March 19, 2014

Lessons in Transport - Plasma? We Got That...

March 19, 2014/ Ryan Gerecht, MD

Why is Air Care starting to transport and infuse plasma? Multiple studies, many from military combat zones, strongly suggest that clinical outcomes are improved by administration of plasma alongside RBCs in a 1:1 ratio. (1,2) Furthermore, the concept of damage control resuscitation advocates for minimizing crystalloid infusion and maximizing early aggressive resuscitation with blood products in patients with life threatening hemorrhage. Recent unpublished analysis suggests that expanding these resuscitation principles to the prehospital environment via helicopter EMS was associated with improved outcomes.

March 18, 2014

Lessons in Transport - Your Friend and the Bleeding Patient's Friend: TXA in trauma

March 18, 2014/ Jeffery Hill, MD M.Ed

TXA… What can be said about TXA that hasn’t already been said. TXA is good for what ails you.

Nosebleed? No problem.

Menorrhagia? TXA can fix that.

Involved in a motor vehicle crash with multiple pelvic fractures, a busted up spleen, hemorrhaging internally? TXA has your back.

In this podcast, Dr. Hill, Dr. Steuerwald, and Dr. Gerecht sit down and talk through the indications for using TXA in the prehospital environment and briefly discuss some of the evidence for its use.

March 14, 2014

Lessons in Transport - Cognitive Biases in Critical Care Transport

March 14, 2014/ Ryan Gerecht, MD

As critical care transport professionals we are often perceived as an action oriented specialty. We frequently pride ourselves on procedural excellence and efficiency. (a difficult intubation, or fast scene-time etc.) However, the reality is that we spend the vast majority of our patient care time engaged in cognitive behavior... in THINKING rather than acting!

Because of this, it is imperative that we make every possible effort to understand how we think while caring for others. In addition, we should be aware of some of the cognitive biases that threaten our thinking processes, decision making, and thus the patients who place their trust in us.

March 13, 2014

Drill, Baby, Drill

March 13, 2014/ Jeffery Hill, MD M.Ed

You need access? You need access right now? Drill, baby drill.

The EZ-IO is pretty ridiculously easy to use. The only real decision points in its use are what site to choose (humeral vs tibial) and what needle to use (pink, blue, or yellow). There are a couple of other nuances which we will cover below and in the embedded video.

March 10, 2014

Ultrasound in HEMS

March 10, 2014/ Jeffery Hill, MD M.Ed

Critics out there may slight the use of ultrasound in the prehospital environment, saying it is just going to delay patient transfer and won’t add much to your decision making. However, when used properly, the ultrasound should never delay patient care and, when used in the correct patient population, it could help greatly in both decision making and treatment. Let’s first talk about when to use it. The logistics of this may be a bit tricky.

March 01, 2014

Finger Thoracostomy

March 01, 2014/ Jeffery Hill, MD M.Ed

We talked about needle thoracostomy a while back and when we did, we talked about the propensity for the needle to fail. There are a lot of reasons why the needle could fail to relieve a tension pneumothorax (or to only temporarily relieve a tension pneumothorax). The needle may be too short to enter the thorax in the first place* or the catheter could kink, allowing reaccumulation of air in the thorax.

February 23, 2014

Transporting Intra-Aortic Balloon Pump Patients by Air Care

February 23, 2014/ Bill Hinckley, MD

Many historians argue that the first use of aeromedical evacuation was during the Siege of Paris in 1870, using hot air balloons (though there seems to be some question regarding the truth of this claim). We're still using balloons during air medical missions in 2014, albeit in a much different way.

The efficacy of IABPs has recently been called into question; see Cliff Reid's recent blog post at http://resus.me/double-balloon-pump-fail/ . Regardless, the decision to initiate IABP therapy isn't going to be ours. But the challenge of moving an extraordinarily sick patient receiving this therapy WILL be ours. We must be ready. How?

February 18, 2014

Lessons in Transport - Upper GI Bleeding

February 18, 2014/ Ryan Gerecht, MD

It is 2am on a cold, dark, winter night and you are dispatched to a small rural hospital to transport a patient by ground with a GI bleed back to UCMC medical ICU. Enroute dispatch notifies you that your patient has deteriorated and is profoundly hypotensive. The ED physician at the outside hospital is attempting intubation for airway control. On arrival you find a middle-aged male with all the classic stigmata of end-stage liver disease. More importantly he has a systolic blood pressure of 60 and a HR of 130. A literal fountain of blood spews from the patients mouth, around a successfully placed endotracheal tube, and is now beginning to pool on the floor. You know this patient needs massive resuscitation from his likely bleeding esophageal varices... but you are 55 minutes by ground to UCMC and know that your patient will not survive the transport unless something is done to control the bleeding...

February 17, 2014

Resuscitation of Penetrating Trauma Patients

February 17, 2014/ Jeffery Hill, MD M.Ed

In our last podcast we covered the basics of the evaluation of the patient with blunt trauma. We switch gears a little bit this week and focus a little more on penetrating trauma. In this podcast, Dr. Hinckley and Dr. Chris Miller discuss several facets of the care of penetrating trauma patients including the initial approach and evaluation, detection of subtle presentations of shock, and triggers to initiate transfusion of blood products. In this accompanying blog post, I’d like to focus primarily on why we might want to withhold fluids on penetrating trauma patients.

February 14, 2014

Traction Splints - Applying the KTD Traction Splint

February 14, 2014/ Jeffery Hill, MD M.Ed

Immobilization of midshaft or distal femur fractures is thought to decrease pain for the patient during transport and to decrease the amount of bleeding and hemorrhage. Application of a traction splint, however, is a somewhat uncommon, and therefore potentially unfamiliar, procedure. A look at the literature on the use of traction splints in the prehospital environment shows that they are used uncommonly. And, when they are used, they are frequently placed incorrectly.

February 11, 2014

Needle Thoracostomy

February 11, 2014/ Jeffery Hill, MD M.Ed

There has been much digital ink spilled over the topic of needle thoracostomy (check below for some additional reading) with most of the hub bub surrounding the proper location to place the needle. We’re not going to completely rehash that which has already been said, but instead focus on distilling the highlights and turning our attention to a video showing how to perform what is ultimately a potentially life saving procedure. We won’t go much into finger thoracostomy as we will cover that procedure in a future blog post. So I heard that you’re setting yourself up for failure if you choose the 2nd ICS MCL to decompress the chest?

February 10, 2014

Who Gets a Pelvic Binder? Lessons from the #HEMS #FOAMed World

February 10, 2014/ Jeffery Hill, MD M.Ed

In our most recent post in the Air Care & Mobile Care Online Flight Physician Orientation, we talked about pelvic binding devices. As we noted, there's generally a paucity of evidence for or against the use of a pelvic binding device in blunt trauma patients. There are no hard and fast indications for the use of these devices. Whenever there is a lack of evidence for a particular treatment, we find ourselves looking to experts in the field for their experience and practice patterns. To that end, I asked some of of the #HEMS #FOAMed community to weigh in on the question and tell us their practice pattern

February 07, 2014

Application of Pelvic Binders

February 07, 2014/ Jeffery Hill, MD M.Ed

As we mentioned in the podcast that accompanied our most recent post, an injury that is critical to identify in blunt trauma yet easy to miss or forget is pelvic fractures and pelvic trauma. Significant injuries occurring to the pelvic ring usually involved high mechanisms of injury such as high speed MVCs, motorcycle crashes, pedestrian struck, and falls from significant height. Pelvic fractures can be associated with a significant amount of bleeding, hypotension, and increased mortality. Mortality for all trauma patients with pelvic trauma ranges from 5-30%. If there is associated hypotension, mortality rises to 10-42%

February 04, 2014

Evaluating Blunt Trauma Patients

February 04, 2014/ Jeffery Hill, MD M.Ed

A quick and thorough evaluation of patients with traumatic injuries is extremely important. The ideal approach is regimented, practiced, expeditious, and flexible to the environment in which it is performed. Advanced Trauma Life Support (ATLS) courses do a great job of teaching the guiding principles to the approach to the trauma patient. However, while it is relatively simple to become facile with the exam of victims of trauma in the (relatively) controlled setting of the trauma bay, it can be especially challenging to examine the same patient in the field.

January 31, 2014

On Tourniquets and Lives Saved

January 31, 2014/ Jeffery Hill, MD M.Ed

Though tourniquets were likely in use since Roman times, the term “tourniquet” was originally turned by Louis Petit, the 18th century inventor of the screw tourniquet. Though numerous design advancements have occurred and new devices have been made in the centuries that have followed, the basic principles of tourniquet use are essentially unchanged. A tourniquet applies an external pressure to a limb (usually) that exceeds the arterial pressure in that extremity. In this way the inflow of arterial blood to an extremity is stopped. For a surgeon, in the setting of a prospective extremity surgery, this allows for the creation of a bloodless operative field. For Emergency Medicine providers, tourniquets can aid in the exploration of extremity wounds, allowing the identification of injuries to tendons, joints, and vascular structures. And perhaps most importantly, tourniquets applied proximal to the site of penetrating traumatic extremity injuries can cease bleeding from arterial injuries.

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SRU (pronounced "shrew") = Shock Resuscitation Unit

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