Doczilla

Over the past few years the Special Operations Medical Association has been expanding offerings of interest to civilian and government tactical medical support providers. The ultimate mission of this organization is to arm medical providers with the knowledge and skills to care for the warfighter and tactical operator in any setting. Continuing with this tradition, we are putting out a call for presentations specific to the civilian TEMS environment. We are especially interested in presentations from medics with field experience that can share that experience in terms of lessons learned. Attendees of the conference are physicians, PAs, nurses, and medics, from US and foreign military, government organizations (FBI, Marshals, ICE, etc.), and civilian law enforcement and rescue organizations. Over 2000 people came to last year's conference, which is nearly double the number that came in 2008. It's also the cheapest 28 hours of category 1 CME you'll get anywhere. December 15-18 Tampa Convention Center Tampa, FL The first 2 days of the conference are mostly presentations from SOF medics and docs, with emphasis on the military special operations medic. Great information in these sessions last year, which included combat vignettes, an 18D discussing firebase medicine in Afghanistan, a member of a female engagement team in Afghanistan, an in-depth presentation on the Tucson mass shooting (that involved Rep Guiffords), and talks on evolving medications and techniques for the SOF medical provider. The last 2 days of the conference are breakout sessions tailored to one's specific environment. There is a military track as well as a civilian TEMS track. Presentations in the TEMS track last year included terrific talks on high rise casualty evacuation, rapid breaching for active shooter incidents, and the CoTECC update. These are the kinds of things we are looking for: After action reviews or lessons learned from tactical or mass casualty events Hands on training in the form of skills training or simulations (VERY popular) Training programs to sustain and improve medical skills among TEMS providers Presentations of original research Innovative problem solving for the tactical medic Topics of importance to TEMS program administration (liability, training, selection, funding) We have a HUGE amount of space at our disposal at the Tampa Convention Center. The exhibit floor can support heavy equipment and vehicles (up to an Abrams tank. Anything heavier, we'll have to ask), and we have plenty of breakout space for hands on sessions. If you can think of a great training exercise, we'd love to do it. If you would like to teach a topic, or can suggest a speaker or topic you think would be of interest to the TEMS community, please drop me an email. If you know of an organization that would like to have a meeting or luncheon at the conference, please let me know as well. The website: www.specialoperationsmedicine.org V/R, j.r. SOMA 2012 Co-Chair

The "number needed to treat" reflects the number of patients that will receive a treatment in order to create one good outcome. Few treatments benefit every patient who receives them. For example, cholesterol lowering drugs are known to help prevent heart attacks, but not 100% of the time. You will have to give hundreds of people the drug before you can say you have prevented one heart attack. A NNT of 1 means that everyone who receives the treatment lives, and everyone who doesn't (the controls) dies. For the spinal study, you have to immobilize over 1000 patients before you could theoretically prevent one bad outcome (doubtful that backboarding would even do so). The "number needed to harm" is the same concept, only looking at bad outcomes. Say a treatment is very toxic, and there is a 5% mortality rate caused by the drug. For every 20 patients who receive the drug, one will die, therefore the NNH is 20. In the spinal immobilization study, you would only immobilize 66 people before you caused a bad outcome. Taking the above numbers into account, if you immobilized 1032 patients with penetrating trauma, you might prevent 1 bad outcome, but cause bad outcomes in 15 others. More on this calculation: http://en.wikipedia.org/wiki/Number_needed_to_treat A "distracting injury" is theoretical. The idea is that if you have a painful enough injury, such as a femur fracture or rib fracture, it may focus your mind so that you do not feel the pain in your neck from a spinal fracture, and you should therefore be immobilized until x-rays are performed. What the study showed was that of these patients with confirmed spinal injuries, 87% of them had other injuries that would meet their definition of potentially distracting. What they found was that even with these other injuries, all but 4 of the patients still had pain and tenderness in their neck. Of the 4 that did not, all 4 had tenderness and bruising of the anterior chest. It calls into question the theory of a distracting injury that would require x-rays of the neck on a patient who has no neck pain, or perhaps we should better define a distracting injury to include anterior chest tenderness. 'zilla

Octreotide causes vasoconstriction of the splanchnic bed (mesenteric circulation), and in theory decreases rate of GI bleeding. Not sure it would do anything for nose cancer, but if there is bleeding further down in the GI tract, it might help. 'zilla

UPDATE: We have implemented new policy on immobilizing patients, and I have copied the policy below. There is substantial room for EMT judgment. It went into effect about a month ago, so I thought I'd share the experience thus far. The director and AD of Trauma thought it looked good. Our trauma team is pretty good about getting patients off of the backboard during the secondary survey and before any CT scans. The medical director for our ER group liked it as well. We've had an internal ER policy in place for a year not where the medics and nurse get the patient off the board upon arrival at the hospital and before being seen by a physician. The competing hospital system has had such an ER policy for at least 2 years with very good success. Acceptance of this internal policy has been mixed. Some nurses are in favor, others nervous about it and unwilling to take the patient off the board, so they will just let the attending know that there is a patient on a board and to see them quickly so they can be removed from the board (easier at some times than others). The EMS response has been interesting. The 2 agencies where we implemented it seem to like it quite a bit, but they tend to be fairly progressive services. There are some who have been teaching in the area, and response has been all over the map. Some medics think it's great. One chief stormed out of the room and said it would never be implemented at his service as long as he was there. Over his dead body, or something to that effect. It seems to be the younger medics who like the policy more. A snide comment by one of the other local EMS medical directors: "The chance of endorsing this policy is inversely proportionate to the size of your prostate." One hospital, a level III trauma center, initially pushed back very hard. As one doc said to the crew, "dumbest f&%#ing thing he'd ever heard." They initially said they would purchase backboards and reimmobilize any of our patients until the scans were done, but subsequently reversed their stance on it and are supportive. Another doc, from the same hospital, said it was "long overdue". Another local agency (with which I have no involvement) has reviewed and adopted the policy. We've had to tweak the policy a couple of times: - The flight service has very strong feelings on immobilizing any patients they transport, and insist that it be done. I think this is not huge, partly because we hardly ever call them due to ground transport times of <30 min, and if we did, it would be for a critically ill trauma patient that is likely to remain on the board anyway. - We had to put stronger emphasis on the multi system blunt trauma patient who cannot follow commands that should remain on the board. - Initially the memo referred to use of the board for extrication, which to my mind meant "movement from point of injury", but was interpreted by some to mean only vehicle extrication. So this was clarified. The medics have been very understanding of it as we adjust the policy and training based on their feedback. Nothing new is perfect the first time out, and they have been very patient. 'zilla To: All Bigredtruck Fire Division Personnel From: Doczilla, MD Re: Change in spinal immobilization protocol The following policy combines policy memo from July 6, 2012 and subsequent clarification from July 14, 2012 memo. Substantial evidence now exists to show that long back boards may cause harm to patients, and no literature has yet shown a benefit of their use. Back boards do a horrible job of immobilizing the spine, and movement is worse on the backboard than on a soft surface that conforms to the patient. Patients who are alert enough to follow commands can typically maintain stabilization of their own spine without assistance. Backboarding increases mortality in certain trauma patients. Backboarding does nothing to prevent neurological complications from spinal injury. Backboarding restricts respiration, which some patients cannot tolerate. Backboarding rapidly leads to skin breakdown and pressure ulcers, even after a short period of time, and is particularly hard on the elderly. Effective immediately, the following changes are to take place in our practices of spinal immobilization: These patients may require immobilization with a cervical collar: High risk injury (high speed MVC, axial loading injury) Focal neurological deficits such as paralysis Intoxication or altered mental status Age >65 Presence of midline bony tenderness of the spine Midline spinal pain with movement of the neck Patients without any of the above findings may be transported without a cervical collar. Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury as above or with clinical indications of spinal injury. Use the long spine board, scoop stretcher, vacuum mattress, short board, or Kendrick Extrication Device (KED) to minimize movement of the patient when moving them from the point of injury to the stretcher. Once the patient is moved to the stretcher, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Elevate the back of the stretcher as needed for patient comfort. Do not transport a patient to the hospital on a backboard, short board, KED, or vacuum mattress unless it is necessary for patient safety. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. Patients may remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. A multi system blunt trauma patient, such as from a high velocity crash or significant fall, who is unable to follow commands due to combativeness, intoxication, or decreased mental status, should remain on the backboard for their safety until handoff to the ED. Never immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury. Emphasis should be on airway and breathing management, treatment of shock, and rapid transport to a Level 1 or 2 trauma center. If manual cervical stabilization is hampering effort to intubate the patient, the neck should be moved to allow securing the airway. An unsecured airway is a far greater danger to the patient than a spinal fracture. Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury. Place a collar and allow the patient to sit on the cot, then lie flat. Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do. Remove cervical collars on conscious patients that tolerate them poorly due to anxiety or shortness of breath. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. Patients should remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. [The Helicopter Service] has requested that we fully immobilize on a backboard all blunt trauma patients transported by them, regardless of complaint. This is so they may remain consistent with their own policies on spinal immobilization. The new protocol will: reduce pain and suffering reduce complications decrease on scene times reduce injuries to crews who are attempting to carry immobilized patients reduce unnecessary imaging costs and radiation exposure Any questions about protocols or medical treatment may be directed to myself or Capt. Awesome. Very respectfully, Doczilla, MD FACEP Medical Director Bigredtruck Fire Division Cc: Chief

Look at the National Collegiate EMS Foundation. http://ncemsf.org/ Under "resources" they have a "new startup" link, and you can contact them for info. http://ncemsf.org/index.php?option=com_content&view=article&id=37&Itemid=136 'zilla

Youtube link, almost 1 hr long. A great illustration of how an incident unfolds, and use of the Incident Command System. Listening to this, the Aurora FD and all of the responders and dispatchers did a phenomenal job in handling this extraordinary event. 'zilla

Yes, look at my post on the spinal immobilization thread in the patient care forum. (null)

To the original post, immobilization of patients with penetrating trauma doubles their mortality rate. Even with penetrating injury of the spinal cord itself or supporting structures, the damage is done. Don't immobilize them. To the question about penetrating trauma arrest, transport is not indicated unless the patient can be in the trauma bay within 5 minutes of the arrest. This only applies to penetrating trauma of the trunk, not the head. All we can do is a thoracotomy in the trauma bay, and survival rates are abysmal. Shot in the head + no pulse = dead. 'Zilla (null)

Rumor has it...... December 5 and 6, 2012

Feel free to share. It's a policy memo, so public record anyway.

I sent the memo to two of the EMS agencies (fire based, as are most around here) where I work. We are attempting to effect a cultural shift for the benefit of our patients. I guess we will see if it takes hold. There is no question that spinal immobilization is painful and anxiety provoking for nearly everyone. Patients often have back pain induced solely by lying on the backboard, pain which resolves not long after removal of the board, but which may prompt imaging in the ED due to pain and tenderness caused not by the presenting injury but by the backboard. We have seen harm in other ways: the demented elderly patient with a ground level fall who becomes more agitated from the pain and restriction of the board, the patient from the MVC with anxiety disorder who panics in the straps, the monstrously obese patient who has the equivalent of another person sitting on their chest and has to fight gravity to breathe. I've summarized below some notes from a presentation I have given on myths in EMS. The bottom line up front is that spinal immobilization on a long backboard has no evidence to support its use, but substantial evidence of harm. It is predicated entirely upon theories of injury that have never been shown. It has been taught dogmatically to EMS providers, nurses, and physicians for 3 decades, though there is now a swell of thought that we should modify the practice. Using a long backboard makes sense when pulling an injured person out of the water, or moving them out of a smashed vehicle, but once on the ambulance stretcher, movement is minimal, even with jarring movements of the ambulance. Being on a hard, slippy surface of a backboard will worsen that movement rather than improve it. The National Association of EMS Physicians is working with the American College of Surgeons on a position paper regarding backboarding. The gist of it is that we should eliminate backboards for anything but extrication. There's a few things I've discovered in the literature: Backboards do a horrible job of immobilizing the spine, and movement is worse on the backboard than on a soft surface that conforms to the patient. Patients who can follow commands can typically maintain stabilization of their own spine without assistance. Backboarding increases mortality in certain trauma patients. Backboarding does nothing to prevent neurological sequelae from spinal injury. Backboarding restricts respiration, which some patients cannot tolerate. Backboarding rapidly leads to skin breakdown and pressure ulcers, even after a short period of time, and is particularly hard on the elderly. I think there are some steps we can take to eliminate some pain and suffering and reduce some unnecessary imaging. Stop transporting patients to the hospital on backboards. Utilize the long spine board only for extrication purposes. Once the patient is extricated, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Do not ever immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Immobilization DOUBLES the mortality rate of these patients. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury. Emphasis should be on airway and breathing management and rapid transport to a trauma center. If patient is being intubated, and manual cervical stabilization is hampering this effort, the neck should be moved to allow securing the airway. An unsecured airway is a far greater danger to the patient than a spinal fracture. Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury. Place a collar and allow the patient to sit on the cot, then lie flat. Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do. Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury or with clinical indications of spinal injury. Remove cervical collars on conscious patients that tolerate them poorly due to dementia, anxiety, or shortness of breath. Leaving the collar on and fighting them will encourage more spinal movement rather than less. Clear patients from any spinal immobilization clinically utilizing the spinal clearance protocol. This protocol indicates those patients who may require immobilization: High risk injury (high speed MVC, axial loading injury), focal neurological deficits such as paralysis, intoxication, age <65, and presence of midline bony tenderness of the spine. Patients without these findings may be transported without spinal immobilization. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. These patients should remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. The above measures will reduce pain and suffering, reduce complications, decrease on scene times, reduce injuries to crews who are attempting to carry immobilized patients, and reduce unnecessary imaging costs and radiation exposure. There is no doubt that our crews will get some push back from the staff at the hospitals. Nurses or physicians may rebuke them for having the patient off the backboard. FD crews should be reassured that hospital staff does not determine their treatment protocols or operational policy, and that any questions can be directed to command staff or to me or to the hospital EMS coordinators. 'zilla, MD Hauswald M,McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000 Oct-Dec;19(4):126-7. This was a survey of inter facility transport services. 18/30 interfac transport services immobilized for transfer, even if cleared by sending ER MD Additional 4/30 immobilized unless cleared radiographically No services moved pts to softer surface if known to have injury McHugh TP,Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998 Mar;5(3):278-80. 51% reported no neck or back pain at scene of accident before full spinal immobilization 13% not even asked about neck or back pain before full spinal immobilization Haut ER,Kalish BT,Efron DT,Haider AH,Stevens KA,Kieninger AN,Cornwell EE 3rd,Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1. Twice the mortality rate in penetrating trauma if immobilized (14.7 vs. 7.2%) 0.01% had incomplete neurological injury and underwent fixation Number Needed to Treat: 1032 Number Needed to Harm: 66 Davis, et al: retrospective study of 32,117 trauma patients 2.3% with c-spine injury 10 patients with delayed diagnosis of spinal injury AND permanent neurological sequelae Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Gerrelts, et al: Review of 1331 trauma patients 5 patients with delayed diagnosis of cervical injury None with permanent deficit Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Platzer et al: 347 with c-spine injuries Of the 18 with delayed diagnosis, 2 had permanent deficit Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Hauswald: 5 year retrospective review New Mexico vs. Malaya Malayan medics do not use spinal immobilization The difference: Malayan patients had less frequent deterioration and less overall neuro disability Limitations: Small numbers, different mechanisms (more MVCs in the USA, more falls in Malaya) Neuro decompensation occurs in 5% anyway, despite ideal attention to spinal immobilization. Spinal immobilization raises intracranial pressure 4.5 mmHg Manual In Line Stabilization (MILS) led to failed intubation in 50% after 30 seconds of intubation attempt vs. 5.7% without MILS Gruen, et al: Trauma mortality in 44, 401 patients. 2594 deaths, errors in 64. Failure to secure an airway in 16% of those If spinal immobilization led to a failed airway, then it killed the patient. Santoni: MILS doubles force necessary for intubation Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. Totten, et al: LBB or vacuum mattress restricted respiration by 15% Bauer, et al: LBB limits respiratory function Respiratory failure is COD in 6% of trauma patients Hauswald: Substantial force required to injure spinal cord Post-injury movement probably not sufficient to injure the cord, even if already partially injured Chan D,Goldberg RM,Mason J,Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. Perry SD,McLellan B,McIlroy WE,Maki BE,Schwartz M,Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1839-44. 3 times more likely to develop pain with LBB than vacuum mattress Trunk movement still significant; no method with a LBB eliminates motion Konstantinidis A,Plurad D,Barmparas G,Inaba K,Lam L,Bukur M,Branco BC,Demetriades D. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011 Sep;71(3):528-32. 101 blunt trauma patients with c-spine injuries 87% had “distracting” injuries: rib fractures, lower and upper extremity fractures 4% had no tenderness on c-spine All 4% had bruising and tenderness of anterior chest Bottom line: "distracting injuries" are largely a myth. Horodyski M,Conrad BP,Del Rossi G,DiPaola CP,Rechtine GR 2nd. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011 May;70(5):1282-5; discussion 1285. Del Rossi G,Horodyski M,Heffernan TP,Powers ME,Siders R,Brunt D,Rechtine GR. Spine-board transfer techniques and the unstable cervical spine. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E134-8. Del Rossi G,Rechtine GR,Conrad BP,Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med. 2010 Sep;28(7):751-6. Epub 2010 Feb 25. Log roll creates unacceptable motion Lift and slide technique creates less motion Scoop stretcher may be better as well J Trauma. 2009 Jul;67(1):61-6. Motion of a cadaver model of cervical injury during endotracheal intubation with a Bullard laryngoscope or a Macintosh blade with and without in-line stabilization. Turner CR, Block J, Shanks A, Morris M, Lodhia KR, Gujar SK. Source Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA. turchris@med.umich.edu Abstract BACKGROUND: Endotracheal intubation in patients with potential cervical injury is a common dilemma in trauma. Although direct laryngoscopy (DL) with manual in-line stabilization (MILS) is a standard technique there is little data on the effect of MILS on cervical motion. Likewise there is little data available regarding alternative airway techniques in this setting. This study compared intubations with and without MILS in a cadaver model ofcervical instability. We also used this model to compare intubations using DL with a Macintosh blade versus a Bullard laryngoscope (BL). METHODS: Complete C4-C5 disarticulations were surgically created in 10 fresh human cadavers. The cadavers were then intubated in a random order with either BL or DL with and without MILS. The motion at the unstable interspace was measured for subluxation, angulation, and distraction. RESULTS: MILS did not significantly affect maximal motion of this model in any of the three measures using either DL or BL. There were no clinically significant differences in maximal median motion in any of the three measures when comparing the two blades. However, there was significantly more variance in the subluxation caused by DL than by BL. CONCLUSIONS: We were unable to demonstrate any significant effect of MILS on the motion of an unstable cervical spine in this cadaver model. The BL appears to be a viable alternative to DL in the setting of an unstable lower cervical spine. Ann Emerg Med. 2007 Sep;50(3):236-45. Epub 2007 Mar 6. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Manoach S, Paladino L. Source Department of Emergency Medicine, State University of New York-Downstate and Kings County Hospital Center, Brooklyn, NY 11203, USA. seth.manoach@downstate.edu Abstract Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients with suspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials of manual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, Index Medicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to this search, we present an ancestral review tracing the origins of manual in-line stabilization and an analysis of subsequent studies evaluating the risks and benefits of the procedure. Allmanual in-line stabilization data came from trials of uninjured patients, cadaveric models, and case series. The procedure was adopted because of reasonable inference from the benefits of stabilization during general care of spine-injured patients, weak empirical data, and expert opinion. More recent data indicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movement and that manual in-line stabilizationmay not immobilize injured segments. In addition, manual in-line stabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumatic brain injury. Patients intubated in the emergency department with suspected cervical spine injury often have traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. The limited available evidence suggests that allowing some flexion or extension of the head is unlikely to cause secondary injury and may facilitate prompt intubation in difficult cases. Despite the presumed safety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques that do not require direct visualization warrant investigation. Promising techniques include intubation through supraglottic airways, along with video laryngoscopes, optical stylets, and other imaging devices.

Actually, Geodon is pretty good for agitation. Works quickly enough, and if dosed properly, brings them down but not out. The side effects aren't any worse than haldol.

Sensitivity and specificity of orthostatic vitals are relatively poor. While there may be certain instances that you might consider it, I don't see a need for a requirement in the protocol. Because of that sensitivity and specificity, it won't change much that you're doing. 'zilla

Holy crap, just saw the thread. Sorry about that, BEorP! Did you at least get to tour the facility? We would have hooked you up with some clinical experiences, as well as beer! Wait, are you old enough to drink? I will monkey stomp you at the next CAP Lab for breezing through Dayton without dropping me a line.

Ketamine is probably better than versed for cardioversion or pacing because of minimal effects on BP or HR. Since any patient you are cardioverting in the field is likely unstable or hypotensive, ketamine makes more sense than a drug that will drop BP. ' (null)

I was once told regarding malpractice, kill them, don't maim them. Malpractice judgments are higher when the patient survives and is crippled than when they die outright. The move for ETCO2 monitoring/detection became standard in EMS only a few years ago, so while the colormetric devices were available, they weren't necessarily in widespread use. The question is, was the tube dislodged, or misplaced in the first place? That's why waveform capnography is so helpful in cases like this; it's written proof of proper placement, and warns you of dislodgement or other problems. There are other issues here which are not clear. Remember that the lawyer will paint everything in the worst light possible. It helps their case to paint the responders as complete idiots to generate negative sentiment against those who don't know them (as this article has done here). Remember that juries generally LIKE EMS providers and firefighters. In order to overcome their generally positive regard, the lawyer has to make them look like complete buffoons. They also (in many states, not sure if IL is one of them) have to overcome a standard of "willful or wanton neglect". It is entirely possible that this patient was already very unstable. An asthmatic who has to be intubated has a very high likelihood of death. Intubation is not particularly helpful unless you can paralyze them, extend the i:e ratio, and maybe give Heliox. The medics were already dealing with a critically ill patient for whom they had few remedies beyond IM epi. Never hang anyone out to dry just based on what's said by the plaintiff's attorney. 'zilla

Children, particularly infants much younger than this child, have a harder time reclaiming sodium from the urine than adults do. A higher intravascular sodium level will draw water from the cells, shrinking the cells down, but infants can't get as hypernatremic as an adult. If hyponatremic, those signs of cell shrinkage and dehydration will be absent as well. A dehydrated infant or child may therefore not show some of the cardinal signs of dehydration, such as sunken eyes, poor skin turgor, and dry mucous membranes. The take home point is that if the clinical situation suggests it, consider giving the child some IV fluid in a typical dose of 20 cc/kg. Hyponatremia can be seen with extreme exercise with inadequate sodium replenishment, such as military recruits who PT to death and drink liters of water without taking in enough sodium by eating well. We typically only see this with intake of >8 L of water per day. They will typically be resuscitated with normal saline initially. Even with profound hyponatremia, you can't go wrong with 0.9% saline as a resuscitation fluid. It will get them on the right track, but not too quickly to where they will have complications. Hypertonic (3%) saline is reserved for very unique circumstances, and honestly isn't given very much for hyponatremia. Bottom line: there is no need for a specific hyponatremia protocol. Resuscitate with the usual isotonic crystalloid, treat seizures with benzodiazepines, and keep a broad differential in mind such as hypoglycemia or other medical problems. 'zilla

When I was a third year medical student on surgery rotation, we had a patient in his late 30s-early 40s with a large pleural effusion (fluid around the lung). He was doing okay on a NRB mask as long as he remained seated upright, but each time we laid him down, he would desaturate. He needed a chest tube to drain the fluid so he could breathe. As a med stud, I was eager to do the procedure. We were on a med-surg floor. I brought the appropriate gear, gowned up, and prepped appropriately. I thought through every step of the procedure: when to put on the sterile gloves, how to position him, filling the bowl with betadine before putting my gloves on, drawing up the right amount of anesthetic and what size needle to use, getting the right scalpel, setting up the Pleurevac and filling the chamber with water, suture, foam tape, everything. The attending, a surgeon who has been cracking chests since the year I was born, stepped into the room, looked around, then out into the hall, looked around, then back into the room. "Transfer him to ICU. We'll do this later." Disappointed, I put the kit away to be resterilized, knowing that it would be done by someone else. Later, we had our daily wrap up meeting between the attending and 4 of us med students. He asked, "Do you know why we decided not to do the chest tube then?" Not really. "How many nurses were in the room helping you set up?" None. "How many nurses did you see in the hallway or at the nurses station ready to jump in if things went sour?" None. They were all in patient rooms, going about their duties, taking care of the patients on the floor. "Do you know if they are experienced running codes? Do they know where all the code equipment is on this floor? How much practice do they get? We know that the resources are available in the ICU, that the nurses there run codes all the time, and know where the equipment is. If something happens, you know there is manpower there to jump in." He meant this neither as a slight to the MS floor, nor a ringing endorsement of the ICU, but a reflection of the bigger picture of anticipating where we would be. He continued. "I'm not thinking about the procedure. I know I can put a chest tube in. I can do it with my eyes closed. I'm not worried about that. What I'm thinking about is, what happens if the patient decompensates? You always have to be thinking ahead of the procedure. Your mind has to be one or two steps ahead, preparing for that event that comes next. Otherwise, he goes down the tubes and you aren't ready to deal with it." I preach this to my residents. Don't get lost in the procedure. Intubation is a physical skill of muscle memory, not a mental exercise. Your practice has taught your hands how to intubate. You know how to intubate, and if you are thinking only of this, you will miss the big picture. When you are in the ER, the OR, the ambulance, or on the street, take it all in. Think beyond the immediate, and wrap your mind around what comes next. Don't think, "I'm going to intubate." Think, "this is what I will do if I can't intubate. These are the parameters that will tell me if I need to intubate, or just give oxygen. This pulse ox level is when I will quit attempting to intubate and bag the patient. This ETA will determine if I need to tube now, or use other methods to support the patient until I get to the hospital." Concentrate on where you are going, rather than how you get there. The little things, like the procedures, will flow. 'zilla

Both are effective (and relatively safe) treatments for nausea and allergic reactions. The BB on phenergan limits its use in pediatrics by practice. Both can be effective for migraine treatment. Phenergan's tendency to cause QT prolongation is shared by many drugs that would treat the same conditions. 'zilla

Yes and yes.

Anyone have prehospital protocols for using hypertonic saline (3% NaCl) for traumatic brain injury? 'zilla

We'd waive the tuition fee. 'zilla It sounds like she was full of ideas as to what she thought they should be doing, and based on her complaint, probably not too quiet about it. If she was being such a massive PITA, I'd drop her ass by the side of the road too. They cynical part of me knows from prior experience with virtually any healthcare provider is that everyone seems to think they know better than the medics, and that they have the right to tell them what to do, being that EMS is apparently at the bottom of the medical food chain. 'zilla

Yup! And Dwayne too... No reason to duplicate work.

I've not seen anyone get agitated with the administration of proper doses of ketamine. They can get agitated as it wears off, however, which is why a benzo should be given.

I wonder who might have put that idea in your head? ¡Davis, et al: retrospective study of 32,117 trauma patients §2.3% with c-spine injury §10 patients with delayed dx of spinal injury AND permanent neurological sequelae ¡Gerrelts, et al: Review of 1331 trauma patients §5 patients with delayed dx of cervical injury §None with permanent deficit ¡Platzer et al: 347 with c-spine injuries §Of the 18 with delayed dx, 2 had permanent deficit ¡Hauswald: 5 year retrospective review §NM vs. Malaya §The difference: Malayan patients had less frequent deterioration and less overall neuro disability §Small numbers, different mechanisms ¡Neuro decompensation occurs in 5% anyway ¡Spinal immobilization raises ICP 4.5 mmHg ¡MILS led to failed airway in 50% after 30 seconds vs. 5.7% without ¡Gruen, et al: Trauma mortality in 44, 401 patients. 2594 deaths, errors in 64. §Failure to secure an airway in 16% of those ¡Santoni: MILS doubles force necessary for intubation ¡Totten, et al: LBB or vacuum mattress restricted respiration by 15% ¡Bauer, et al: LBB limits respiratory function ¡Respiratory failure is COD in 6% of trauma patients ¡Hauswald: Substantial force required to injure spinal cord §Post-injury movement probably not sufficient ¡Pain scale: 9.7 vs. 3.7cm on pain scale with LBB vs. LBB with air mattress ¡76% reporting pain after 60 min ¡15% with point tenderness of spine after 30 min, 25% after 60 min ¡18/20 reported increasing pain and discomfort Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6. Lerner EB, Billittier AJ 4th, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002 Oct-Dec;6(4):421-4. ¡3 times more likely to develop pain with LBB than vacuum mattress ¡Trunk movement still significant; no method with a LBB eliminates motion Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1839-44. ¡101 blunt trauma patients with c-spine injuries ¡87% had “distracting” injuries §rib fractures, lower and upper extremity fractures ¡4% had no tenderness on c-spine §All 4% had bruising and tenderness of anterior chest Konstantinidis A, Plurad D, Barmparas G, Inaba K, Lam L, Bukur M, Branco BC, Demetriades D. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011 Sep;71(3):528-32. ¡Log roll creates unacceptable motion ¡Lift and slide technique creates less motion ¡Scoop stretcher may be better as well Horodyski M, Conrad BP, Del Rossi G, DiPaola CP, Rechtine GR 2nd. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011 May;70(5):1282-5; discussion 1285. Del Rossi G, Horodyski M, Heffernan TP, Powers ME, Siders R, Brunt D, Rechtine GR. Spine-board transfer techniques and the unstable cervical spine. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E134-8. Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med. 2010 Sep;28(7):751-6. Epub 2010 Feb 25. ¡Twice the mortality rate if immobilized (14.7 vs. 7.2%) ¡0.01% had incomplete neurological injury and underwent fixation ¡NNT: 1032 ¡NNH: 66 Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1. ¡18/30 interfac transport services immobilized for transfer, even if cleared by sending ER MD ¡Additional 4/30 immobilized unless cleared radiographically ¡No services moved pts to softer surface if known to have injury ¡ ¡51% reported no neck or back pain at scene ¡13% not even asked about neck or back pain before FSI Hauswald M, McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000 Oct-Dec;19(4):126-7. McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998 Mar;5(3):278-80.