Cricothyroidotomy training for the pre-hospital setting

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Newest addition to the ARHT simulation centre. Cricothyroidotomy task trainers built from old manikins. Rolled them out successfully last week with our paramedics using them for the first training session.

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an in-situ simulation scenario for the registrars that required the performance of a cricothyroidotomy. The goal of the simulation was only to perform a cric…in fact, we even gave the registrar team a heads up that the patient would required a cric. Amazingly while we only used a task trainer that didn’t even allow for intubation, the trainees still tried to proceed with intubation. There was considerable reluctance to finally acknowledge that it was a “can’t intubate, can’t ventilate” situation.  I don’t think we train enough to practice taking that cognitive leap to the final step in the failed airway algorithm. Even this short little scenario provided evidence that such scenarios require practice and should be simulated.

This past week at the base we rolled out our cricothyroidotomy task trainers. We constructed our trainers based on a model created by Agnes Ryzynski & Dr. Jordan Tarshis at Sunnybrook Health Sciences Centre. They described the creation of such task trainers using old/broken manikin heads and some innovation using easily found products within the hospital. The value of such a trainer extends beyond its simplicity as it also  maintains good fidelity, it costs less than $30 to make and it recycles old manikin heads! 
Such a trainer might supplement an even lower fidelity construction depending on the setting. At the ARHT, our go-to method for cricothyroidotomy is a bougie-assisted technique which is described in this article and video. We’ve selected this technique based on simplicity in the field and relatively minimal equipment required. But there’s good debate out there whether these should be performed using the needle or surgical approach. Scott Orman (ED physician and blog author for aucklandhems.com) wrote about the topic last week with some great links.

You can see from the pictures, that the paramedics have set up on the left side of the patient. We were trying out different approaches and set ups to find out what works best. Personally, I prefer the right side of the patient. In our setting within the helicopter  we only have access to the patient’s right side. As a result, there may be some benefit to be on the right side. The ergonomics of such a high stakes procedure are probably understated so training in the same way that you’ll perform the procedure is essential. I acknowledge that you might need to be a bit flexible regarding setup but in general, the airway team should be well prepared and anticipate where equipment and personnel will be placed.

Here’s a few more pictures of our training day.

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Next post will have a bit more about the evidence base around cric performance.

 

Is it time for tranexamic acid in the pre-hospital setting?

Recently, we had an elderly patient brought into the ED after being involved in a fairly substantial motor vehicle collision. As we began treating her, I asked the trauma surgeon who was taking over the patient’s care whether he wanted tranexamic acid given (TXA). As she was relatively hemodynamically stable (despite several  transient hypotensive episodes), he declined providing her with TXA without elaborating.

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In my view, this patient was definitely someone who would have benefited from TXA especially after later imaging revealed retroperitoneal bleeding. I also wondered, whether this patient could have been given TXA in the pre-hospital setting? At ARHT, we’re not currently using TXA but there’s some question as to whether the pre-hospital setting may be an optimal place for initiation of therapy.

In 2010, the Crash-2 study was published. It was an unbelievably impressive undertaking that randomized trauma patients (a very broad cohort) to TXA or placebo. More than 20,000 patients were enrolled in 40 countries, many of which were resource poor settings. The results were quite remarkable with an absolute risk reduction in all cause mortality from 16% (placebo) to 14.5% (TXA). The authors concluded that “TXA should be considered for use in bleeding trauma patients”.

A closer look at the data suggests that this benefit is primarily if TXA is administered within 3hrs of injury. More recently, additional analysis revealed that death due to bleeding was significantly reduced when administered in <1hr (NNT 42) and between 1-3hrs. This re There was concern about harm if there was a delay >3hrs.

This time dependent effect has considerable ramifications for pre-hospital health care providers. As far as I can tell, there’s no data to support the use of TXA in the prehospital setting but our existing data would support early administration which could easily be provided for patients before arriving in hospital. In particular, patients with prolonged extrications, longer scene times or longer transport times may benefit the most.

A recent retrospective study (MATTERs) study looked at the use of TXA in a combat setting among patients who received at least 1 unit of red cells. They found an association with lower mortality for those who received TXA. Clearly the methodology of the study precludes immediate clinical adoption but it provides additional evidence of the possible benefits.

My bias is that if this was a drug that wasn’t off patent and that there was some pharmaceutical company that could make billions then we would be much more aggressive with its use. In cardiology, most statins have numbers needed to treat of 100-200 and yet with massive (an apparently effective) marketing campaigns, I’ve heard some cardiologists say it should be in the drinking water! I digress.

I think it’s time to consider TXA in the pre-hospital trauma setting in a well defined protocol. The relatively broad inclusion criteria used in Crash-2 which still resulted in impressive outcomes suggests that it would be reasonable to consider in many of our suspected bleeding patients prior arrive in hospital.  And clearly, there needs to be a move within the hospitals and trauma bays to actually implement protocols and give TXA early. Based on existing evidence, we will only be providing better patient care.

Helicopter Underwater Escape Training (HUET) course

It’s been a busy week so I’ve been a bit delayed getting up this post.

Our choppers at the base are extremely well maintained by a whole crew of super experienced staff, but regardless, there remains the possibility that we’ll “ditch” into the water during a flight. Ideally this occurs in a “controlled” manner but it’s possible that it happens suddenly. This unlikely occurrence has been the impetus for the HUET course that’s occurred at the base for the past 20 years. This course really highlights lots of stuff we can be doing in medicine – practicing rarely performed, high-stakes procedures in a simulated setting. The concept is fantastic and what’s great is that not only do we discuss what to do, we actually go out and practice.

We just finished up a really solid day at the base where we completed our Helicopter Underwater Escape Training (HUET) course. There was a combination of flight crewman, pilots, physicians, paramedics and surf rescue guards who all came together for an excellent day of training.

We started off the day with a full review of our lifejackets, seat belts and exit from the chopper.

Letting off flares over the bay

Then we headed out to the pier where we channelled our inner caveman, got to play with fire and let off  a bunch flares (ones usually kept in our life vests). I think there’s a genetic element (left over from the prehsitoric era) that provides us with great satisfaction from setting off fire into the air and watching fireworks launch into the air. Nothing quite like challenging your manhood with “my flare went further than yours”.

We then headed up to the local dive pool to practice our underwater escape plans. The Trust has a great training apparatus – a mini chopper known as the “dunker”! This thing functions as a practice model for escaping as the chopper is flipped upside down. As it was described in our course, we have to wait at least 7 seconds once we hit before we escape. By then all the chopper blades will have stopped and it will be safer to exit. This simulation process helps you gain appreciate for the complete clusterf*#)@ that it would be if the helicopter crashed into the water. While we couldn’t recreate the likely injuries you’d suffer, the gasoline in the water, the inability to see, the hectic ocean swells, we were at least able to go through the motions of our exit plans. When my wife asked, “how was your day?”, I started explaining what we were up to.  Judging by her reaction on my training for a possible helicopter crash, it appears that such things are best left on the list “things not to tell your wife”.

We had 4 divers in the water watching us as we got dunked under and to help us escape if we ended up down too long.

Two crewman getting the dunker back to “right side up” for another simulation

Imagine being in a set of rapids, hanging upside down without an idea of which way is up and completely disoriented while not being able to breath. This is exactly what we went through today…except in real life we’d then probably have to get to the surface (some 30-50m away). There’s little around to help you navigate except the simple technique of opening the door first then seat belt (otherwise you can float away and have no idea of your bearings).

This was a fascinating experience that helped emphasize the importance of in-situ training. When experiences are vastly different than what we’re used to, we must engage this environment and practice in a foreign situation.

A nice side-profile of the dunker! What a sweet ride!

I’ve included a video of the dunker, so that it can be observed in action! You’ll see the two that were belted in, pop up right at the end of the clip! Another successful escape!

http://youtu.be/OF1NuZFJZIk

Another day at the office…

We just got back from a beautiful day working at ARHT. Not a super busy day but we did get out flying for a few jobs. We enjoyed amazing weather, great crew and got the patients safely to the hospital. Weather was about 20 degrees, sunny without much wind. We had a stunning trip out to Great Barrier Island…I’ve just posted a few pics from the day.

View during the flight home with Waiheke Island in the background.

Great Barrier Island

Doing my best Topgun look…maybe I should have a more serious face

Me and Leon (crewman). Probably the best guy to have on your team. Keeps us all under control and has tons of experience! Plus fairly certain he can bench 300lbs…not bad to have on your side

Surf Rescue Videos

Just put together my first iMovie! This is an edited clip from part of the rock swim at Muriwai that we did with the Surf Rescue Life Guards last week.

http://youtu.be/criFEz9UwL4

At the beginning of the clip you’ll see the video pan over to a large hole in the rocks, known as the blowhole. This has been the site of several rescues recently where the team has winched down to rescue people that fall in. As you can imagine it could get a little hectic. Luckily when we were there the waves we’re relatively calm. But even climbing out once after you jump in can be tough – I learned this the hard way. You’ll see me jump in (wearing the blue & black wetsuit)…pretty much the tallest and lankiest guy there. I didn’t get out successfully the first time but I did completely shred my hands. They continued to bleed for the rest of the swim. After we all got out, we walked around the point and did the most advanced part of the swim. Unfortunately I dont have footage, but it was pretty wild, you swim like an idiot then body surf through this cave.

Also, I re-posted this video of the static line rescues that we were doing. Amazing opportunity to jump out of the helicopters into the ocean, get lifted by a 50ft static line and brought to shore!

Successful pre-hospital simulation day!

Thursday’s have turned into our structured simulation day at the helicopter base. Part of my learning objective at ARHT (in Auckland) is to improve my abilities in running and debriefing simulation scenarios. While the group has (and continues) to run impromptu simulation sessions we have moved to a structured aspect that will allow us to be creative and try new things. We have the luxury of our Rescue Helicopter Trust being the subject of a TV show so there’s an abundance of footage of previous jobs. Today we selected a scenario from a previous episode that was viewed by the sim team before starting (check it out all the episodes here). This set the scene and we immediately jumped right into the scenario. The team stormed out to the scene and within minutes were immersed within the scenario. Check out a few pics from the scenario below.

Scott and Ati working hard during a V. Fib arrest. Great to see Scott providing some solid CPR!

The debrief – doing my best to keep people interested! Do you think they were listening?

The duty crew for the day formed today’s team and it was comprised of three members who did an awesome job! We had great teamwork from all three; Ati (crewman), Ross (Advanced paramedic), Scott (HEMS physician). Two key themes emerged from the day:

1) Role assignment and leadership: sometimes pre-assignment of a leader in the pre-hospital setting can be disrupted depending on available personnel (or lack thereof). The team decided as long as it’s well verbalized that there’s going to be a transition in leadership that it shouldn’t be an issue

2) Ergonomics: Placement of equipment and personnel is super important for being efficient and maximizing speed. Following the scenario we examined the set up the team had established then looked at ways to improve it. Chris Denny (HEMS physician supervising the scenario) spoke of using the stretcher as “table” and the use of angles as a strategy to improve scene ergonomics.

This session was a great opportunity for me to practice my debriefing skills using some stuff from the Harvard Simulation group. The idea of advocacy-inquiry method moves away from the idea that we shouldn’t judge during debriefings. Instead, the debriefer can provide an opinion but at the same time they try to understand how/why the learner decided to make such a decision even it may have been incorrect or controversial. “The instructor can help the learner reframe internal assumptions and feelings and take action to achieve better results in the future” (Rudolph JW et al. Simul Healthcare 2006).

Jumping out of helicopters, surf lifesaving and rock swims

Haven’t been able to post for a few days, in part due to the fact my hands were shredded after a wild day of training last week (and a short little vacation out of town over the weekend!).

I don’t have all the videos/pictures yet as I’m trying to gather them up from a few sources but as part of our helicopter rescue training we got the opportunity to work with the local surf lifesaving squads to do some static line rescues at Muriwai beach!

Muriwai Beach

What this involves is flying out over the surf in the helicopter. The pilot then lowers the helicopter down to somewhere between 10-15 feet above the water. The issue is that obviously too low and a wave will cause serious havoc if it catches the chopper (I only realized this once we were out there…probably a good thing)! The crewman sits in the open door and helps you outside. The goal is to time your jump into the water so that you land on the high part of a swell. Failing to do so could increase your jump by another 10-15ft or more depending on the swells!

Lucky for me (and my reluctance to engage in considerable acts of jumping from high places), the swells were fairly calm. Before we knew it, we were all decked out in wetsuits and fins and aboard the chopper for our jumps. Each group had two people, so one was a rescuer and one was a rescuee…not sure if I was chosen to be a rescuee based on my “holy sh&^” expression on my face that day but I guess they felt that I would likely need a rescue! There’s a standard procedure of taps on the knee, then two on the back as you exit the helicopter by the crewman who guides you out. As I got out on the helicopter skid looking down, it was a bit more hectic than I had imagined! I’m fairly certain I had to get a few more taps on my shoulder (then previously planned) to tell me to jump but I made the plunge! Turned out ok! I was still alive! The amount of spray kicked up by the helicopter is crazy…I felt again like I was GI Joe! The paramedic in charge of my “rescue” got in shortly after. He secured me up to the 30-40ft rope that is dropped down from the helicopter and we got carried about 50 feet in the air to shore where we landed very nicely on the beach. Huge thanks to the ARHT flight crew (crewman and pilots), and my rescuer (Chris Deacon) for getting that all done. Was a great session! I’ve attached a video from 2 years ago from our helicopters doing a static line rescue training – it was very similar to what we did last week so this will give you a great idea.

Afterwards we headed out on the jetskis with the surf lifesaving guys. These guys have an awesome job and are super skilled! I got to hold on for dear life on this boogie board attached to the back of the jetski while we practiced  water rescues! Absolutely awesome and a huge amount of respect for how they do their job – not easy managing massive surf while looking for drowning victims! Here’s a few pics as we were getting ready.

Getting an explanation from the surf rescue paramedic how to stay in (and not fall out) of the inflatable rescue boat

Jetski loaded up on the quad – responds to rescues asap all over the beach

“boogie” board folded up on the jetski. when in use, it folds down (which is where I was lying on, holding on to the sides) during our practice rescues. Victims are pulled onto the board with a rescuer beside them. Driver remains on the jetski.

Finally, last but not least, was the rock swim. I’m hoping to get some video footage this week so I’ll save the rest of the post, but definitely pushed my aquatic limits with this! Scrapped my hands to shreds and a few hectic moments! Though definitely huge thanks to the surf lifesaving guys who swam with me the whole way – as one of the guys told me just before I was about to jump into the crashing waves, “no better time to do this then when you have 20 surf rescue life guards with you!”…sweet!

Lung ultrasound for pneumothorax: literature for practice & simulation

Here’s a few articles on lung ultrasound. This post is a result of discussions as ARHT has recently added portable ultrasound as a new tool on the helicopters. This should be particularly useful in the assessment of pneumothorax! One study showed that rotor rotation doesn’t really affect image acquisition in M-mode – very cool!

In the trauma or pre-hospital setting, if you’re using ultrasound you want to be able to slap it on quickly and rule out that pneumo. Where to scan on the chest however hasn’t been well delineated and different institutions use different protocols. This study shows that we might need to scan lower down than we usually do. It may not change management but could be helpful to know your patient has a pneumo if they suddenly deteriorate in the trauma bay or in flight for those transporting patients. The authors suggest, based on CT scan analysis, that >80% of pneumothoraces will be detected by scanning between the 5th & 8th intercostals parasternally and 7-8th intercostal lateral to mid-clavicular line. Equates to regions 9, 11 and 12 on the image below. Much higher than the frequency of pneumothorax over the traditional regions scanned (regions 3 and 6 or the 2nd – 4th intercostals). This will definitely be useful for those in the pre-hospital setting who want to make a decision regarding flight as it may change with a patient who has a pneumothorax.

Regions 9, 11 and 12 based on CT scan analysis have higher frequencies of pneumothorax compared to regions 3 & 6. Image from Am J Emerg Med. 2012 Sep;30(7):1025-31

Finally, as we strive to make simulation accessible, this article outlines a slick way of simulating lung ultrasound at a very low cost! This is extremely useful if you’re running a sim scenario and don’t have access to pre-generated images or you forgot to bring them! The authors describe performing an ultrasound on the palm of the hand. To recreate the lung slide, you move the dorsum of the hand while scanning on the palm – they show some images how this worked using M-mode. Great idea and look forward to using it!