Flights - A Stab in the Dark - Curated Comments and Expert Commentary

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.”  If you didn’t get a chance to check out the case and the discussion, check it out here.  Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng

Q1 - Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa.  As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.”  Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries.  This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.

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Flights - A Stab in the Dark

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Flights - A Stab in the Dark

You are working overnight as the H2 doc based at Butler County Regional Airport.  It’s bitter cold out (for Ohio that is).  Its only 11 PM and already the temperature has dropped to 9 degrees fahrenheit on its way to a low of 0.  You are in the lounge refamiliarizing yourself with the contents of the critical care cells when the tones go off: “Scene: stab wound – Hamilton Ohio”

You and the nurse grab your equipment, the blood cooler, and head to the helicopter.  You put the critical care cells back in their spot in the rear of the helicopter and then buckle in for the short flight to the scene.

Your patient is a 23 year-old female who was in an argument with her boyfriend earlier in the evening.  The verbal argument quickly escalated, her boyfrienf pulling a knife and stabbing her multiple times in the right arm and right chest.  He fled the scene and she managed to call 911.  The first responders found the patient with significant active bleeding from her arm as well as chest.  She was initially responsive, but is now only awake to painful stimuli.

You meet the EMS crew in the back of the squad truck and assess the patient from the head of the bed.

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Flights - One Road too Far - Curated Comments & Expert Commentary

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Flights - One Road too Far - Curated Comments & Expert Commentary

Thanks to everyone who chimed in for our first ever "Flight"!!  If you didn't get a chance to read the case, take a look here.  There was some excellent discussion on how best to care for the blunt polytrauma patient.  Below is the curated comments from the community and Dr. Hinckley's take on the questions posed to the community.

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Flights - One Road too Far

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Flights - One Road too Far

You are working as the UH-doc.  Driving into your shift with the windows down and music playing, you figured the first warm day of the year would result in a busy day for you and the rest of the Air Care 1 crew.  You arrive for your shift, grabbing the radio from the Pod doc when the tones go off for your first flight of the day.  You grab the blood cooler head to helipad, checking your pager you find you’ll be responding to Southeastern Indiana for a “MVC rollover, entraped.”

You strap into the helicopter and fly over the city and to the rolling hills of Southeastern Indiana.  Landing on the 4 lane divided state road, you unstrap and head to your patient who is waiting with the BLS squad.

You open the side door of the EMS truck and head to the head of the bed to assess your patient...

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Neurologic Emergencies in the Air

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Neurologic Emergencies in the Air

Several months ago, I sat down and talked about the management of neurologic emergencies in the prehospital environment with Dr. Erin McDonough, an Emergency Physician and Neurointensivist who attends both in the ED and the Neurosciences ICU, and is a member of the Cincinnati Stroke Team.  In the brief podcast found below and on iTunes, we covered a wide range of topics including blood pressure management in spontaneous ICH, aneurysmal SAH, and ischemic stroke and some of the more rare complications associated with tPA administration.

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The Glories of End Tidal CO2

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The Glories of End Tidal CO2

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.

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PEEP PEEP PEEP

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PEEP PEEP PEEP

Ventilator management can be one of the more intimidating aspects of caring for critically ill patients both in the ED and in the prehospital setting.   There are several great #FOAMed resources out there on varying aspects of ventilator management including the well-known series by Dr. Weingart of emcrit.org (here and here).  Ventilator management can be an absolutely massive topic but for this post, and specifically for the embedded video below, I wanted to do a little deeper dive on only one of the components of ventilatory management: PEEP.

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Sepsis in the Air

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Sepsis in the Air

Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis.  However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care.  I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.

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The Myth of the Stable STEMI Transfer

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The Myth of the Stable STEMI Transfer

We fly/transfer many patients with STEMI on Air Care and Mobile Care.  And, fortunately, a majority of these patients end up doing very well.  You accept them at the referring facility, load them in the helicopter, and transfer them to the cath lab at the receiving facility without incident.  You certainly may make some adjustments in nitro drips, maybe give some metoprolol, certainly review their outside hospital records, but usually the biggest benefit you are offering them is rapidity of transport.  Transport 20 or 30 of these patients without incident and you might get lulled into thinking that these patients are so incredibly stable that nothing bad will happen during the course of the transport.  To do so would be folly.

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Running a Code (in Tight Quarters)

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Running a Code (in Tight Quarters)

How many hands does it take to run a code?   Think about that for a bit...

In the SRU, the available hands seem essentially limitless.  There's a train of PCAs and medical students lined up to perform CPR, a nurse to run the monitor and defib, a nurse and/or pharmacist pulling up meds and mixing drips, a nurse charting, a MD dedicated to the airway, a RT to help with bagging, not to mention the MD running the whole show.  At a minimum you probably have 10 hands ready to ensure compressions are as uninterrupted as possible, to keep a check on the respiratory rate, to hook up monitors, push meds, defib, and all the other tasks that are necessary to code a patient.

Now what do you do in the back of the helicopter when a patient loses a pulse?

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Prehospital TBI - Beyond the "Code"

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Prehospital TBI - Beyond the "Code"

Of the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging.  Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics.  In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury.  This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.

To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:

  1. NO Hypoxia (SpO2 < 90%) – therefore, apneic oxygenation for all TBI patients
  2. NO Hypotension (sBP < 90 mmHg) – greatest iatrogenic risk is with induction and provision of positive pressure ventilation
  3. Blown pupil -> Hyperosmotic therapy + Hyperventilate
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Video Laryngoscopy in the Field? Absolutely

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Video Laryngoscopy in the Field? Absolutely

Close your eyes... actually open them up, you won't be able to read the description if you close your eyes... Imagine you are on flying on the helicopter for a scene flight.  You land and are brought to the patient, a victim of a motorcycle accident who is clearly in need of an airway.  He is obtunded with sonorous respirations, a GCS of 6, O2 sats in the low 90's.  You start to look and assess the patient's airway and you are decidedly less than pleased.

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Rescue Me

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Rescue Me

Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

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Decision is a Sharp Knife

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Decision is a Sharp Knife

In emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).”  I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.

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Needle Cricothyrotomy

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Needle Cricothyrotomy

Circumstances rarely are such where we must perform a surgical airway emergently. When we do, it is always for the same indication: you have a patient that you can’t intubate AND can’t oxygenate. In most cases where a surgical airway is required, a traditional open or Seldinger technique is preferred.

In children, however, these approaches are contraindicated (most authors describe age less than 10 or so as the cut-off). Thus, the needle cricothyrotomy is a procedure that we must be prepared to perform as emergency providers as this can be done in pediatric patients.

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