# Call for ideas: Improvising in the field



## icefog (Mar 27, 2013)

As an EMS instructor, I've recently received the unenviable task of preparing a 90-minute practical training course on "planning for improvisation" (namely, what to do when a certain resource you need isn't available). It could relate to practically any challenge in the field: diagnosis, treatment, extrication, transport, etc. Some examples of what I've got so far are: improvised Heimlich valve, makeshift pelvic sling, using a SAM splint to get a baby out of the baby seat, using an extrication collar to temporary hold pressure on a neck wound when there's no other way to do it... (I know, I know...)

I'm also looking into some wilderness EMS manuals, trying to dig something out.

I'm aware of the legal issues connected to improvising in the field, and I've got that one covered (actually, that was the easy part).

So, my question is: any ideas I could work into this MacGyver show? Anything you've done or heard of that could be implemented with a reasonable chance of success?

Thanks!


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## joshrunkle35 (Mar 27, 2013)

Maple syrup for oral glucose, supposedly.


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## Veneficus (Mar 27, 2013)

icefog said:


> As an EMS instructor, I've recently received the unenviable task of preparing a 90-minute practical training course on "planning for improvisation" (namely, what to do when a certain resource you need isn't available). It could relate to practically any challenge in the field: diagnosis, treatment, extrication, transport, etc. Some examples of what I've got so far are: improvised Heimlich valve, makeshift pelvic sling, using a SAM splint to get a baby out of the baby seat, using an extrication collar to temporary hold pressure on a neck wound when there's no other way to do it... (I know, I know...)
> 
> I'm also looking into some wilderness EMS manuals, trying to dig something out.
> 
> ...



Intending no offense,

It has been my experience that a lot of the improvised gimmics are not really needed at all.

They are just techniques that people who don't really have experience or need of medicine in any austere condition like to make up to seem informed.

Most successful improvisation comes from being very knowledgable in basic medical prinicples. 

In my experience, high volume critical care and traditional education are the secrets to my success.


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## Brandon O (Mar 27, 2013)

Emphasize understanding the needs of the task and then reflecting on how you can achieve them. I would stop before each task and ask, "What do we need to accomplish here?" For instance, maybe for a splint the goals are to secure the limb exactly as it's currently positioned, comfortably, and supported against gravity, but leaving space for distal neurovascular monitoring. Now you can look at what you've got and ask how to accomplish those objectives. If you have 'em, doesn't matter if it looks funny. If not, you're just playing make-believe, like cargo cults.


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## WuLabsWuTecH (Mar 27, 2013)

I would recommend doing it like real life.  Things that you are most likely to forget to restock.  Give them a jump bag, but "forget" to put the NC or NRM back in.  That SAM splint that you used?  "Forget" to put that back in and only have ones that are too short or too long.  Forgetting to refill O2 is an easy one, but there are ways to get O2 to people without an O2 bottle.  Have your stephoscope break, will these newbies remember in the heat of the moment that you can still palp a BP?  While on the subject, tape the knob of the BP cuff open so that there's a slow leak, can they still get you a BP?  Do they even need to if we're in a trauma situation and feeling for a radial pulse is all we need?  What if we restocked the sterile water but not the nozzle cap?  Is there another way to flush out the eyes?  We ran out of backboards on this mass casualty, what do we do now?

Think less about what ideas you want them to come up with, but more about common scenarios they might have to deal with.  Don't try and make a scenario where you try and get them to come up with the "right" answer, but rather make a scenario that is common and plausible, and let them come up with their own answers.  While the questions I posed above may have a particular answer that I would go with, any answer that accomplishes the task is a right answer.


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## RocketMedic (Mar 27, 2013)

Improvised nebulizer: neb treatment + 15ml bottled water + compressed air hose ran into an MRE bag. Decent seal too.


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## Veneficus (Mar 27, 2013)

Rocketmedic40 said:


> Improvised nebulizer: neb treatment + 15ml bottled water + compressed air hose ran into an MRE bag. Decent seal too.



Did you really do this?


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## RocketMedic (Mar 27, 2013)

Veneficus said:


> Did you really do this?


Yep...got some funny looks, but it worked pretty well.

NTC 2009, the Stryker, Abrams and military trucks draw ambient air into seperate compressed-air system (no oil associated) and the rest was just proper allocation of tape and careful regulation of the air pressure delivered. We didnt have any neb setups or O2 bottles and some asthmatic kid who lied his way through MEPS. All you need is to keep the nozzle just below the surface of the puddle.


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## Veneficus (Mar 27, 2013)

Rocketmedic40 said:


> Yep...got some funny looks, but it worked pretty well.
> 
> NTC 2009, the Stryker, Abrams and military trucks draw ambient air into seperate compressed-air system (no oil associated) and the rest was just proper allocation of tape and careful regulation of the air pressure delivered. We didnt have any neb setups or O2 bottles and some asthmatic kid who lied his way through MEPS. All you need is to keep the nozzle just below the surface of the puddle.



That is awesome. Great thinking.


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## Brandon O (Mar 27, 2013)

I have heard tell about nebulizing orange juice to clear noxious odors (or alcohol to... well, whatever), but I cannot vouch for this.

Some BP cuff tricks: http://www.youtube.com/watch?v=6-_PEEwduUM (sorry for the 'stache)

An irrigation trick: http://www.youtube.com/watch?v=uhZ3EZp7bK4


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## mycrofft (Mar 27, 2013)

Stray shots:

I'm curious about the "getting around the legal thing"-thing.

Need to cover those improvs which are apocryphal or seem self-evident to everyone at some point but just do not work.

Good basics and experience make for success with plan C (plans A and B failed). Things like keep a double male oxygen tubing adapter handy, an "O"-ring for the E cylinder yoke, spare A and/or AAA cells, a note pad with cover for when the tablet crumps or the forms all get wet, etc etc. Phone change in the event cell and radio are out. Check air pressure in your spare tire, rehearse changing a tire on your ambulance. If you have a LED flashlight, have an incandescent one as well because of color masking by the LED.


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## Brandon O (Mar 28, 2013)

mycrofft said:


> Things like keep a double male oxygen tubing adapter handy



Nota bene: a single or double male connector (of great length if needed) can be created by trimming one or both ends off a nasal cannula, non-rebreather tube, double female extension, or any similar tubing. Just wield those shears and snip. The bare tube will insert into a female connector without a problem.


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## frdude1000 (Mar 28, 2013)

Using a nasal cannula connected to a bag of saline to irrigate eyes.

Using a nasal cannula to secure a king airway or combitube. (Plastic on plastic works really well)


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## Clipper1 (Mar 28, 2013)

Rocketmedic40 said:


> Improvised nebulizer: neb treatment + 15ml bottled water + compressed air hose ran into an MRE bag. Decent seal too.



What was the purpose? 

Without the baffles the particles would be too large to be of any use to an asthmatic patient.


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## CritterNurse (Mar 28, 2013)

I was in a training class where we were taught that a KED placed upside down can be used to stabilize a pelvis (put the 'head' part under the thighs, and the 'torso' part around the pelvis).

Rolled up and taped towels can be used as improvised head blocks.

A dixie-cup can be used to protect an injured eye.

Wrappers from various supplies can be reused on scene if containers are needed in a pinch. For example, I used a couple of wrappers slipped over a pair of bloody trauma shears and taped in place to keep the blood from being smeared around until we could clean the shears. I've also used wrappers to contain smaller bits of rubbish to minimize the amount of cleanup on scene when a waste basket isn't readily available.

Most of my MacGyvering has been done on injured animals though, and I'm not so sure what I've done there would be much help in the ambulance, since most humans know better than to lick wounds and keep bandages dry.


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## climberslacker (Mar 28, 2013)

WEMT Here, gimmicks aren't what we learned. We learned our stuff well with the idea being that if you know why you are doing something, it makes it much easier to improvise. For some of our scenarios, we would be told to "pack as if you were going on a real hiking trip" so that we could see what we would actually have with us. Then sometimes we would go with full equipment associated with SAR teams and have to deal with that. We even spent a day making and then carrying improvised litters. 

That being said, yeah, I can improvise a traction splint pretty easily. But it comes down to lots of practice to learn yourself how to think outside the box. I don't think a 90 minute lecture will do it.


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## Veneficus (Mar 28, 2013)

climberslacker said:


> WEMT Here, gimmicks aren't what we learned. We learned our stuff well with the idea being that if you know why you are doing something, it makes it much easier to improvise. For some of our scenarios, we would be told to "pack as if you were going on a real hiking trip" so that we could see what we would actually have with us. Then sometimes we would go with full equipment associated with SAR teams and have to deal with that. We even spent a day making and then carrying improvised litters.
> 
> That being said, yeah, I can improvise a traction splint pretty easily. But it comes down to lots of practice to learn yourself how to think outside the box. I don't think a 90 minute lecture will do it.



and how often do people really used improvised liters, make shift traction splints etc.

Ask around.

Preferably ask people who didn't sell you that class but really do it.


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## RocketMedic (Mar 28, 2013)

Clipper1 said:


> What was the purpose?
> 
> Without the baffles the particles would be too large to be of any use to an asthmatic patient.




Asthma ecacerbation, no neb baffles available. Sorta worked.


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## ExpatMedic0 (Mar 28, 2013)

icefog said:


> So, my question is: any ideas I could work into this *MacGyver show*? Anything you've done or heard of that could be implemented with a reasonable chance of success?
> 
> Thanks!



I think the classic that is often sarcastically joked about; is using a ballpoint pen for a makeshift cricothyrotomy. While I have never done such a thing, I have "heard stories" 

On a side note, are you a German Paramedic working in that system or a U.S. military personal stationed in Germany?


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## MrJones (Mar 28, 2013)

Veneficus said:


> and how often do people really used improvised liters, make shift traction splints etc.
> 
> Ask around.
> 
> Preferably ask people who didn't sell you that class but really do it.



Why does it matter "how often" an improvisation is used?


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## Veneficus (Mar 28, 2013)

MrJones said:


> Why does it matter "how often" an improvisation is used?



Because charging students for a class, who do not know any better, to "teach" them something that isn't really what happens or what they can expect seems a bit dishonest to me.


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## MrJones (Mar 28, 2013)

Veneficus said:


> Because charging students for a class, who do not know any better, to "teach" them something that isn't really what happens or what they can expect seems a bit dishonest to me.



Interesting. So, in your back country experience what really happens when a group is deep in the back country and one of them is seriously injured?


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## Veneficus (Mar 28, 2013)

MrJones said:


> Interesting. So, in your back country experience what really happens when a group is deep in the back country and one of them is seriously injured?



No, I think that based on my experience and speaking with people who are more active in providing medical aid in austere conditions that a lot of what is taught is generally BS. 

Some of the advocates claim the purpose of teaching these interventions is to teach critical thinking skills. Which I definately do not buy into. 

Making somebody reherse a skill is very different from teaching the basic principles required to understand and implement an intervention which will achieve the goal with some measure of success. 

There is also the question of the practicality of some of the " core interventions" as they are taught.

I can teach you how to measure hematocrit using a ruler, a glass tube, and a needle mounted to a piece of wood. Not only because I was taught how to do it, but because I understand the principle behind it. (and I do'n even really need the ruler because I know the measurements of multiple paper currencies) 

But the question becomes "what will this information add or change?" How much is going through this procedure going to be worth in terms of outcome?

Perhaps if you are in a a remote medical facility with broken equipment, but really nowhere else.   

But it is definately not on the list of "things you should know before you travel."


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## MrJones (Mar 28, 2013)

Veneficus said:


> No, I think that based on my experience and speaking with people who are more active in providing medical aid in austere conditions that a lot of what is taught is generally BS.
> 
> Some of the advocates claim the purpose of teaching these interventions is to teach critical thinking skills. Which I definately do not buy into.
> 
> ...



Again, interesting, but it didn't really answer the question. You stated that teaching "something that isn't really what happens...seems a bit dishonest...." and I asked you what really happens when a group is deep in the back country and one of them is seriously injured.


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## Veneficus (Mar 28, 2013)

MrJones said:


> Again, interesting, but it didn't really answer the question. You stated that teaching "something that isn't really what happens...seems a bit dishonest...." and I asked you what really happens when a group is deep in the back country and one of them is seriously injured.



That depends on where you are, what you have, and what you need to do. 

It is quite a large topic, but I would propose the first part of the decision is "can you do anything for this person at all?"

You are then going to have to determine if you can be rescued, have to travel some distsance to make it possible, or self evacuate. 

There are considerations of the capabilities of the rescuers and a bit of logistics with the materials available. 

As a brief example, making a rope litter to carry somebody out may use up much needed rope, may not be feasible due to terrain, or you may not even have rope because it wasn't on your list of things to carry hiking through a desert or flatland.

Another good one, are you going to improvise a traction splint? If you have to self evacuate, how are you going to transport this person? Is the terrain conducive to carrying somebody in traction?

The list is endless, but to my knowledge, nobody ever died from not having a traction splint.

The femur is also not easily or effectively stabilized by many splinting techniques, so you might have an intervention that is doing nothing, or worse, making it harder to evacuate.

But I seriously doubt anyone is going to start a story with: "so there I was...When all of a sudden...When I remembered how to... that I learned in wilderness emt class... and the day was saved because I made a traction splint out of piece of fishing line and a stick."


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## Brandon O (Mar 28, 2013)

CritterNurse said:


> Wrappers from various supplies can be reused on scene if containers are needed in a pinch. For example, I used a couple of wrappers slipped over a pair of bloody trauma shears and taped in place to keep the blood from being smeared around until we could clean the shears. I've also used wrappers to contain smaller bits of rubbish to minimize the amount of cleanup on scene when a waste basket isn't readily available.



Gloves are good for this. Don, grab items, peel off glove around rubbish -- self-contained rubberized junk ball.


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## AK_SAR (Mar 28, 2013)

*Jelly Roll splint for leg*

Take two ensolite pads, put under leg, adjust overlap to fit leg length. Best to put something under knee so it is flexed slightly. Roll in from each side, secure with webbing, cravats or whatever.   It works kind of like a ski patrol quickie splint. Just as good, or even better in some situations. It effectively immobilized the leg, pads, insulates, is comfortable for the patient and easy to adjust for swelling. I learned it in a WFR class. 

And yes, I have seen it used in the field. A young woman blew her knee on a back pack in a remote area in the Talkeetna Mtns. The rest of the group splinted her up and took her pack. She was able to slowly hobble out to a lake where they were already planning to be met by float plane.  A nice self rescue, in a situation where it would have otherwise required a helicopter to get her out.

That's why I always carry an old school ensolite pad when I'm out in the backcountry, rather than thermarest or other types. They are extremely versatile. You can do lots of great improv with them.


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## MrJones (Mar 28, 2013)

Veneficus said:


> That depends on where you are, what you have, and what you need to do.
> 
> It is quite a large topic, but I would propose the first part of the decision is "can you do anything for this person at all?"
> 
> ...



Exactly. But then you go off the rails....



Veneficus said:


> As a brief example, making a rope litter to carry somebody out may use up much needed rope, may not be feasible due to terrain, or you may not even have rope because it wasn't on your list of things to carry hiking through a desert or flatland. Don't have enough rope? There are other ways to improvise a litter. Not feasible due to terrain? Shelter in place and send for help or, if there's not enough people available to do that, shelter in place and take appropriate steps to make it as easy as possible for the search effort to find you
> 
> Another good one, are you going to improvise a traction splint? If you have to self evacuate, how are you going to transport this person? Is the terrain conducive to carrying somebody in traction? The issue for self-evacuation isn't the traction splint (they're actually quite easy to build in such as way as to make evacuation possible), but the number of personnel available to bear the litter. As is true for any back-country injury that requires a litter evacuation.
> 
> ...


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## medictinysc (Mar 28, 2013)

*Improvising*

In one of your hands on portions of the class, ask a couple of the members of the class to imbolize a patient with only these items


2 1000cc bags of NACL
1 LSB
2 towels
1 short roll of duct tape
3 triangular bandages

Stand back and watch them scratch thier heads.... make it more interesting offer a bonus if they can do it NREMT style (and pass)


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## Brandon O (Mar 28, 2013)

medictinysc said:


> In one of your hands on portions of the class, ask a couple of the members of the class to imbolize a patient with only these items
> 
> 
> 2 1000cc bags of NACL
> ...



Of course, ask a group of firefighter to do it, and you'll just end up with a patient cocooned to the board with the entire roll of tape


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## medictinysc (Mar 28, 2013)

Brandon Oto said:


> Of course, ask a group of firefighter to do it, and you'll just end up with a patient cocooned to the board with the entire roll of tape



 your right they might even forget the board HA HA just cocooned in tape  LOL


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## Veneficus (Mar 28, 2013)

medictinysc said:


> In one of your hands on portions of the class, ask a couple of the members of the class to imbolize a patient with only these items
> 
> 
> 2 1000cc bags of NACL
> ...



So after you immobilize this patient for spinal precautions, how do you deal with the inflammatory response that causes secondary damage?

Better still, how do you move them?


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## AK_SAR (Mar 28, 2013)

Veneficus said:


> You are then going to have to determine if you can be rescued, have to travel some distsance to make it possible, or self evacuate.
> 
> There are considerations of the capabilities of the rescuers and a bit of logistics with the materials available.


You have a marvelous grasp of the obvious.


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## Veneficus (Mar 28, 2013)

AK_SAR said:


> You have a marvelous grasp of the obvious.



I do my best...


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## medictinysc (Mar 28, 2013)

I work for a medical director who has very clear spinal precautions. It's like tic tacs everyone gets em. I don't have a choice. I understand the train of thought that says LSB does more harm than good.  But if I wish to continue work. I will LSB all  trauma with mechanism regardless.


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## Veneficus (Mar 28, 2013)

medictinysc said:


> I work for a medical director who has very clear spinal precautions. It's like tic tacs everyone gets em. I don't have a choice. I understand the train of thought that says LSB does more harm than good.  But if I wish to continue work. I will LSB all  trauma with mechanism regardless.



I am not suggesting you have a choice or that you shouldn't follow your protocols, but in the context of wilderness medicine, using what you described:

2 1000cc bags of NACL 
1 LSB 
2 towels 
1 short roll of duct tape 
3 triangular bandages 

How do you move them or think this is helping?

You are not walking around the woods with a LSB surely?


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## mycrofft (Mar 28, 2013)

Veneficus said:


> and how often do people really used improvised liters, make shift traction splints etc.
> 
> Ask around.
> 
> Preferably ask people who didn't sell you that class but really do it.



I spent weeks making a powerpoint about improvising litters (as well as other litter lore) and the truth is, in a disaster or a hurry or both,  carrying someone is faster and more certain. Improvs can go bad. They are for long distances.


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## Veneficus (Mar 28, 2013)

mycrofft said:


> I spent weeks making a powerpoint about improvising litters (as well as other litter lore) and the truth is, in a disaster or a hurry or both,  carrying someone is faster and more certain. Improvs can go bad. They are for long distances.



That is what I was thinking.

About 5 years ago I actually saw an account of a group of 4 climbers from Japan (I forget where in the world they were climbing) where one broke her leg and they took turns carrying her back to civilization over a period of 2 days without making camp. They claimed to have no medical training and were worried the injury would get worse over time.

I thought that was an awesome feat of discipline and comraderie.


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## mycrofft (Mar 28, 2013)

As for how often it has been used, I even prefer "Show me". And before you try to show 'em you had better have done it. I've embarrassed myself a few times doing something I'd read about but when it came time to do it, didn't work. I've also caught folks who are spouting.

Again and again and again...truth and fact before rumors and dogma. Experience before armchairs.

NOTE: a quarter of my litter lecture was about how NOT to do stuff, such as lifting improv rolled fabric litters with the longerons (poles) over the fabric or rope litters without longerons or too few bearers without hand protection, etc.


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## mycrofft (Mar 28, 2013)

And the nasal cannula for eyewash deal...seen it fail more times than not, takes time to set up, not enough liters per minute for serious eye exposure as initial treatment, and if there is toxic exposure to the face and head it doesn't help wash that off like sluicing with bottles of clean solution does. Sure looks great though.


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## MrJones (Mar 28, 2013)

medictinysc said:


> In one of your hands on portions of the class, ask a couple of the members of the class to imbolize a patient with only these items
> 
> 
> 2 1000cc bags of NACL
> ...



Am I correct in understanding that this is a response to icefog's request for improv ideas in general and not the side discussion of wilderness medicine?


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## AK_SAR (Mar 28, 2013)

Veneficus & mycrofft:

Not sure what the fuss is about? Some improvs work great, some sorta' work, some don't work at all.  That would be true of any improvisation in any facet of life, not just EMS.

Yes, it is worthwhile to try to sort out the good from the bad from the ugly. However, you guys give the impression (whether intended or not), that you think ANY improvisation is misguided.  And you act kind of snotty about it, in my opinion.

Improvisation is not something most EMS providers working in urban settings are going to do in their normal day to day work. Nor should they.  However, when out in the bush, one sometimes has to do the best one can with what one has. The same would be be true in a major disaster scene. In that case your well stocked ambulance will soon run out of stuff, and you will .... do the best you can .... with what you have.

One needs to learn the basic theory first. 'What is it we are trying to do?...why do we want to do it?....how does the store bought stuff do it?....'  After that, some freewheeling experimentation in a class is a good thing, in my opinion.  Put it together, then try it out. Try to make it fail. See what works and what doesn't.  

I've spent a fair bit of time knocking around the bush in Alaska, and I've seen some pretty wierd looking but ultimately successful improvisations in all sorts of areas, not just first aid.

That's my $.02


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## Veneficus (Mar 28, 2013)

AK_SAR said:


> Veneficus & mycrofft:
> 
> Not sure what the fuss is about? Some improvs work great, some sorta' work, some don't work at all.  That would be true of any improvisation in any facet of life, not just EMS.
> 
> Yes, it is worthwhile to try to sort out the good from the bad from the ugly. However, you guys give the impression (whether intended or not), that you think ANY improvisation is misguided.  And you act kind of snotty about it, in my opinion.



It is not that I am against improvisation, I have done well more than my fair share of it. I will let Mycrofft speak for himself, but we are not the new guys to this.

My problem comes in when improvisation is taught as a series of skills to be performed and try to disguise it as "education" which it certainly is not. 

My point is that doing such things needs to be goal oriented, understanding and working towards the underlying principle. 

As you can see from  my comments to Rocketmedic, I very highly appreciate the ability to improv. 

As I said, I further have a problem with "schools" or "classes" that use these feeble and often unused in reality drills and take peoples money for it. As I said, I think it is dishonestly taking advantage of people who do not know any better.

I am highly educated, experienced, and well spoken. (despite this really crappy keyboard and my deteriorating spelling in English from being away from it so long) I have even been called "smart" from time to time too.

I don't like to be patronized or spoken to like I am an idiot. Esecially with elementary, misleading, or disingenious argument.


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## NomadicMedic (Mar 28, 2013)

Folks, I've already removed some posts from this thread and infractions are forthcoming. 

I suggest you all play nice and keep this thread on topic and polite.


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## icefog (Mar 28, 2013)

WuLabsWuTecH, that's definitely the best way to go, I'll set up some realistic scenarios and see what they come up with and how we can improve. The goal won't be for them to get a list of tips and tricks they can whip out on scene and peruse until they find the fitting answer, but rather to get them to act in a goal-oriented manner, think out of the box and - why not - have some fun. Well, after getting drilled on how important sticking to protocols is, once we're done, they'll either buy me a beer or shoot me 

Veneficus, I agree that the only way to come up with adequate solutions is to have a solid knowledge base to work with. On the other hand, I won't be teaching "core improvisation skills" or handing out leaflets on "7 steps to successful problem solving as an EMT". It's not mandatory training, nobody's shoving this course down anyone's throat. All participants will be at EMT-I level or above and have at least 2 years of experience, so I assume they can make their own decisions - if they wouldn't be able to do that, I wonder what they'd do out there every day. Perhaps I should have provided more info in the beginning, but I'm trying to avoid a TL;DR issue here (for instance, I also left out the fact that there will be evaluators present to assess my instructor skills). To clarify, it's not a course for WEMTs or one on survival techniques, but one for regular EMT-Is and EMT-Ps - although I think examples taken from emergency situations out in the bush or suggestions coming from WEMTs can be very valuable.

Actually, there are a ton of "different" optional courses in our region, ranging from "Emergencies in red light districts" (sometimes it's fun to work in Europe) to "Krav Maga self defense for EMTs". Not being a stranger to that last subject, I admit I was highly prejudiced about someone claiming to teach effective self defense in 6 hours, but ultimately I was pleasantly surprised. Long story short, the SciFi/Bruce Lee tactics I expected never came up; instead they placed a lot of emphasis on deescalation and ways of avoiding direct engagement and saving your neck in a tight spot.

Brandon, your videos gave me an idea, I'll take some of the tricks they should already know (like using a BP cuff as a tourniquet) and see if they watch out for the dangers and complications that could arise and how they deal with them.

mycrofft, the legal issues in the EMS field are pretty interesting in Germany, we're almost always is a "gray area" when we work on our patients. Ask 10 paramedics here and you'll get 11 different opinions on what's legal and what's not, but the bottom line (supported by court rulings) is: any [invasive or improvised] measure that would save the patient's life *or *prevent further damage to the patient's health or well-being, undertaken in an extreme circumstance (even if it's against the law or against local protocols) is acceptable (will not be prosecuted and cannot be a ground for termination of employment), if (A) the same results could not have been achieved using a traditional or less invasive measure, and (B) the provider is "adequately trained" for carrying out that specific measure. In the course, I intend to emphasize the fact that to go outside protocol (or, perhaps more pertinent to the issue at hand, to break the law forbidding the use of medical equipment in a manner for which it hasn't been certified) *might *be accepted as adequate, but every one of them must make their own informed decision with regard to their own specific situation.

schulz: I'm a paramedic working in Germany, but I'm neither German nor American; I'm originally from Romania, I moved to Germany looking for better EMS training. However, I've got my doubts about how long I'll stay here, considering the general attitude towards the EMS and the unclear legal situation I've mentioned.

Everyone, thanks a lot for all your comments and suggestions, they really come in handy!


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## RocketMedic (Mar 28, 2013)

Please never use a BP cuff as a tourniquet. Its not good patient care, and theinstant someone taps the velcro, it blows.

Either use a commercial one or get two triangle bandages (cravats) and a thick stick. A pocket flashight works. Open one cravat, keep it folded but unrolled straight. Loop it around limb proximal to wound, tie a tight square knot on top, put in stick, tie another square knot reversed to the first. Spin the stick to tighten. Use second cravat to tie down the stick.


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## icefog (Mar 28, 2013)

Rocketmedic40 said:


> Please never use a BP cuff as a tourniquet. Its not good patient care, and theinstant someone taps the velcro, it blows.
> 
> Either use a commercial one or get two triangle bandages (cravats) and a thick stick. A pocket flashight works. Open one cravat, keep it folded but unrolled straight. Loop it around limb proximal to wound, tie a tight square knot on top, put in stick, tie another square knot reversed to the first. Spin the stick to tighten. Use second cravat to tie down the stick.



This is exactly what I'm talking about. You're perfectly right, a commercial tourniquet is the best option. But what if you don't have one? Many regions here refuse to allow them. And assume you're reaching for the triangle bandage when the physician on scene says NO, we'll use the BP cuff. We can talk about proper training and keeping up with the times on this thread all day long, but out there, you can't very well start a polemic while treating the patient. So in this particular situation (which occurs *very *often over here), I'd prefer to know that the paramedic is aware of the risks involved with using a BP cuff and the way to manage them and secure it properly.


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## Brandon O (Mar 28, 2013)

Rocketmedic40 said:


> Please never use a BP cuff as a tourniquet. Its not good patient care, and theinstant someone taps the velcro, it blows.
> 
> Either use a commercial one or get two triangle bandages (cravats) and a thick stick. A pocket flashight works. Open one cravat, keep it folded but unrolled straight. Loop it around limb proximal to wound, tie a tight square knot on top, put in stick, tie another square knot reversed to the first. Spin the stick to tighten. Use second cravat to tie down the stick.



Disagree. Working, well-maintained BP cuffs allow for carefully-titrated pressure (to a specific pressure in fact), evenly applied over a wide circumferential band, and they're both available (usually in multiple sizes) and -- most importantly -- familiar to us. I agree that the two main risks are leaking and slipping. I knot or clamp the tubes to prevent the former; if your velcro is intact and applied properly the latter shouldn't be a huge problem, but you can always wrap a few loops of tape around the whole apparatus for security if you'd like.

Now, I wouldn't try to haul someone off a mountain like this, but for the typical civilian EMS environment, I think it fits the bill. I know that Dr. Weingart likes them in the ED as well.


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## RocketMedic (Mar 29, 2013)

icefog said:


> This is exactly what I'm talking about. You're perfectly right, a commercial tourniquet is the best option. But what if you don't have one? Many regions here refuse to allow them. And assume you're reaching for the triangle bandage when the physician on scene says NO, we'll use the BP cuff. We can talk about proper training and keeping up with the times on this thread all day long, but out there, you can't very well start a polemic while treating the patient. So in this particular situation (which occurs *very *often over here), I'd prefer to know that the paramedic is aware of the risks involved with using a BP cuff and the way to manage them and secure it properly.




I would challenge that MD and use the option that doesnt suck. If he insists, its his patient. If its one of my patients or joes, he gets politely ignored. A smart doctor wouldnt trade a good TK for a cuff. Dumb calls dont get listened to if they are abjectly dumb and I can articulate my reasoning for it.

An improvised tourniquet is also tension and size-adjustable and far less prone to failure.


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## RocketMedic (Mar 29, 2013)

Brandon Oto said:


> Disagree. Working, well-maintained BP cuffs allow for carefully-titrated pressure (to a specific pressure in fact), evenly applied over a wide circumferential band, and they're both available (usually in multiple sizes) and -- most importantly -- familiar to us. I agree that the two main risks are leaking and slipping. I knot or clamp the tubes to prevent the former; if your velcro is intact and applied properly the latter shouldn't be a huge problem, but you can always wrap a few loops of tape around the whole apparatus for security if you'd like.
> 
> Now, I wouldn't try to haul someone off a mountain like this, but for the typical civilian EMS environment, I think it fits the bill. I know that Dr. Weingart likes them in the ED as well.




A bp cuff is not optimized to maintain high pressures, tape or not. If the air balloon ruptures, no pressure, no TK. 
Physicians that choose to use BP cuffs as prehospital tourniquets are idiots. Theres research and data available showing why the idea is bad. It is an idea on par with using rotating tourniquets for CHF instead of BiPap.
If a true tourniquet scenario comes up, its way better to use the commercial or improvised before you get weird.
BP cuff makes a little sense in the ER, but not prehospital. I dont care about patient comfort or the pressure involved. I care about stopping bleeding. There is no such thing as "a little reperfusion by loosening it". I would go so far as to say all civilian medics have a serious misconception as to the negative effects vs rewards of tourniquets.


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## Brandon O (Mar 29, 2013)

Rocketmedic40 said:


> A bp cuff is not optimized to maintain high pressures, tape or not. If the air balloon ruptures, no pressure, no TK.
> Physicians that choose to use BP cuffs as prehospital tourniquets are idiots. Theres research and data available showing why the idea is bad.



I'm interested to see the research you mean. I'm open to being wrong.

I'm guessing that you have a military background? I do think there may be a disconnect there. I really doubt that a BP cuff would make an adequate tourniquet for a combat environment; you need something that allows for mobility (potentially self-mobility), easy application, and potentially long duration. For most of us in an urban civilian setting, the demands are much simpler.


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## RocketMedic (Mar 29, 2013)

Brandon, I do, but there really isnt a difference. For research, look at the Army's tourniquet studies. Plenty of alternates are in there, to include BP cuffs if I recall correctly. Simple, mechanically-locking Velcro devices like the CAT are the most effective devices to put on and the hardest to dislodge. Your BP cuff is literally one jerk away from total failure, not to even begin to include the possibility of the bladder failing or an ignorant provider assuming youre trying to take a BP. 

If anything, a military unit does massive hemorrhage way better than a civilian team. We dont hesitate with tourniquets, we dont loosen them, and we dont fear them. All are massive problems in civilian EMS. As for the demands being simpler. I disagree. I had a shooting tonight. Protocols insisted I backboard, start multiple IVs rapidly and transport emergently. Fire got excited and jostled him a littld in the load process...no harm, but a bp tk would probably have popped off. 

If the front-lind infantry forces ofthecivilized world swear by them, its because theyre vastly better than the alternatives.


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## Brandon O (Mar 29, 2013)

Rocketmedic40 said:


> Brandon, I do, but there really isnt a difference. For research, look at the Army's tourniquet studies. Plenty of alternates are in there, to include BP cuffs if I recall correctly. Simple, mechanically-locking Velcro devices like the CAT are the most effective devices to put on and the hardest to dislodge. Your BP cuff is literally one jerk away from total failure, not to even begin to include the possibility of the bladder failing or an ignorant provider assuming youre trying to take a BP.



If a civilian unit carried a well-designed, purpose-built tourniquet, then obviously that would be ideal. However, many don't, which means you're left trying to improvise something. A cravat or two is probably the most likely, but I don't like 'em; once you tighten it it turns into a very narrow band, and it's not as easy to deal with as it might seem unless someone practices the technique.

Again, I would submit that while there's much to learn from the military's work on trauma (as always), the requirements and demands are not identical to civilian EMS. I think the way to go is to take what they've learned and use it to understand the principles, not necessarily try to duplicate them in all respects.

(We're required to carry a couple tourniquets in my state... which my service interprets to mean that we should have a couple rubber venous tourniquets. Gonna go great if someone tries to tie off a leg with that...)


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## EpiEMS (Mar 29, 2013)

Military tourniquet study for those interested: http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA480277

"Improvised tourniquets were ineffective 67% of the time (10 of 15 limbs, 15 patients, 16 tourniquets) with 10 morbidities (6 amputation injuries, 3 fasciotomies, 1 palsy), and seven limbs continued to bleed. The wider improvised tourniquets (cravats and windlass type, especially when two were used side by side) were effective in 42% (3 of 7) of limbs, whereas the narrower ones (strings, i.v. tubing) were effective in 25% (2 of 8) of limbs. The mortality rate in patients with improvised tourniquets was 0% (0 of 15), and the amputation rate was 40% (6 of 15, all 6 were traumatic amputations). Tourniquet ineffectiveness, (visible bleeding or distal pulse remained), and morbidities corresponded. "

:O


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## VFlutter (Mar 29, 2013)

Anesthesia uses pneumatic tourniquets, similar to BP cuffs, for Bier blocks which produce a bloodless anaesthetized extremity. However these are purpose built and not realistic for the field.


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## NomadicMedic (Mar 29, 2013)

Okay folks. Again... Back on topic please.


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## Summit (Mar 30, 2013)

I was taught the backwards KED for a hip. I had one situation where a KED would have been useful to immobilize a really really weird fracture, but I was misheard on the radio and brought a KTD. The solution ended up involving miles of tape, kerflex, 4 SAM splints, and a snowshoe. 

I think splinting is the area where the most improvisation occurs. I've seen shovels, poles, sticks, paddles, etc.

Some of my favorite improvisations are using camelbacks as an airsplint. You have to watch and continuously adjust air pressure due to temp/pressure changes (particularly if going downhill). You can also use them with real splits to have a conforming liquid cooling option to help with pain and swelling! It is better than a cold pack! For _litters_, frame packs with sticks and hiking/ski poles, webbing, tarp, and cordellete are actually impressive if done right , and don't take too long (and use what people commonly have). Rope _stretchers _are a waste and nobody remembers how to do them. 

There are definitely some improvisations that work, and others that don't work very well or may be harmful. I'm a pretty pragmatic guy.

As far as the discussion on practicing or taking classes on improvised care techniques, I think that it an get the gears turning if the provider has not been presented with the need to improvise before. For EMS providers specifically, I think courses like WEMT upgrade etc also help enforce the idea of preventing problems and thinking beyond 5, 10, 15, 30 minutes, thinking about limited resources and wilderness extrication, etc when making care decisions and plans. They'll think about it. They may even remember some ideas and techniques that they might even be able to apply with some level of effectiveness. 

I will agree that the courses are rife with gee-whiz improvisations that nobody (besides the instructor) would remember how to do effectively, much less ever choose to implement in the real world. My favorite example is the rope litter. It looks neat, requires practice, and sucks even when done correctly. But I can surely go grab a book, Dr. Aurebach's giant wilderness cornucopia or ASHI's Wilderness manual and see an example of how to make your very own rope litter. Sure, I learned how to improvise a traction splint from ski poles or paddles and webbing... they were even timed drills. I could still make one easily, but I cannot think of a situation where one would be better off with an improvised traction splint versus a litter+splint and padding. 

I am uncertain why a BP cuff is a bad idea for an improvised TK. I'd like to see the study showing that?


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## AzValley (Mar 30, 2013)

Rocketmedic40 said:


> Improvised nebulizer: neb treatment + 15ml bottled water + compressed air hose ran into an MRE bag. Decent seal too.



very cool


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## mycrofft (Mar 31, 2013)

I'm not fussing. I've had to improv too (cutting the O2 line at a bias behind the female fitting to create a sort of male end is know as the "Mycroft Maneuver", didn't you know?) 

Teaching improvisations is a slippery slope. If they're that good, include them in protocols, or make a protocol appendix of acceptable substitutions or extemporaneities. Otherwise students, especially the bright eager and impatient students, will seize on these at least mentally, especially if they are off the clock or freelancing without employment since they won't have the real equipment.

A cook learns recipes before improvising; a good and experienced driver will be more liable to get out of an unexpected situation, and less likely to get into one, than someone who has studied "improvs" but has no firm grounding*.  Ditto medical staff.

Again, I think teaching about both the dangers of improvs, and the ones we see come up so often and so ineffectively, is as important as teaching how to use a suction machine as a nebulizer compressor or vice versa.

(oops.....)

(In fact, EVOC should be limited to drivers with ten years' experience...how's that?).


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## ExpatMedic0 (Apr 12, 2013)

Here ya guys go. Recent news of "improvising in the field" 
http://www.emsworld.com/news/10919338/off-duty-calif-medic-macgyver-ed-it-to-save-cut-man


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## ExpatMedic0 (Apr 22, 2013)

Another one, THE CLASSIC! 
http://www.ems1.com/ems-education/articles/1435990-Ex-medic-tangles-with-death-saves-co-worker/


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## Brandon O (Apr 22, 2013)

ExpatMedic0 said:


> Another one, THE CLASSIC!
> http://www.ems1.com/ems-education/articles/1435990-Ex-medic-tangles-with-death-saves-co-worker/



Welp, never again will I say that suction is irreplaceable.


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## chaz90 (Apr 22, 2013)

ExpatMedic0 said:


> Another one, THE CLASSIC!
> http://www.ems1.com/ems-education/articles/1435990-Ex-medic-tangles-with-death-saves-co-worker/



I don't think I could bring myself to suck vomit out of someone's nose with my mouth. Good on this guy though! Also, am I the only one that wondered about the "take off the shoes and stimulate the feet" portion in the article? That must have been taught in class on a day I missed...


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## ticktoc (Apr 26, 2013)

You should definitely look into some of the ski patrol forums.  They do some cool stuff especially with splinting.  Try looking up a spider/octopus cravat splint.


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