the 100% directionless thread

Tigger

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Incidentally I had a 90 second response to an MVC with trauma arrest yesterday. Got ROSC with six needle decompressions, an iGel, pelvic binder, and a lil epi once I had a fair bit of fluid pounded in there. Sinus tach looking PEA throughout so I was suspecting an obstructive cause/low volume and maybe we were right. Flight arrived and powered in two units of blood enroute and well...it was still not successful as she coded in the resus bay.

It was also beaten into my head that I had to be able to intubate anyone, anywhere, anytime. Initially the iGel was not doing a great job so I elected to try and intubate. I gave that one my all laying downhill in a steep ditch with my feet in the air resting on the car (of course our lone king vision was sitting at the station in a truck with a dead battery), and was rewarded with what was likely a fractured trachea. Put the iGel back in and it worked fine. At the ED the EM doc looked and didn't bother trying, anaesthesia failed, and the trauma surgeon took multiple attempts to cric her.

Sorry all you local salty medics, there are gonna be some patients that EMS just can't tube.
 

Peak

ED/Prehospital Registered Nurse
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You and your science don’t sound cool, so the clear answer is to take the ideas of a few EM docs and people and substitute their limited anecdotes for your real-world concerns!/sarcasm

In all honesty, to my knowledge, none of the systems that are transfusing blood pull labs beyond a hemoglobin assessment, and although they do use warmers, I don’t think there’s much consideration given beyond “blood is good”.
And I actually have no problem with adding cool things to EMS, but I think that there really needs to be a balance not only based on need but also across the things that are 'less cool'.

I'm surprised that we don't see a push towards towards things like POC U/S, I remember when the flight teams started to really implement it with the vscan and cost was a huge burden but my butterfly cost less than 3k all in and one of our PEMs recently bought a lumify and he said he paid somewhere in the realm of 5k. From an emergency intervention standpoint both systems seem to be more than adequate. I don't think it is unrealistic to train medics on a basic EFAST survey (and adding a parasternal or suprasternal view for our bariatric population).

Similarly I would love to see more POCs in the field. Both the iStat and EPOC offer lytes, H/H, gas, and lactate (and the iStat has even more) which can absolutely drive prehospital care.
 

Peak

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Incidentally I had a 90 second response to an MVC with trauma arrest yesterday. Got ROSC with six needle decompressions, an iGel, pelvic binder, and a lil epi once I had a fair bit of fluid pounded in there. Sinus tach looking PEA throughout so I was suspecting an obstructive cause/low volume and maybe we were right. Flight arrived and powered in two units of blood enroute and well...it was still not successful as she coded in the resus bay.

It was also beaten into my head that I had to be able to intubate anyone, anywhere, anytime. Initially the iGel was not doing a great job so I elected to try and intubate. I gave that one my all laying downhill in a steep ditch with my feet in the air resting on the car (of course our lone king vision was sitting at the station in a truck with a dead battery), and was rewarded with what was likely a fractured trachea. Put the iGel back in and it worked fine. At the ED the EM doc looked and didn't bother trying, anaesthesia failed, and the trauma surgeon took multiple attempts to cric her.

Sorry all you local salty medics, there are gonna be some patients that EMS just can't tube.
It sounds like that outcome happened far before you showed up and there wasn't gonna be much to change it. Its one of the big reason I left level 1 trauma, if the basics don't save you statistically you are going to have a poor outcome (and I got burned out of the NATs and neglect, but that's a different topic). Unwitnessed trauma arrests have such poor outcomes they almost just become a skills practice session. Add in the anoxic down time and even if she lived the quality would be so poor it isn't worth it.

Did they consider doing a retrograde intubation (which is still mostly a shot in the dark) or trach in the ED? As smashed as her airway sounds I doubt a cric had much of a chance. I'm going to assume she had too much facial trauma for a king or just dropping a OG, OPA, and bagging her.
 

StCEMT

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@Peak I'd love to see ultrasound, but I feel like I may have an easier time at least laying logistical ground work on blood transfusions.

My idea is to do it how we do drug boxes. We just swap them out at hospital pharmacies and they deal with expirations and stuff. We have a really good relationship with this hospital and I know a couple of their attendings are big in prehospital or have even worked with us.

We don't have enough volume to justify it on every truck, but we have only two supervisor trucks and we could easily justify them carrying it. We still get enough trauma on a regular basis I think we would actually put it to use regularly. I can think of a lot of GSW's last year I'd have used it on considering I was uncomfortably behind the curve when I got to them.

Having sups carry it would cut down on waste, storage issues, and overall equipment needed. But I want to talk to the doc I know that is involved with the hospitals HEMS service since they do what I'm trying to do I believe.
 

RocketMedic

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@Peak I'd love to see ultrasound, but I feel like I may have an easier time at least laying logistical ground work on blood transfusions.

My idea is to do it how we do drug boxes. We just swap them out at hospital pharmacies and they deal with expirations and stuff. We have a really good relationship with this hospital and I know a couple of their attendings are big in prehospital or have even worked with us.

We don't have enough volume to justify it on every truck, but we have only two supervisor trucks and we could easily justify them carrying it. We still get enough trauma on a regular basis I think we would actually put it to use regularly. I can think of a lot of GSW's last year I'd have used it on considering I was uncomfortably behind the curve when I got to them.

Having sups carry it would cut down on waste, storage issues, and overall equipment needed. But I want to talk to the doc I know that is involved with the hospitals HEMS service since they do what I'm trying to do I believe.
Anecdotal, but Creek gave more blood in 2017-18 for medical calls than trauma. GI bleeds in particular, cancer-related anemia, pregnancy. Trauma calls were somewhat less frequent due to severity and positioning (why wait 20 minutes when you could be at hospital in 22)?
 

Remi

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I'm curious how systems rotate through fresh whole blood and justify the relative high volume of loss. I can certainly see the potential benefit, but things like HEMS not included I would think those systems that would have the greatest benefit (rural systems with long transports) would also have pretty high product waste.

We have entertained the idea a couple of times in our system but even at our our sister level 1 when they looked at uncrossed transfusions there still isn't enough volume to justify implementation (granted here there are way too many trauma centers in the state). We are also very limited with what we can do with the blood afterwards as we cannot use it for routine inpatient administration, priming bypass, and so on; and once you pass the initial resuscitation the value of whole blood over lab guided resuscitation (Pt/INR, TEG, hemogram, lytes, etc) quickly wanes. Our primary and specialty teams teams are BCT, I don't think there is any really push towards FWB currently.

I wonder what percentage of services that carry blood product actually use a warmer, it seems like a battle to get smaller centers to use them consistently in the ED and even in larger trauma centers it doesn't seem to be a priority outside of the ED and OR. I remember it was quite the battle on our department to even keep fluid bags warmed and that cost was minimal.

I would hope that any service that carries blood would also carry an iStat or similar device so that you can look at your pH and electrolytes and treat accordingly. We test our blood before priming our bypass and ECMO circuits and it is amazing how not compatabile with life stored blood can be.
I would argue that blood is very rarely necessary prehospital. Combine the fact that it's rarely needed with the cost and logistics, and it's clear why most agencies don't bother. That said, if an agency happens to see a lot of serious trauma and has the resources to deal with the logistics, why not do it?

Returning unused blood to the blood bank for emergency release a week before expiration isn't a big deal. That's all the O-neg was ever going to be used for anyway, and at any busy center it'll get used within a few days of re-stock. Warming the blood is certainly ideal but definitely isn't necessary when a patient is exsanguinating. The same is true of labs. When you have a barely-palpable BP and most of your patient's blood volume is trickling out the clamshells of your EC, I can't imagine what an iStat would tell you that has any impact on your decision to hang your PRBC's.
 

Remi

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Initially the iGel was not doing a great job so I elected to try and intubate. I gave that one my all laying downhill in a steep ditch with my feet in the air resting on the car (of course our lone king vision was sitting at the station in a truck with a dead battery), and was rewarded with what was likely a fractured trachea. Put the iGel back in and it worked fine.
You'll often see a significant leak initially with an igel, but after a minute or so the gel warms and expands and forms a much better seal.
 

Tigger

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You'll often see a significant leak initially with an igel, but after a minute or so the gel warms and expands and forms a much better seal.
I had it in for five or so minutes and it wasn't doing it much, even with repositioning. After putting it in a second time it worked great.
 

StCEMT

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Anecdotal, but Creek gave more blood in 2017-18 for medical calls than trauma. GI bleeds in particular, cancer-related anemia, pregnancy. Trauma calls were somewhat less frequent due to severity and positioning (why wait 20 minutes when you could be at hospital in 22)?
It's rare a supervisor shows up on those though. Either they're just hanging out with you and tag along for something routine for fun or something sounds arresty from the start.

But the GSW to the neck with an arterial bleed? The GSW that just ****ed the dudes liver? Neither of those I expected to get to the hospital alive and barely did. I was really wishing I had the ability to transfuse with them, simply due to the blood loss that occurred before I even stepped foot out of my truck. One of our common areas for these is literally a mile..maybe..from the level 1. Not gonna mess with it there. However, we pick up plenty in distant corners or tight neighborhoods where there is more time before we even get on a main road.

A big part of what's renewed my interest is we have a new director that's actually interested in our feedback and how we can be better and I've been working on some other things for them. So a lot of things I've been trying to push aren't too (if at all) resource intensive, but I feel like right now, despite my complaints, this is probably the most receptive I've seen our upper management. I'd like to try to push us back to actually earning the reputation this place had a long time ago.
 

RocketMedic

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It's rare a supervisor shows up on those though. Either they're just hanging out with you and tag along for something routine for fun or something sounds arresty from the start.

But the GSW to the neck with an arterial bleed? The GSW that just ****ed the dudes liver? Neither of those I expected to get to the hospital alive and barely did. I was really wishing I had the ability to transfuse with them, simply due to the blood loss that occurred before I even stepped foot out of my truck. One of our common areas for these is literally a mile..maybe..from the level 1. Not gonna mess with it there. However, we pick up plenty in distant corners or tight neighborhoods where there is more time before we even get on a main road.

A big part of what's renewed my interest is we have a new director that's actually interested in our feedback and how we can be better and I've been working on some other things for them. So a lot of things I've been trying to push aren't too (if at all) resource intensive, but I feel like right now, despite my complaints, this is probably the most receptive I've seen our upper management. I'd like to try to push us back to actually earning the reputation this place had a long time ago.
It’s not a bad idea. Creek has a fairly robust EMD protocol for blood carrying supervisors, basically anything coded as a hemorrhage. They’ll share it with you 2813780800 ask for Samuel Kordik.
 

DesertMedic66

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My HEMS company is in the process of getting approvals and all the equipment necessary to carry blood at all our bases nationwide. Sounds like we have partnered with the Red Cross for our blood supply. We have some areas that are doing testing to find out any issues with receiving, sending back, and storage.
 

GMCmedic

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My HEMS company is in the process of getting approvals and all the equipment necessary to carry blood at all our bases nationwide. Sounds like we have partnered with the Red Cross for our blood supply. We have some areas that are doing testing to find out any issues with receiving, sending back, and storage.
Air Methods? They've been doing a lot of blood drives in Kentucky lately, made me wonder if something wasn't coming soon.
 

DesertMedic66

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Air Methods? They've been doing a lot of blood drives in Kentucky lately, made me wonder if something wasn't coming soon.
Yeah. We are still in the process of purchasing all the supplies needed. Last update is the end of 2019 or the first part of 2020
 

GMCmedic

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Yeah. We are still in the process of purchasing all the supplies needed. Last update is the end of 2019 or the first part of 2020
That's good news for kentucky, The Kentucky program seems to be well run.

We used a fair amount of blood at my Kentucky base, being the only program on the west side of the state to carry it.
 

Tigger

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When it rains it pours...went to go teach an in-service class out in the prairie and ended up helping the department fly a CVA/three days post CABG and altered patient out. I enjoy that my medical directors explicitly back us to help BLS departments wherever we are.
 

GMCmedic

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Didnt get drawn for Kentucky Elk, and back to work tomorrow, hopefully I can avoid an EMS week activities to catch up on FPC study and the NAEMT instructor thing.
 

CALEMT

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When you got forced OT on your two days off in-between shifts putting you on a 10 day shift.
 
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