flightmedic608

Interesting would not be the word I would have used at the time. Looking back retrospectively, it is quite interesting.

Great point Doc and that is how we approached this patients airway. We took into account (1) unstable airway (2) suicidal patient (3) 2 cm of tissue holding tachea (4) GR transport would be risky. We decided that taking an oral ETT approach while utilizing Etomidate and Fentanyl only would be the safest. Prior to administering any meditcation we prepared two "kelly" clamps and had my partner place sterile gloves on from the OB kit. Once the patient was given Fentanyl and Etomidate, my partner actually reached into the wound and held structure in place. I took the two "kelly" clamps and attatched one to each side of the trachea and securing to patient. We were very concerned about relaxing the patient and having the trachea detach and withdraw in to the thoracic cavity. Once both sides of the trachea were secure, I orally intubated the patient and "stented" the airway, ensuring the cuff was in position past the opening. Once the airway was secured, we gave the patient a long acting NMB for transport. This was a very interesting airway case and I am glad I have had an opportunity to share it with you.

Hi Kick, my comment "Not in this case" was for ERDoc about transport decision based on airway, not in regards to what your local HEMS program would do.

Not in this case, although some cases in regards to ariway management are thought out before beginning transport. I am waiting for more posts/thoughts on this subject...but a couple of things to consider (1) The tranchea is being held in place by approx 2 cm of tissue are you concerned about this (2) If you are going to intubate this patient at the scene are you considering paralytics?

We, as I believe that most HEMS programs have a policy in place not to transport suicidal patients who are awake with the means to continue their suicidal intentions. There was a case in Germany where a suicidal patient transported from a scene (which the crew did not intubate/paralyze for crew safety) and he unbuckled from stretcher, grabbed flightmedic and went out back door of helicopter at 1000 feet.

I wanted to post an interesting airway scenario, not to elicit right or wrong answers but to allow people the opportunity to discuss their approach (with reasoning) to this specific airway. Scene – 32 y/o male with a self inflicted knife wound to anterior neck (suicide attempt). The patient was awake with an 8 cm laceration through his Thyroid Cartilage above his Cricoid Cartilage that had transected his trachea, leaving approximately 2 cm portion of his tracheal ring in place. EMS had started an IV of crystalloid, placed a NRB over patients opening in neck (think of a trach mask – similar thought) and administered 4 mg of Zofran IV. Upon our assessment we found patient sitting upright, awake, non-verbal, vitals HR 110 sinus, BP 136/70, RR 14 SpO2 92%. Anterior neck presents as listed, with edema and oozing from around laceration site, the patient’s NRB was blood specked. Questions to be answered:(1) Do you consider this patient airway stable (flight time to tertiary care is 17 min, ground time to local hospital is 20 min) (2) Do you feel as though you can maintain his present airway (3) If you feel that you need to intervene with this patients airway, why and what approach would you take – at your disposal are the following adjuncts: normal ETT kit, bougie, LMA, surgical cric kit Medications available: Fentanyl, Midazolam, Lorazepam, Morphine, Succinyhcholine, Vecuronium, Pavulon, Etomidate, you are also in an ALS ambulance with normal supplies (4) Are you concerned with the fact that he is a suicide attempt I look forward to posts, I will respond with our approach to this airway after people have given some thought and discussion. Sean

No prob Arc can you email me at flightmedic608@comcast.net so that I can forward you a copy?

Such different approach on transporting these patients. Yes, I may not have been clear enough in my post, there is a difference between 3rd trimester and imminent delivery, I wasnt trying to infer that they were similar I apologize. Where I work, we have guidelines regarding air transport of OB patients and try to take every aspect into account. Good luck though sounds like a very tough situation you are facing, I can forward you a link to our protocols as an example if you think that would help.

Hi, I am not familar with the legal practices in Canada, but will comment based on what experience I have from here in the US. I would be very cautious is allowing any transport of a third trimester patient who is in active labor to be tranported to a facility that is approximately one hour away. And although I do agree that babies are born in ambulances throughout the world, what if there is an unknown complication? What if the neonate is born in arrest? I would error on the side of caution, if I had an imminent delivery and given the choice I would deliver with a physcian at the bedside. Even if that facility had no OB/GYN capability, the idea of having multiple hands/minds in case something goes wrong is one that I like. It sounds like this may something for the local and tertiary hospitals to sit down and formulate a transport plan/policy. I know this may not be the information that you are looking for, but I would not like to resuscitate neonate and mother at the same time whether by ground or rotor. Good luck with a very tough (high litigation - OBs have one of the highest litigation rates) issue

Very interesting case, without knowing the results of the CXR or chest CT if taken the differentials can be many. If called to a scene in this case, I would provide supportive care as many have suggested. Looking at some of his symptoms does the pain change upon inspiration/expiration? Does it extend to shoulder or abdomen - common refferal pain for pleurisy. My thinking with the sudden onset would less likely be from bacteria/virus and more along the lines of these i.e. Pulmonary Embolism, pneumothorax, does patient of history of TB, pulmonary tumor? Maybe a pneumomediastinum? Interesting case thank you for presenting. Would like to hear the follow up on patient if you're able to give.

Hello Arct, are you in the United States or abroad? Are your patients in active labor, high risk OB, having complications or a simple transfer? If you are in the US you have to take EMTLA (Emergency Medical Treatment and Active Labor Act) laws into effect when making any sort of protocol for your providers. That, and you would want to have medical direction involved when making a decision about a patient in labor and bypassing physican level care, there are many factors to consider. Abroad I am not sure of what legal responsibilities exist.

Hello, unless I am mistaken they are a reputation status bar. I would assume based off your posts and involvement in forums etc.

We are more likely to see a change in blood pressure, since we aggressively treat blood pressure(s) to ensure adequate MAPs through the use of vasoactive medications. The reduction of mortality (reduction of secondary brain injury) after giving an agent such as Mannitol or hypertonic saline would be most likely seen in a 24-48 hour time period. Our service follows up with receiving hospitals at the 24 hour and weekly mark until discharged or expired. So we have an opportunity to trend which of our patients have improved neuro outcome. Here is an interesting article that you may enjoy reading discussing Hypertonic Saline in TBI: http://www.anesthesia-analgesia.org/content/102/6/1836.full.pdf

Hello, while it would be ideal to transport a patient with a ventric in place, most of our administration comes from either scene or ED transports.. We base our administration of Hypertonic Saline base on clinical signs of increased ICP/herniation ie Blood pressure, unilateral pupil change etc

Hi in response to your topic, we utilize 3% (hypertonic) given at 3 cc/kg with sign/symptoms of increased ICP/herniation. This seems to be the growing trend in neuro care within our region.

Hello, it is not a BBB, more likely 60 cycle interference.

I am very amazed at what is being written here. Has paramedic education dropped so low as to have students only spend one day in an OR? Yes, intubation is a skill...but you still need to learn the reasons why, how to assess an airway and how to mask a patient way before you attempt at placing an airway. This needs to be done in an OR, not on mannequins. With all of the articles and literature being written about the negative sides of prehospital intubation, I would make it a point to spend as much time with an anesth or crna that I possibly could. This type of post makes me very depressed....I would hope that as a student or a ems provider you would advocate for increased education and OR rotations. My thoughts only....

In regards to posts here....first since the Good Samaritan Act is a nationally accepted statute you are covered on domestic flights for rendering aid (as long as certain criteria are met), but you can be sued for negligence. Second in regards to Dustdevil stating that you can only practice first aid, you are mistaken..a great majority of airlines now carry AEDs as well as a stocked ALS kit, this does include IV starting supplies, IV EPI/Atropine and Dextrose. If you volunteer your services while on board and provide prudent medical care, you will not be in danger of being sued or losing your ability to provide ALS as a paid provider. You should contact your state OEMS if are that concerned about assisting someone under the Good Samaritan Act. here is a link discussing AED/Medical supplies carried onboard airlines: http://www.fda.gov/fdac/features/1998/198_air.html

System, I was going to post a link to an OG/GYN website, but I thought that maybe you should research this medical issue on your own. To think that an eclamptic patient is not a true emergency, shows clearly that you do not understand the nature of this disease process. Before you make posts like this one....ensure that you completely understand the etiology of the disease process....and its mortality on gravid patients.

Hello, we usually D/C the infusion for our transports. When we transport anyone who is intubated, we use IV boluses of Fentanyl/Lorazepam/Midazolam for analgesia/sedation. The are some risk vs benefits of using Propofol like anything else you need to weigh them. I personally like using IV boluses of medication, I have found the using Propofol in the transport environment tends to keep the patient too "light" and increase their PIPS. This is just one opinion, I am sure that there are many.

No worries, just one of my anal tendencies coming out....

In our service area, whether the provider be a private or FD based we utilize the FD for securing our scene/LZs. We have a PR program in which we go out to each area FD and discuss the needs/capability of our program. I would try and initiate contact with the EMS director and speak to him about the necessity of safety on an LZ. If this is still an issue I would contact the safety director for the program and ask him for assistance.

I agree with Rid, many patients that are transported can be effectively managed by Level II and in some isolated cases Level III. In this case, I would look at the resources available for the patient, if your closest facility is 10 minutes away and they have the ability to perform a FAST scan on the abdomen and provide airway/blood products prn...I would start there. If you opt for the longer transport and the patient de-compensates en-route what are your options? What is your closest facility to divert too? Most EDs have the ability to at least start a trauma resuscitation. Oh, and on a personal note, I find it hard to imagine that an ems provider can only obtain a BP of 100/p....if you are taking the time to assess and treat your patient, please take the extra 15 seconds to obtain a diastolic pressure...MAP is very important for cerebral perfusion.

Hello, I work for a flight program in Massachusetts. We are a non-profit/hospital affiliated program. We work in an RN/Paramedic configuration. We operate three rotor wing aircraft, two ground ambulances and one fixed wing. We have pins and a very generic patch...if you would like one of either let me know. You also stated that you had a few questions, I will try and answer as many as I can. Sean Weather mins: Within 30 miles of Boston VOR Day Ceiling 800 feet Visibility 2 miles night Ceiling 1000 feet Visibility 3 miles Within 30-90 miles of Boston VOR Day Ceiling 1000 feet Visibility 3 miles Night Ceiling 1500 feet Visibility 4 miles and it continues upward, there is not optimal weather conditions so to speak...safety comes first no matter what!

Haro.....let me begin by apologizing for the posts that you received here, not all in EMS think as dust does. He can be quite the condescending ass at times. There is nothing wrong with any education that you may wish to pursue, and if you believe that being an EMT/Paramedic will make you a better MD then so be it. It can only help you with your bedside manner and give you an appreciation of prehospital providers. I will have to agree on some of the posts though, admission boards for med school look for a diverse background in education and experience, as well as high MCAT scores. Saying that, stay focused and don't let the opinions or statements of a few assholes persuade you from taking the course that you are choosing, some of us have decided to stay a paramedic and fore-go medical school and are happy that we made the choice. Good luck.