Post Arrest Care in the Ambulance Enviroment

This is a short podcast, on the current position of prehospital care in Post Arrest patient, produced as part of my post graduate work.

As always the podcast can be found in the I Tunes feed, or streamed via podomatic.

https://itunes.apple.com/au/podcast/downstairs-care-outthere-podcast/id876296199

402 Podcast Reference Note:

Begin with introduction (Identify time, date, location and person recording)
Case Study for OHCA with ROSC, Setting the scene for beginning of podcast.
Review review reversible causes of Cardiac Arrest to review whats caused and what will be the guide to post arrest care
Review Airway interventions, ETT has been deemphasised if SGA is in situ.
Post arrest patients may need sedation, if they have spontaneous changes in LOC that may cause them to become agitated and regain purposeful movement.
Attention needs to be paid to the rate and volume of ventilation, ideal is 98% to 94% SPO2 post arrest
Post arrest capnography is standard of care for intubated patients.
Support patients cardiac output with fluids and Adrenaline infusion.
Attempt to move patient to a Percutaneous Coronary Intervention Capable hospital or Service capable of Thrombolysis.
If your service is capable of providing Prehospital Thombolysis this can be performed if indicated. Evidence shows that thrombolysis can be safely performed post arrest.
Close off patient case study from beginning of podcast.

402 Podcast Reference List;

Deasy, C., Bernard, S., Cameron, P., Jacobs, I., Smith, K., Hein, C., . . . Finn, J. (2011). Design of the RINSE Trial: The Rapid Infusion of cold Normal Saline by paramedics during CPR. BMC Emerg Med, 11, 17-17. doi: 10.1186/1471-227X-11-17

Dumas, F., Cariou, A., Manzo-Silberman, S., Grimaldi, D., Vivien, B., Rosencher, J., . . . Spaulding, C. (2010). Immediate Percutaneous Coronary Intervention Is Associated With Better Survival After Out-of-Hospital Cardiac Arrest: Insights From the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) Registry. Circulation: Cardiovascular Interventions, 3(3), 200-207. doi: 10.1161/circinterventions.109.913665

Kern, K. B. (2012). Optimal Treatment of Patients Surviving Out-of-Hospital Cardiac Arrest. JACC: Cardiovascular Interventions, 5(6), 597-605. doi: 10.1016/j.jcin.2012.01.017
Kilgannon, J., Jones, A. E., Shapiro, N. I., & et al. (2010). ASsociation between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA, 303(21), 2165-2171. doi: 10.1001/jama.2010.707

Neumar, R. W., Nolan, J. P., Adrie, C., Aibiki, M., Berg, R. A., Böttiger, B. W., . . . Vanden Hoek, T. (2008). Post–Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and Prognostication A Consensus Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation, 118(23), 2452-2483. doi:

10.1161/circulationaha.108.190652

Nielsen, N., Wetterslev, J., Cronberg, T., Erlinge, D., Gasche, Y., Hassager, C., . . . Friberg, H. (2013). Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. New England Journal of Medicine, 369(23), 2197-2206. doi: doi:10.1056/NEJMoa1310519

Spöhr, F., & Böttiger, B. (2003). Safety of Thrombolysis during Cardiopulmonary Resuscitation. Drug Safety, 26(6), 367-379. doi: 10.2165/00002018-200326060-00001
Sunde, K., Pytte, M., Jacobsen, D., Mangschau, A., Jensen, L. P., Smedsrud, C., . . . Steen, P. A. (2007). Implementation of a standardised treatment protocol for post resuscitation care after out-of- hospital cardiac arrest. Resuscitation, 73(1), 29-39. doi: 10.1016/j.resuscitation.2006.08.016 1

RSI Basics Podcast with Minh Le Cong (@ketaminh on twitter)

A Podcast with Minh Le Cong on beginner RSI. Recorded for my own personal reference but its such a great resource for Paramedics, Paramedic Students and a good all round touch up on the subject with a person much more knowledgeable than I.

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If your not listening to Minh I highly suggest you start! His podcast was my first step into #FOAMed, so its an absolute honor to have him on my own.

You can find the Podcast over on I-Tunes:

https://itunes.apple.com/au/podcast/downstairs-care-outthere-podcast/id876296199c

(please take time to leave a review or rating!!)

Below you will find some of the papers, trial and websites that we mention throughout, all are a good read. There’s also a number of different checklist ideas.

PHARM Podcast 61:
http://prehospitalmed.com/2013/02/19/pharm-podcast-61-rapid-sequence-intubation/

The Original RSII Article;

http://journals.lww.com/anesthesia-analgesia/Citation/1970/07000/Rapid_Induction_Intubation_for_Prevention_of.27.aspx

The study protocol for the Head Injury Retrieval Trial (HIRT): a single centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics

By: Garner, Alan A, Michael Fearnside, and Val Gebski.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
http://www.sjtrem.com/content/pdf/1757-7241-21-69.pdf

SOAPME Memonic for RSII Prep:
https://umem.org/educational_pearls/2577/

Sydney HEMS Check List

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EM CRIT Intubation Checklist  

http://emcrit.org/podcasts/emcrit-intubation-checklist/

When there’s no hospital

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Remote and Rural Paramedicine, the final frontier.

Hospitals are far between and in some towns the Ambulance is the only health resource.

The transition between practicing rural paramedics and practicing in a major urban centre is difficult but rewarding.

Backup is always far away, my closest additional Ambulance Resource is 40 minutes by road, you have to learn to survive on your own. With you and your partner.

This can make the management of critical illness more difficult. Sometimes you can’t wait for backup, sometimes back up isn’t available. Often you can be the highest trained provider on the scene. Not only do you need to perform treatment, but movement towards definitive treatment you can’t provide needs to be considered.

Knowing more that the bare basics will serve you well, being able to assess a patient and provide appropriate decisions for that patient. When the hospital is a 40 minute trip away and bringing a patient home poses significant difficulties for family and friends treatment at home, or in the outpatient setting if it can be accomplished provides significant benefit.

Education; You need to educate yourself! typical ambulance training focuses on the metro experiences of a majority of cases and in most metropolitan and peripheral metropolitan areas your no more than 25 minutes from a hospital by road, backup is rarely far away. You need to learn about long term management, calculate drip rates to administer appropriate fluids, plan to administer larger amounts of analgesia because a patient may be in your care for 5 to 7 hours. If you ever have the opportunity to pick the brains of a nurse, learn how they plan long term care of the critical care patient. Because thats what you’ll be doing, be it on an inter hospital transfer or a scene call.

Below are some of the lessons learned and the hot tips for those new and old;

Equipment; You may need to use syringe drivers and pumps or borrowed equipment from a hospital or patients house (i.e. at home ventilators for brain injured) Learn to fault find and fix common problems. You can end up using this equipment over longer transfers and as the only professional for a long way you need to know common problems and what you can do to fix them.

Medications; The patients condition on transfer may require the administration of of medications not typically part of the Ambulance Pharmacy. Know what needs to be done with that, if they want a repeat dose, make sure the sending hospital provides enough premixed medication to last the transport (ie. if the patient is coming out of a hospital needing 250ml of NACL an hour for a 3 hour transport, get a new bag hooked up to the Infusion Pump, if running Insulin for DKA ensure you have enough in the bag or burette for the transport. Know the side effects, know how to stop the infusion and what to do if adverse events occur.

Best care: you need to know how to provide best care, where that can be gotten. Be that the local community nurse to provide wound care without going to hospital, or referring a patient to their GP in a timely manner (get to know your community transport people, they will really help you out), or if the patients presentation requires it then transport to the nearest appropriate hospital facility.

Learn to provide your patients the best care, learn to triage to the appropriate hospital, talk to you local hospital staff, learn what they can and can’t handle. What you are best to take to them and what will be best transported to the nearest Base Hospital or what you may need a helicopter or fixed wing mission for. Learn to work with your local hospital, they will be your greatest ally.

If you take the time to work on relations they may even let you perform procedures( often we don’t require a prehospital cannula but hospitals do, this can be an opportunity to practice a skill in an environment where you may cannulate less than once a week on the road or in the back of the ambulance.

I’ll take this moment as well to talk about the relationship between volunteer agency and your work on road, get used to working closely together, as these agencies will be providing most of the initial assistance on the scene of road accidents, we know my great love of pre planning and training before the fight. Time spent working with these agencies on their training nights will pay of in the long run. You may give up 4 hours of your time but the assistance you gain on scenes will be well worth it. Giving the agency the time to look at your truck and your gear teaching some of the basics of road side care, providing first aid materials for mass casualty events (most agencies require Senior first aid qualifications, they can be invaluable when they are on the scene and not otherwise occupied). Some examples of lessons include, first aid refreshers, extrication from cars, using long board, scoop and KED, practice the calls and timing so everyone has a chance to learn, because its far easier to instruct and correct when your in a well lit, quiet and non stress environment than on the roadside by headlamp with everyone learning how to extricate for the first time.

If you have any further ideas and experience I welcome feedback, I would love to have you on a podcast or to write an article!

While your thinking rural its well worth heading over an looking at this article by some very active rural health advocates;

Rethinking remote and rural education; Alan Batt, Jessica Morton, Mathew Simpson Canadian Paramedicine

http://emsnews.com/features/featured-articles/_rrr

Inter Hospital Transfer

wpid-20150111_130054.jpg Not much research has been done in this area relating to interhospital transport, but a lot of good practice from the hospital can apply to us. You obviously have fews sedating medications available but the principle remains the same. Take your safety into account and if your concerned raise it with your partner, the sending and receiving hospitals. It takes a few minutes to sort out any issues and can prevent a major mishap further down the road. All view and opinions are my own, always observe local protocols and procedures. Work Hard and be good to your patients!

You can find the Podcast here https://itunes.apple.com/au/podcast/downstairs-care-outthere-podcast/id876296199?mt=2

While your on itunes, please rate and leave a review.

What to read; ABC’s Transfer and Retrieval Medicine; Chapter 42, Acute Behavioural Disturbance M. Le Cong ABC’s Prehospital Emergency Medicine; Chapter 4, Scene Safety V. Calland & P. Williams What evidence exists about the safety of physical restraint when used by law enforcement and medical staff to control individuals with acute behavioural disturbance? Peter Day http://www.otago.ac.nz/christchurch/otago014012.pdf

Emergency Psychiatry: Contemporary Practices in Managing Acutely Violent Patients in 20 Psychiatric Emergency Rooms
Renée L. Binder and Dale E. McNiel

Psychiatric Services 1999 50:12, 1553-1554 http://ps.psychiatryonline.org/action/showCitFormats?doi=10.1176%2Fps.50.12.1553 Jennifer Rossi, Megan C. Swan, Eric D. Isaacs, The Violent or Agitated Patient, Emergency Medicine Clinics of North America, Volume 28, Issue 1, February 2010, Pages 235-256, ISSN 0733-8627, http://dx.doi.org/10.1016/j.emc.2009.10.006. (http://www.sciencedirect.com/science/article/pii/S0733862709001242) Keywords: Violent; Agitated; Sedation; Restraints; Psychiatric; Substance abuse

A Very Particular Set of Skills ; Assessing Trachea Deviation 

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Assess deviation of Trachea, something we talk about often, but are you pressing on the right point.

Recently working a shift with a rather junior paramedic, she made the same mistake that I had at the start of my training.
When assessing the Trachea she palpated the Bony prominence of the Larynx. I made the same mistake a few years ago, having read the procedure but never watched or looked at pictures.

Showing Incorrect finger placement, not that the area palpated is superiors to Tracheal Structures and fingers rest on the Larynx. The Larynx won’t deviate with Pneumothorax as its a fixed.

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Below shows the correct placement of the fingers in assessing Deviation of the Trachea.

Note that the fingers are placed only 1-2 cm superior to the Suprasternal Notch.

Its worth reviewing the the underlying anatomical structures that we are trying to feel when palpating the Anatomy of the neck

An open access CT giving you an appreciation for the structures that your trying to palpate.

From Radiopedia  (viva la FOAMED!)

http://radiopaedia.org/cases/normal-ap-barium-swallow

Otherwise take a quick flick through which ever Anatomy Text your using.

Let’s be clear! Not all trauma patients must be treated with spinal immobilization during prehospital resuscitation and transport.

jrparameddscot:

Some good reading for those who still think SMR for everyone is the gold standard.

Originally posted on MEDEST:

ems-backboardsSpinal immobilization is performed in all trauma patients from the rescuers in EMS systems all over the world, regardless the mechanism of injury and the clinical signs.
This kind of approach is nowadays been rebutted from the recents evidences and the actual guidelines.
ACEP, in Jan 2015, released a policy statement entitled :”EMS Management of Patients with Potential Spinal Injury” clarifying the right indications, and contraindications, for spinal immobilization in prehospital setting.
The lack of evidence of beneficial use of devices such as spinal backboards, cervical collars etc… is in contrast with the demonstrated detrimental effects of such instruments: airway compromise, respiratory impairment, aspiration, tissue ischemia,increased intracranial pressure, and pain, consequent to spinal immobilization tools, can result in increased use of diagnostic imaging and mortality.

Already in 2009 a Cochrane review demonstrated the lack of evidences on use of spinal restriction strategies in trauma.

Recently the out of hospital validation…

View original 370 more words

Immediate care at the community level

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I want to talk about getting your community involved in CPR Programs and CPR education. Often I hear people, friend, family, acquaintances, bystanders talking about CPR, often I hear “I couldn’t do CPR I haven’t done a course”

Ambulance Computer aided dispatch has been providing CPR instruction over the phone for years, once a Cardiac or respiratory arrest is identified by information given by the caller a prompt is delivered to the call taker scripting providing  CPR instruction to the caller, after establishing the ability of the person to perform CPR instruction is given for 100 beats per minute with no “rescue breaths”

CPR is an easy skill to provide a passing understanding of to the general public.

I can do the shopping centre version in under two minutes with a short practice.

1; Make a W start at the top and bottom of the sternum

2: Press at the top of the middle point of the W, that will be where your performing compressions

3: 100 per minute, think of staying alive!

Don’t stop until Ambulance Arrives! Wait for us to tell you to stop!

I will often take the opportunity to give the person the experience of having paramedics come in work around them for about 30 seconds and take over, this can take some of the anxiety out of the experience especially for the young and old.

If your a health professional, don’t hesitate to provide instruction! Encourage your friends and family to receive CPR or First aid Training. if you live in a small rural community, there can be benefit in providing short periods of instruction to any interested comers.

There is no disservice to providing instruction.

The basics of CPR and Haemorrhage control can save lives when the ambulance is coming but distances prevent immediate response.

In my current coverage area we could be responding to a Urgent Case for over 50 minutes, with the extensive network of dirt roads and long distances a minor haemorrhage could easily become a life threat without timely self aid.

4

Keeping Hand Hygiene close at hand.

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To those of us in the Prehospital field holding the various gel and solutions to clean our hands is difficult. I’m provided with pocket sized bottles of sanitiser.
I found issues carrying them in pockets, I lay on them in bed on nightshift then gel goes everywhere.

This is where planning comes into play, putting gel in the car, front seat back seat, in shift bags and near gloves, this last one is important, near gloves.

You need to build a habit of washing or sanitising before you put on gloves. Clean gloves in a box can very easily become contaminated, especially if you consider the work environment, you can touch, dirt, smashed bugs and tomato sauce all within 20 seconds on the ambulance.

Placing the products in a easy to use place is half the battle next is conditioning yourself to use them at every available opportunity.

 

The Range of products available, fairly standard across ambulance services.

The Range of products available, fairly standard across ambulance services.

Gel stashed in the side bin of the Rear Ambulance compartment. Can also be pink sanitiser or foam depending on availablity

Gel stashed in the side bin of the Rear Ambulance compartment.
Can also be pink sanitiser or foam depending on availablity

Pink hand wash bottle by the gloves in the rear compartment.

Pink hand wash bottle by the gloves in the rear compartment.

We’ve known the benefit of hand cleaning for years! Health care providers have been shown to be very reliable at hand washing post patient contact. Now to develop your practice and clean before your contact.

Best practice is the basics done right, Hand hygiene is a basic we need to improve our performance in.

Monitor yourself and work on your own self improvement.

 

References; Related to EMS Hand Hygiene and monitoring of compliance.

http://www.biomedcentral.com/content/pdf/2046-4053-2-101.pdf

http://www.jem-journal.com/article/S0736-4679(13)01061-5/abstract?cc=y

http://www.journalofhospitalinfection.com/retrieve/pii/S0195670109001868

What’s in your pocket

With everyone on Twitter emptying out there flight suit pockets to show what they carry on shift I wanted to draw particular attention to a peice of kit I carry every shift.

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This box is my survival kit.  The tin is a black “tobacco” style tin, with an Australian Flag sticker and two pieces of glow in the dark tape.
Built from scratch based on useage and others recommendations and experience.
What does this have to do with paramedics?
Not much, however it’s an item you should give consideration to if your work puts you in remote locations frequently.
Where phones don’t work and radio coverage can be spotty, a breakdown or the Ambulance being disabled by a collision with wildlife could find you in a situation where the only option is to survive of your car supplies until help arrives.
This box is supplemented by 4L of water carried in my shift bag that’s gets moved from Ambulance to Ambulance for every shift.

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This is it, first packed up and layed out.
From left to right you have
1. Two “riggers” rubber bands
2. 25 ft of Kevlar Cord
3. 1 pack of Steri Strips
4. “Commando” wire saw
5. Safety Whistle
6. 10 water purification tablets
7. Gerber Dime Multi Tool
8.Wet fire tinder tab (white bag)
9. Quick fire tab (zip lock bag)
10. Button compass
11. 2x Oven bags wrapped with “riggers” rubber bands (water carrying, transpiration collection)
12. Striker rod
13. FRED can tool/ spoon
14.aviation survival striker tool (like a lighter wheel)
15. 2 meters of Duct Tape
16. 2 packets of sutures (emergency sewing)

While it rarely gets used for its intended purpose, surviving without much else, in the event of catastrophic event. Leaving me without transport, this kit is designed to provide me with tools that are difficult to make or find in the initial hours.
Often I use this kit for general problem solving, duct tape and sutures being the most used items for minor repairs.

If you work in regional areas thought should be given to extra water, change of clothes and some food. If your concidering making your own kit its an easy process with a number of how to guides online. It doesn’t have to be in a hard tin or contain as much as mine it has to be a kit you carry and know what’s in it and what you use it for.

Get on twitter and show off what’s in your pockets when you clock onto shift!

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This is what I carry day to day, plus the above tin.

This is Australia! Where the bloody hell are you?

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Green rolling hills on the way back from Orange

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A well loved resident in a local Nursing home (bottom left)

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Roadside stop on the way back from a long transfer

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Stained glass window in a Hotel

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Sunset Over the Ardlethan Medical Center

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The disused Ardlethan Tin Mine

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Take off from a small coastal airport

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Canola fields

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Extremes of Weather

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Rainbow out the front.

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Dirt road response

This Australia day take a look at the best office in Australia.
Rural and Remote Paramedics is the best job you’ll ever have and in country like this you’ll have a hard time leaving!

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