Your out with some friends, in the bush/ backyard/on the mountain bike trail, behind you your mate screams and you turn around to see him holding a hand to his wrist, pressurised blood managing to makes its way around his clamped down palm. In the past, I would have improvised, made a solution out of whatever was easily available. But now for a relatively cheap outlay (less that $60 for a top of the line setup) I have some proper equipment. This scenario isn’t all that common, but to those of us who enjoy venturing far away from human habitation we recognise its a game ender. Often in prehospital work we say we’re nothing without our kit. While I can perform CPR and basic patient assessment with my hands. As the cautious prepared gent that I am I like to have some equipment handy should a situation arise.
There are various designs of Tourniquet out there. I’m not here to say that one is better than the other. But if your looking for the best, the SOFTT-W is hard to beat, I have about 4 or 5 rattling around bags, cars and my fiancés handbag.
They have been proven again and again in numerous trials that show without a doubt that stopping severe extremity bleeding early can only be advantageous. Leading to the placement of arresting life threatening hemorrhage above all else as the initial responsibilities of prehospital providers. This also goes for the outdoors and every day life. For 30 dollars you can get a pressure bandage and a SWAT Tourniquet which could be the tools you need at some point. Why improvise when the proper kit is available for two lunches at a hospital café!
The SOFTT-W (SOF Tactical Tourniquet Wide) is to my mind the best available. I own about 4 of them scattered throughout various equipment setups. The metal windlass and thick straps make for easy application, the D ring clip is secure and with some slight modifications the Tourniquet can be made thinner for packing away.
Credit to ITS Tactical for the Video.
The SOFTT-W if purchasing it out of your own pocket is quite on par with the cost of most other devices and for that money you get a better device less likely to fail. It is currently the top recommended device for TCCC.
https://www.youtube.com/watch?v=aJEKD_exUkA video from the manufacture Tac Med solutions.
CAT (Combat Application Tourniquet)
https://www.youtube.com/watch?v=tzXNsfesUb0 Manufactures video advising on use.
One of the original Tourniquets initially adopted for widespread used in the US Military after the need for more formalized TCCC was recognized in the Iraq and Afghanistan Wars. Issue has been drawn with the Plastic Windlass bar snapping on lower limbs due to the tension required to successfully occlude femoral flow. Its important to note that that their have been various issues with inferior quality CAT’s making their way onto the market for the purpose of Re-enactment and these are not intended to be used as medical devices. Try and ensure your buying from reputable dealers of medical supplies.
The MAT (Mechanical Application Tourniquet) My least favourite device. Don’t spend your money on it. The housing in bulky, the release is far to easy to trigger, there’s a reason this thing got a solid not recommended rating from the TCCC Committee.
This is my super compact trauma kit, no larger than a Phone its got a perminate place in my trail running pack. A Sling, and elastic bandage, A SWAT-T Torniquet and a Quickclot sponge is enough to get me or someone else out of trouble without having to carry a firstaid pack. This augments a Boo Boo kit for scrapes, blisters and minor wounds.
All packed up and ready to go!
If your Still not convinced have a look;
Naimer, S. (2014) A Review of Methods to Control Bleeding from Life-Threatening Traumatic Wounds. Health, 6, 479-490. doi: 10.4236/health.2014.66067.
, and Minimising blood loss in early trauma resuscitationTrauma January 2014 16: 27–36, first published on October 1, 2013 doi:10.1177/1460408613504066
If your unaware, the big day for the Paramedic Registration vote is the 7th of August! Time to start making some noise about what we want as paramedics.
Registration is Important. So get on social media and make some noise the tag is #PararegAus
Its time to stop playing prehospital care state by state an move to a national qualification system!
This is a quick primer on how to dress!
Our job requires us to sometimes spend extended periods of time in conditions others would soon give up on. The Rainstorm in the middle of winter, the 45+ Degrees on the side of the road in the middle of summer.
Its cold now, so I’ll lead with that. I’m lucky to work for a service that issues, Thermals, A fleece, A soft shell jacket and a Hardshell (Goretex Rain Jacket), I’m going to quickly talk about these items and how to use them.
One big jacket is not the answer to everything, the best thermal regulation is achieved by multiple thiner layers. This cuts down on bulk and allows you to adjust your clothing as the temperature dictates.
Thermals are a light thin clothing long or short sleeved, they are typically made of polypropylene or wool, in various weights from 150 to 300. The smaller the number the lighter the fabric. Thermals are designed to be worn under clothing. To trap heat they aren’t windproof or waterproof they will also move moisture away from your skin and keep you warmer. These are a Base layer, worn closest to your skin should always be directly on your skin, you will then put T-shirt’s and uniform shirts over the top.
Insulating Layers, Fleece and High Loft Jackets;
Everyone is fairly familiar with Fleece jackets, Look for a good 200 or 300 weight jacket made with Polartech, a fairly popular fleece fabric. Fleece will also wick moisture away from the skin, Fleece is best worn closer to the skin to move moisture. Its best to layer it over a base layer and then layer a uniform shirt or Shell layer on top. It can also be thrown over your uniform shirt on those not so chilly days where you just need something to take the edge off.
The icing on the cake, these block wind, keep you dry and add a little extra insulation. The shell layer exists mostly to reduce the chill from the wind. I’m issued both Pants and Jacket for work. In most Ambulance services this can be achieved by topping off your layers with the issues rain jacket or soft shell (these are a popular jacket combining fleece lining and a windproof water resistant fabrics creating an all in one garment for those days that aren’t to chilly or wet)
Here I can be seen at 0300 in the morning at Bowral Hospital, Its -3 degrees outside, I’m wearing a set of thermals, a fleece jacket and My Ambulance issued rain jacket a High Vis Goretex jacket.
With a little planning before your next shift you can be comfortable and warm.
While your out looking try and find a thin set of softshell gloves (these will set you back about $80) but will make cannulating on the side of the road at 0 degrees much easier.
Daily responses of a variety of Ambulance and Aeromedical Platform, as a tribute to Dr Hinds.
What an amazing talk he gave that day.
Second year of SMACC, this year I made the decision to go to a Workshop, that was not a mistake!
The second time round I get worried, I’ve been let down by second performances before (Jurassic Park: The Lost World, anyone?)
This was not a let down at all! After arriving at the hotel at 0100 on the Morning of SMACCForce, I went to sleep and awaited the bus.
SMACCForce was far less a workshop, more of a prehospital conference just prior to SMACC The speech by Ashley Leibig on PTSD, provider wellness, taking care of your own. I’m rather sad that that wasn’t filmed because it just got to me and really resonated.
There was also a captivating speech on what to do after an incident or accident by Mike Abernethy that was all about keeping the team functional but not rushing back into work.
Post incident time should be given for people to come to terms with what happened and their should be no pressure to return immediately to operations. I’ve seen it done both ways and I’ve seen the fallout from returning to immediate operations. I know how it effects the team and why it probably shouldn’t be done from an emotional perspective and probably effects the quality of care your providing and the degree to which you can render care.
Then onto the demonstrations by some of the HEM’s services on how Roadside RSI Should be done, How an inter-hospital transfer should look when done well.
After all this prehospital goodness, it was off to meet the EMSWolfpack, if you haven’t heard of the EMSWolfpack, it initially started as a discussion group among friends about what we would do and wanted to see in Chicago. Then we planned a meeting, opened it up to twitter and ended up packing out a pub in Chicago, we initially booked for 25…. I can say we far exceeded that. It was a great opportunity to meet a lot of Prehospital Providers in a great space.
I will talk about the EMSWolfpack later in a separate post, needless to say its something you should look out for especially as you attend conferences round the world.
With Day one, SMACC Was off to a start, after a cannon malfunction the talks began. Cliff Reid lead off with Advise to young resuscitationists. Then Crack the Chest get Crucified by the late John Hinds. This has been made available faster than usual.
Of course all the conference talks will be available through the magic of FOAMED as the months go on in the lead up to SMACCDUB.
As with all Smacc conferences, this was all about putting faces to names, shaking hands and hearing some truly amazing speakers who are not only experts in their field, but also nice people who you can hang out in a pub with.
I’m going to talk less about the Day to day running of SMACC because all the talks will come out and you’ll get most of the experience.
I will tell you to be on the look out for Tim Leeuwenburg’s All alone on Kangaroo Island, you have probably already seen the finishing move of the talk, but please don’t let that over shadow the message.
SMACC truly is an open conference as a prehospital provider, I felt it easier to pick my way through talks that interested me, because of the increase in concurrent sessions from last year.
If you have been having thoughts of going to SMACC its in Dublin next year! Start planning now, put in for leave, find a place to leave the kids or the dog and get there!
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.
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:
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
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.
You can find the Podcast over on I-Tunes:
(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.
The Original RSII Article;
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
SOAPME Memonic for RSII Prep:
Sydney HEMS Check List
EM CRIT Intubation Checklist
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
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
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
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.
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!)
Otherwise take a quick flick through which ever Anatomy Text your using.