# CCT in Fly-cars



## MonkeyArrow (Jan 26, 2014)

I was reading literature on pre-operating room thoracotomies and there was a study of outcomes from the U.K. (http://europepmc.org/abstract/MED/21131854) and read that emergency physicians drive with fly-cars to the scene when they are needed. It seems to work very well for them and allows them to perform advanced interventions without a hospital.

I was wondering why we couldn't implement a method in the U.S. where E.M. doctors or CCT medics could intercept and perform advanced interventions (field thoracotomy, open cric, clamp and ligate, etc.) in the field where HEMS is not available or not feasible. CCT rigs could also perform this function but they do not perform in a 911 capacity in any place i have seen rather operating privately doing IFT.


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## NomadicMedic (Jan 26, 2014)

I'd be curious if it would decrease trauma mortality. I think anywhere docs in fly cars are close enough to be of any use, the PT could be in the ambulance and en route to the OR. And most paramedics can already perform a chest decomp and surgical airway.


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## MonkeyArrow (Jan 26, 2014)

DEmedic said:


> I'd be curious if it would decrease trauma mortality. I think anywhere docs in fly card are close enough to be of any use, the PT could be in the ambulance an en route to the OR. And most paramedics can already perform a chest decomp and surgical airway.



Sorry, I wasn't clear. By thoracotomy, I meant a surgical one done by making an incision from the sternum to the stretcher and using rib spreaders to open the chest to relieve pericardial tamponade and/or cross-clamp the aorta. Oh, and in GA, medics aren't allowed to do open crics, only percutaneous/closed ones. If the training were sufficient in, say, trauma surgery, I think trauma mortality would decrease given the appropriate equipment for the doc is on the rig. I think that civilian EMS needs to learn a thing or two from the military and how they care for their casualties. Everything is so slow to transition from saving lives on the battlefield to civilian care (Ex: tourniquets: widely used and highly effective in the mil but still see rigs without TQ or EMTs still trying to stuff massively  hemorrhaging wounds with 4x4s).


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## chaz90 (Jan 26, 2014)

Trauma Centers with fully functional ORs and surgeons are far closer in the American civilian world than on some remote battlefields. I don't see any utility to add something as drastic as a thoracotomy to anyone's scope other than physicians. Even physicians working full time in urban Level I trauma centers EDs aren't doing these anywhere approaching often, and they're used emergently as last ditch measures as is.


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## MonkeyArrow (Jan 26, 2014)

chaz90 said:


> Trauma Centers with fully functional ORs and surgeons are far closer in the American civilian world than on some remote battlefields. I don't see any utility to add something as drastic as a thoracotomy to anyone's scope other than physicians. Even physicians working full time in urban Level I trauma centers EDs aren't doing these anywhere approaching often, and they're used emergently as last ditch measures as is.



But is that really a good reason not to do something? Well, I could say the same thing about some paramedics and intubations. Because some medics only have X amount of intubations per year, they shouldn't be able to do them. Training and retraining is the key to any successful skill set. And yes, field surgery should only be reserved for physicians. However, that was the person originally proposed to be in the fly car doing such skills. The thoracotomies were performed with a relatively high level of success as noted in the study in the OP.


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## chaz90 (Jan 26, 2014)

MonkeyArrow said:


> But is that really a good reason not to do something? Well, I could say the same thing about some paramedics and intubations. Because some medics only have X amount of intubations per year, they shouldn't be able to do them. Training and retraining is the key to any successful skill set. And yes, field surgery should only be reserved for physicians. However, that was the person originally proposed to be in the fly car doing such skills. The thoracotomies were performed with a relatively high level of success as noted in the study in the OP.



A Level 1 ED where I did a portion of my field internship did ~1 ED thoracotomy a year, and often none at all. The risk benefit ratio doesn't bear out the utility of this intervention pre hospitally. Intubations are somewhat rare pre hospitally in some systems, but nowhere near approaching the lack of use of this kind of intervention. Situations in which this would be considered prior to arrival at the hospital would make surgical crics seem routine by comparison.


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## NJEMT95 (Jan 26, 2014)

One of NJ's main ALS services has an ER doc on duty who can respond to scenes in a flycar: http://www.emsworld.com/press_release/10615990/nj-based-monoc-adds-ems-physician-md-1-program


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## WestMetroMedic (Jan 26, 2014)

*Opals*

It is an older study, but I think that it still rings true.  OPALS reaffirmed the theory that critical, but possibly survivable trauma and cardiac arrest benefit from BLS.  ALS and physician level crews were detriments to their patients survival.  It is all a distraction from what really needs to happen, but it does keep our futility muscles well toned.

I am very proud of the range of skills that I have as a Medic, but at the end of the day, ambulances are for taking people to the doctor and taking naps in.


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## feldy (Jan 26, 2014)

Our medical director has his own sprint car and we usually have a EM resident (required as part of EM rotation) or doc riding with our sprint medic.


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## NPO (Feb 24, 2014)

MonkeyArrow said:


> I was reading literature on pre-operating room thoracotomies and there was a study of outcomes from the U.K. (http://europepmc.org/abstract/MED/21131854) and read that emergency physicians drive with fly-cars to the scene when they are needed. It seems to work very well for them and allows them to perform advanced interventions without a hospital.
> 
> I was wondering why we couldn't implement a method in the U.S. where E.M. doctors or CCT medics could intercept and perform advanced interventions (field thoracotomy, open cric, clamp and ligate, etc.) in the field where HEMS is not available or not feasible. CCT rigs could also perform this function but they do not perform in a 911 capacity in any place i have seen rather operating privately doing IFT.



We often have doctors on board our CCT units. But as you said, its IFT not 911.


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## jwk (Feb 24, 2014)

MonkeyArrow said:


> But is that really a good reason not to do something? Well, I could say the same thing about some paramedics and intubations. Because some medics only have X amount of intubations per year, they shouldn't be able to do them. Training and retraining is the key to any successful skill set. And yes, field surgery should only be reserved for physicians. However, that was the person originally proposed to be in the fly car doing such skills. The thoracotomies were performed with a relatively high level of success as noted in the study in the OP.



Sorry - you really gotta look at these stats with a critical eye.

71 cases in 15 years.  That's less than one every two months - barely five a year.  

Only 13 survived, and two of those had poor neurological outcomes.  Six of those 13 indicated the physician was already present at the time they arrested.

Although successful, these are very rare events.  These statistics indicate that about one patient out of five survived each year.  These are NOT "relatively high level of success" statistics to me.  

Even if you're working out of Grady, AMC, or Emory Midtown in Atlanta - these are simply not procedures that you would see docs performing out on the streets.  NOBODY wants that liability.  And EMS is already underfunded - particularly at Grady which does the bulk of the city of Atlanta.  Where on earth do you think the funding would come for having physicians driving around 24/7/365 for the incredibly rare instances where they would actually make a difference?


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## MonkeyArrow (Feb 24, 2014)

I understand the prospect of MDs being too costly but for a metro system like Grady (notwithstanding their funding issues), they have docs sitting around for OLMC. Why can't said docs actually get into fly cars and do things in the field? Just like a tiered BLS-ALS system where ALS gets activated under certain call types, why can't OLMC drive around and be able for on-site med assistance for extended extraction, etc.


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## Handsome Robb (Feb 24, 2014)

If we really need it, read field amputation or something of the sort, we can request a trauma surgeon and we will get one.

I work in a metro system, for the most part, we've got really rural areas too and our OLMC docs are not sitting around waiting for our call they're attending physicians in the ER and we get whoever can come to the phone first. 

The vast majority of the time I can be packaged, loaded, transported and to the TC before they could get on scene.

I'm not completely opposed to it but I think there needs to be more of a need than for potential thoracotomy cases. We do surgical and needle crichs on standing orders so I don't need a doctor for a surgical airway.


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## jwk (Feb 24, 2014)

MonkeyArrow said:


> I understand the prospect of MDs being too costly but for a metro system like Grady (notwithstanding their funding issues), they have docs sitting around for OLMC. Why can't said docs actually get into fly cars and do things in the field? Just like a tiered BLS-ALS system where ALS gets activated under certain call types, why can't OLMC drive around and be able for on-site med assistance for extended extraction, etc.



Knowing the Grady system, I don't think docs are sitting around doing nothing but OLMC.


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## MonkeyArrow (Feb 24, 2014)

Robb said:


> I'm not completely opposed to it but I think there needs to be more of a need than for potential thoracotomy cases. We do surgical and needle crichs on standing orders so I don't need a doctor for a surgical airway.



I understand the current expanded scope but what do you think about prospects for this becoming the majority in the future. With the ever declining scope of basics (even though they are being phased out for AEMTs) *cough* cali *cough*, do you think that the scope of medics and basics will become restrictive enough to force the current ALS scope to become one relegated to CCT? With a bunch of providers in the field having worked a good amount of time and never worked a 911 call in their career just acting as a taxi for IFTs, do you think that one day, enough pts. will have negative outcomes due to lack of experience from said providers to force a change to the above. 

BTW I completely support the requirement for medics to have an associates degree and have actually taken in depth A&P, bio, and chem courses to actually understand what pushing CaCl will do instead of matching the picture with the monitor and pushing whatever drug the book/protocls say to push.


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## Handsome Robb (Feb 24, 2014)

My scope has been expanding over the last few years, not narrowing. So no I don't think that's the future. Our Community Health Paramedics are expanding as well. Our system has basically phased out ground critical care providers and added it all to the 911 medic scope. True CCTs will get a HEMS crew from our air service and us as a taxi. 

As far as getting rid of basics, the only thing we use them for is special events staffing. No basics on ambulances here. Been that way for a long time. 

Off topic but I saw your pm, read it then got busy and it got buried in there I'll get back to you a little later about that!


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## the_negro_puppy (Feb 25, 2014)

I have personally witnessed a medical officer with our service intercept on a job and perform a clam-shell thoracotomy on a PEA arrest stabbing patient.

He died :unsure:


Some of our Intensive Care medics in fly cars now carry blood, can perform thoracostomy and RSI


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## MonkeyArrow (Feb 25, 2014)

the_negro_puppy said:


> I have personally witnessed a medical officer with our service intercept on a job and perform a clam-shell thoracotomy on a PEA arrest stabbing patient.
> 
> He died :unsure:
> 
> ...



Your system seems to be a lot alike to what I was describing. If you don't mind, can you describe the rest of your systems operating procedures relevant to the advanced medical care/intensive care medics/medical officer intercept. Also, do you have any statistics from QA/QI on the advanced med procedures performed by the aforementioned people.


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## Pond Life (Sep 21, 2018)

Ive just completed an annual update with my service and we have been told that if a patient has blunt chest trauma cardiac arrest or peri-arrest that we are to notify HEMS immediately and if doctor on board they will come along and do a roadside clamshell thoracotomy with damage control surgery as required. Thing is it has to be in 10 minutes of the arrest or its a non starter.
The policy has been in place for 6 months now - haven't heard of any patients receiving this treatment as yet.


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## TXmed (Sep 21, 2018)

the_negro_puppy said:


> I have personally witnessed a medical officer with our service intercept on a job and perform a clam-shell thoracotomy on a PEA arrest stabbing patient.
> 
> He died :unsure:
> 
> ...



Wheres this at if you dont mind me askin ?


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## E tank (Sep 22, 2018)

Surgeons are really expensive to train and the only times they're hanging around not doing anything is when they turn their phones off because a partner is covering. Other than that they're making money for themselves and the hospital. A widespread system of American surgeons dropping what they're doing to go to the scene of a trauma is the stuff of fantasy. And an ER doctor is not a surgeon. 

An aortic cross clamp isn't the end of the intervention. It is only the beginning and it is only useful in very specific situations. Once applied, a very specific course of action needs to be planned and taken. And stupid quickly. Cross clamping without a plan and the ability to carry it out,  is not undertaken often, if at all, at least by thoraco-vascular/CT surgeons. It surely shouldn't be by an ER doc.


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## VFlutter (Sep 22, 2018)

I still like the idea of field REBOAs. Has a lot of the same practical and logistical limitations but is a much more obtainable goal than field thoracotomy.


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## PotatoMedic (Sep 22, 2018)

I think junctional tourniquet is the way to go.  https://www.ncbi.nlm.nih.gov/m/pubmed/29661286/


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## jwk (Sep 23, 2018)

Pond Life said:


> Ive just completed an annual update with my service and we have been told that if a patient has blunt chest trauma cardiac arrest or peri-arrest that we are to notify HEMS immediately and if doctor on board they will come along and do a roadside clamshell thoracotomy with damage control surgery as required. Thing is it has to be in 10 minutes of the arrest or its a non starter.
> The policy has been in place for 6 months now - haven't heard of any patients receiving this treatment as yet.


That timeline is pretty much a non-starter period.  Your arrival time post-arrest likely ate up the bulk of your "10 minutes of the arrest".  Then you have to make the call, load staff and surgeon (who is not sitting in the lounge directly across from the helipad), then spin up, take off, land, etc.  The response time window doesn't work.


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## rescue1 (Sep 23, 2018)

E tank said:


> Surgeons are really expensive to train and the only times they're hanging around not doing anything is when they turn their phones off because a partner is covering. Other than that they're making money for themselves and the hospital. A widespread system of American surgeons dropping what they're doing to go to the scene of a trauma is the stuff of fantasy. And an ER doctor is not a surgeon.
> 
> An aortic cross clamp isn't the end of the intervention. It is only the beginning and it is only useful in very specific situations. Once applied, a very specific course of action needs to be planned and taken. And stupid quickly. Cross clamping without a plan and the ability to carry it out,  is not undertaken often, if at all, at least by thoraco-vascular/CT surgeons. It surely shouldn't be by an ER doc.



Thoracotomy with cross clamping of the aorta is taught as part of an emergency medicine residency, and the emerg docs (not surgeons) do it prehospitally with London Air Ambulance and all the other sexy flight doc programs that people like to talk about.

You are correct though, that unless step 2 is "be at a trauma center with a surgeon very quickly" its a useless procedure. There is also some data that REBOA might be more effective/safer.


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## E tank (Sep 23, 2018)

rescue1 said:


> Thoracotomy with cross clamping of the aorta is taught as part of an emergency medicine residency, and the emerg docs (not surgeons) do it prehospitally with London Air Ambulance and all the other sexy flight doc programs that people like to talk about.
> 
> You are correct though, that unless step 2 is "be at a trauma center with a surgeon very quickly" its a useless procedure. There is also some data that REBOA might be more effective/safer.



Right...anyone can be taught to throw an aortic cross clamp. That isn't the hard part. It's the guy that takes it off that needs to be around...

But I think there is a distinction between a huge-a** thoracotomy and possible X clamp and a REBOA, not the least of which is you can't cross clamp the aorta in zone 2 and 3 anywhere else than in an OR. An occluded aorta in zone 1 knocks out the mesenteric, spinal and renal arterial supply which can mean dead bowel and kidneys and possibly paraplegia in short order. Some might argue a dead person doesn't need kidneys so what does it matter, but the REBOA is a way better device in that the operator can decide and weigh the consequences of where he occludes the aorta.

A thoracotomy isn't of any use in an abdomino/pelvic injury, aortic occlusion in the chest for such an injury risks taking out bowel and kidney unnecessarily and a low (infra-renal) aortic X clamp outside the OR is not practical. So, yeah, REOBA.


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## rescue1 (Sep 24, 2018)

Thoracotomy can be indicated in abdominal trauma, though it's not the best indication, purely for clamping the aorta in what would be REBOA zone 1 and knocking out all abdominal blood flow. You can't really control those bleeds with REBOA either because the celiac and SMA are superior to the renal arteries, and they're both in zone 2 anyway, which is (I don't know why) considered a no go zone for REBOA. REBOA you can clamp zone 1 or 3, and 3 maybe lets you control the IMA, but mostly the iliacs and below. A completely untested advantage is the ability to partially inflate the balloon and still try and allow some intestinal and renal blood flow, but I don't think anyone's actually studied how effective that could be. 

Weirdly, one of the few "not recommended" indications for thoracotomy is blunt trauma with no signs of life, so I'm not sure why the above poster has that as an indication for HEMS, in addition to the fact that unless HEMS is on the initial dispatch it's probably too late anyway.


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## Pond Life (Sep 25, 2018)

jwk said:


> That timeline is pretty much a non-starter period.  Your arrival time post-arrest likely ate up the bulk of your "10 minutes of the arrest".  Then you have to make the call, load staff and surgeon (who is not sitting in the lounge directly across from the helipad), then spin up, take off, land, etc.  The response time window doesn't work.



Quite agree, I think its a daft idea and unachievable - the tutor couldn't grasp why we thought it wasn't going to work. May do in London where you have HEMS doctors on cars and helicopters a few minutes away. But I live in a remote area of the UK were distances b road to an incident is often greater than 30 minutes and then we have to call the HEMS unit out. Unlikely to happen down my neck of the woods.


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## Pond Life (Sep 25, 2018)

rescue1 said:


> Thoracotomy can be indicated in abdominal trauma, though it's not the best indication, purely for clamping the aorta in what would be REBOA zone 1 and knocking out all abdominal blood flow. You can't really control those bleeds with REBOA either because the celiac and SMA are superior to the renal arteries, and they're both in zone 2 anyway, which is (I don't know why) considered a no go zone for REBOA. REBOA you can clamp zone 1 or 3, and 3 maybe lets you control the IMA, but mostly the iliacs and below. A completely untested advantage is the ability to partially inflate the balloon and still try and allow some intestinal and renal blood flow, but I don't think anyone's actually studied how effective that could be.
> 
> Weirdly, one of the few "not recommended" indications for thoracotomy is blunt trauma with no signs of life, so I'm not sure why the above poster has that as an indication for HEMS, in addition to the fact that unless HEMS is on the initial dispatch it's probably too late anyway.



Don't shoot the messenger - just relaying what those upstairs told me whats going to happen. Here is a recent paper citing a move away from penetrating chest trauma only for CST and adopting it for blunt trauma cardiac arrest. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098997/


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## rescue1 (Sep 25, 2018)

Pond Life said:


> Don't shoot the messenger - just relaying what those upstairs told me whats going to happen. Here is a recent paper citing a move away from penetrating chest trauma only for CST and adopting it for blunt trauma cardiac arrest. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098997/



Oh that's pretty neat, I'll check it out. 

Yeah I know it's not your fault, just like others have said it seems like a strange use of resources. But what do I know.


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