreonam + levofloxacin
  • When to get blood cultures: ICU admission, alcoholics, leukopenia, ESLD, pleural effusion, asplenia
  • CURB-65: scoring system to help determine need for admission
    • Confusion
    • BUN > 19
    • RR > 30
    • SBP < 90 or DBP < 60
    • age > 65

* Note that these are based on local resistance patterns and may not be broadly applicable in other regions/locales.

Indications for Non-Invasive Positive Pressure Ventilation w/ Dr. Erin McDonough
  • CPAP = PEEP. Use for oxygenation
  • BiPaP = Pressure support + PEEP. Use for ventilation
  • Pros of NIPPV
    • Decreases intubation rate and thus decreases resource utilization, decreases risk of VAP, decreases airway trauma and preserves speech/swallow
  • Cons of NIPPV
    • Risk of vomiting and aspiration
    • Increased secretions
    • Unable to give oral intake
    • Can cause facial pressure ulcers
    • Can delay intubation
  • NIPPV in COPD
    • Good data that shows that NIPPV decreases mortality, decreases need for intubation and decreases treatment failure
    • Leads to rapid improvement of CO2 and symptoms
    • Decreases length of stay
  • NIPPV in asthma: no evidence for or against but reasonable to try
  • NIPPV in CHF: mainly data for CPAP as issue is with oxygenation
    • Opens alveoli and improves gas exchange
    • Improves work of breathing
    • Decreases afterload
  • NIPPV in pneumonia: no studies looking at this however PNA is one of the predictors of failure of NIPPV
  • Predictors of failure of NIPPV
    • High APACHE II score
    • Low pH
    • Altered mental status
    • Secretions
    • Poor initial response
    • Presence of pneumonia
  • Other indications: extubation to NIPPV (especially in COPD), preoxygenation for RSI/DSI
  • Pitfall: any condition that will last for more than 24 hours is unlikely to improve with NIPPV
  • The most important factor when putting patient on NIPPV is reassess in 1 hour
Leadership Curriculum w/ Dr. Brian Stettler
  • Components of our leadership curriculum:
    • Large group lectures
    • Academies: education,  research, operations
    • Optional small group meetings and workshops
    • Mentored project: this is an optional one-on-one labor intensive project of self-exploration and service
  • Small groups on how to solve some issues that came up in program evaluations:
    • Attributes of a leader to make these changes possible: humility, trust, communication, approachability, broad perspective, flexibility, collaborative
    • These decisions and changes will always include representatives from multiple circles: residents, RLT, operations leaders, MLP and nursing leadership
MDM

If you were to choose one vital sign for your critically ill patient, what would you choose?  Blood pressure?  Pulse?  Respiratory rate?  O2 sat? Temperature?

Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.

Tachycardia presents earlier in shock but what about the elderly patient on beta-blockers?  What about the trauma victim with a belly full of blood (vagal nerve stimulation leading to an attenuation of their tachycardia)?  Too easy to be misled with that one, I say.

What about respiratory rate?  …  How many times have you seen a respiratory rate documented correctly? Lovett, et al (2005) found that neither the clinical measurement of respiratory rate by nursing staff or electronic monitors at triage accurately measured respiratory rate.  For a critically ill patient, you can imagine how much more difficult this can be?  You can probably look at the patient for 5-10 sec and get a sense of too-fast or too-slow, but subtle changes in respiratory rate are tricky to pick up.

What about O2 sat?  Even if you can keep it on your patient’s finger/strapped to their ear or forehead, you are going to be late in the game at detecting complications peri-intubation and during sedations.  You may have experienced this lag time after intubating a patient and having a brief drop in the O2 sat into the 70’s.  Everyone in the resus bay turns and stares at the monitor for 20 sec while someone bags (furiously and unnecessarily fast) as the O2 sat slowly rise into the 90’s.  And, have you ever seen an oxygen-dissociation curve? That thing looks dangerous.  I’ve seen cliff’s that have shapes similar to it…

O2 dissociation curve cliff

Temperature?  Really?  Temperature?

Nope, for me the vital sign of choice is undoubtedly EtCO2 (End tidal CO2).  Why?  A single, non-invasive, set up that can give you a glimpse into the ventilation, perfusion, and metabolism of the patient?  Yes please, I’ll have some of that.

EtCO2 Meme

I think it’s well documented that waveform capnography can help lead to better prevention of hypoxic events in procedural sedation (Deitch, et al, 2009) and can help in the detection of esophageal intubation (though probably shouldn’t be relied on as a sole indicator ET tube location). (Grmec, S. 2002) In the accompanying podcast to this post, Dr. Jason McMullan, the EMS Fellowship Director here at UC, talks about the use of EtCO2 in the prehospital environment.  Whether it is detecting tube dislodgment in an intubated patient, avoiding hypercapnia in a patient with TBI, or even monitoring your resuscitation in a patient with hemorrhagic shock, waveform capnography is a powerful piece of monitoring equipment in the prehospital environment.

For a rundown on interpreting waveform capnography check out these excellent FOAMed resources:

References:
  • Lovett, P., Buchwald, J., Sturmann, K., & Bijur, P. (2005) The vexatious vital: Neither clinical measurements by nurses nor an electronic monitor provides accurate measurements of respiratory rate in triage. Annals of Emergency Medicine. 45(1) 68-76. doi: http://dx.doi.org/10.1016/j.annemergmed.2004.06.016
  • Deitch, K., Miner, J., Chudnofsky, C., Dominici, P., & Latta, D. (2009) Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia with Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial. Annals of Emergency Medicine. 55(3). 258-264. DOI: http://dx.doi.org/10.1016/j.annemergmed.2009.07.030
  • Grmec, S. (2002) Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Medicine. 28(6) 701-704.
  • Donald, M. & Paterson, B. (2006) End tidal carbon dioxide monitoring in prehospital and retrieval medicine: a review. Emergency Medicine Journal. 23. 728-730. doi: 10.1136/emj.2006.037184