SMACC Sonowars – E-FAST race

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Yours truly in action

(video from prehospitalmed.com)

 

 

Case Based Learning in the New Year: pneumothorax & lung ultrasound

Last week we ran another case-based learning session. The session consisted of a short discussion based around a case that we were tasked that involved a patient with a suspected pneumothorax.

We discussed the issues and challenges of managing a patient on the ground and in-flight with a pneumothorax. In addition, we discussed then practiced how we can use ultrasound as an added tool in the diagnosis of a pneumothorax in the prehospital setting.

To briefly summarize, I’ve divided up some discussion points

Medical

  • Both paramedics and doctors discussed the most important aspect in the patient with a pneumothorax in the pre-hospital setting was the clinical status
  • The ultrasound was noted to be extremely helpful for diagnosis however, presence of pneumothorax didn’t necessarily warrant intervention
  • Clinical condition was the overwhelming driver for intervention. The question arose regarding the role of ultrasound – “if the presence of pneumothorax did not necessarily mean intervention required, why use it?” In general, clinicians felt that knowledge about the condition would help make subsequent decisions in the case of deterioration
  • One theoretical approach was proposed – in a patient with pneumothorax that was reasonably stable, consider anesthesitizing & exposing the site for a chest drain then proceed with finger thoracostomy if deterioration. Several clinicians felt that it there was such concern to proceed with local anesthesia then probably a drain should just be placed.
  • In the patient with a left sided pneumothorax, there was strong agreement that loading the patient feet first such that the clinicians would have access to the left side (of our typically starboard loaded patient)
  • The likelihood of needle decompression success is only 50% – brief discussion about an anterior approach vs. a lateral approach

Operational

  • Knowledge regarding pneumothorax is key depending on the location of the patient. In situations on the east coast of the Coromandel then altitude becomes extremely important.
  • The early rule out diagnosis that the ultrasound can provide is very useful for managing flight plans
  • Weather was decided as a key factor that would alter management and it would impact possibly both medical decision making and flight operations
  • Placement of ultrasound in the machine: crewman/paramedic at the head of patient holding the machine with doctor on the patient’s right side
A little in-situ training. Enabled us to figure out optimal ergonomics and positioning for in-flight ultrasound. In case you're wondering, I donated my chest to science for this ultrasound to be done

A little in-situ training. Enabled us to figure out optimal ergonomics and positioning for in-flight ultrasound.
In case you’re wondering, I donated my chest for this ultrasound to be done (free of charge!)

Summary

  • Overall based on our evaluations of the process, it was a successful event with more case-based learning sessions planned
  • Clinicians reluctant to intervene for pre-hospital pneumothorax unless unstable
  • Strong communication among the team about the presence of a pneumothorax is essential and ultrasound greatly aids with this – affects both medical & operational decision making
  • Ergonomics are important but dependent on each setting; however a standard approach in the machine might be appropriate for positioning of the ultrasound

 

A simulation update: Latest session at the ARHT base

This week we ran an in-situ simulation with our duty crew (crewman, paramedic and doctor). We had great participation in a challenging scenario of massive hemorrhage in a blunt trauma patient.

As our simulation experience continues to grow we are always trialling new things. This past week we integrated several techniques that helped enhance the scenarios fidelity.

The scenario was a patient who had fallen off his motorbike at highspeed. There was a paramedic already on scene when our team arrived. The patient was in shock: BP 95/60, 130bpm, RR 28, 87% on room air, GCS 15.

Here’s a brief outline of what we did and why!

  • In-situ simulation: Make the most of the availability of your team. On the job training during a work day is a great way of maximizing educational opportunities. It doesn’t require that people come in on their day off and they still get paid while at work except their learning. We don’t use any expensive simulation centre – instead only using our training packs and equipment we were able to run this scenario at NO COST!
Mid way through a resus. We have all hands on deck, even getting our cameraman Matt to hold the IV!

Mid way through a resus. We have all hands on deck, even getting our cameraman Matt to hold the IV!

  • Set the scene with a video: using footage from the TV show Rescue 1 (filmed on our helicopters) we were able to begin the simulation with our team watching 2 minutes of a scenario to help them better picture the scene and envision the challenges of the local surroundings
  • Live patient actor: in scenarios that don’t require intubation this is especially powerful since we were able to capture our team’s ability to communicate with a live patient. Our patient had multiple traumatic injuries that was causing considerable pain. The team used managed the pain with ketamine and small doses of fentanyl. It was especially helpful to have a live patient since participants would receive real-time feedback if their pain regimen was working.
Having a live patient actor is a great asset and can add extra fidelity to the scenario. Definitely alters the way clinicians approach and speak with the patient.

Having a live patient actor is a great asset and can add extra fidelity to the scenario. Definitely alters the way clinicians approach and speak with the patient.

  • SimMon: I highly recommend this for anyone interested in doing in-situ simulation. Using an iPad and an iPhone, linked by Bluetooth (no Wifi needed) we are able to have a patient monitor with fully adjustable and modifiable vital signs! I have no relationship with the company that makes the app but we use it regularly and it’s must have for any educator running in-situ simulation. Available for download for less than $20NZD.
  • Ultrasound images for eFAST: Our doctor (Alana) performed a pre-hospital FAST and lung ultrasound. We had images and video downloaded ahead of time on a computer to show her the findings. This provided more realistic visual feedback that closely mimics a real clinical setting.
Alana checking out the eFAST findings on the laptop. Diagnosing pneumothorax & positive FAST

Alana checking out the eFAST findings on the laptop. Diagnosing pneumothorax & positive FAST

  • Integration of new medication: We are in the process of integrating a Tranexamic Acid protocol for trauma patients with suspected hemorrhage. This was our first time trialling the medication in a simulation setting. Great discussion around timing and especially helpful for our clinical team that we have clear guidelines when it can be administered.
  • Observation/Feedback by an industrial engineer: Tammy Bryan, is an industrial engineer from Auckland District Health Board, who joined us to observe our work with an interest in the ergonomics of scene set up. This was useful for a current state analysis and the beginning to work towards any changes that can make us more efficient!

Huge thanks to Bruce Kerr, Greg Brownson and Alana Harper who participated as our clinical and operational crew for the scenario. Also a huge thanks to Alice who was our live patient for the scenario. She did an outstanding job acting as a patient in pain with multiple injuries! Don’t worry, our team took care of her with lots of pain meds administered! And Chris was our paramedic who provided outstanding pre-hospital care before the team arrived

Prehospital Ultrasound – a new tool for our HEMS community

Several months ago, our HEMS service introduced a portable ultrasound machine onto our helicopters and so far it has been a great success!  While this blog post won’t be presenting the data we’re collecting, our physicians have reported it to be extremely useful. Most often we use it in the evaluation of a trauma patient to perform an eFAST (extended focused assessment with sonography in trauma) that includes assessment for free fluid in the abdomen but also importantly, lung ultrasound for the diagnosis of pneumothorax. Recently, I was part of a mission to transport a patient who had suffered a fall and there was question of a pneumothorax as reported by the ambulance team on scene. We were quickly able to perform an ultrasound of the lungs which ruled out pneumothorax. This enabled our pilot to fly at normal altitude rather than having to fly lower. Furthermore, as a clinician, it helped with decision making during transport as the patient still required treatment in hospital for other injuries. Knowledge that a pneumothorax was virtually unlikely allowed me to focus on other treatment priorities.

Picture of a similar model portable ultrasound that is being used at ARHT by HEMS physicians

We’re using a similar model of portable ultrasound as pictured above at ARHT 

More recently, one of our physicians performed an ultrasound guided femoral nerve block to assist with pain management of a patient with a femur fracture. It worked brilliantly and the patient was transported with considerably less pain!

In the spirit of our new technology, I’ve reviewed what’s out there in the literature regarding prehospital ultrasound (and emphasis on HEMS). There’s very little but this is definitely a growing field!

A recent review of HEMS pre-hospital ultrasound feasibility was published with good results. They performed 144 pre-hospital scans. On average scans took less than 2 minutes with a symptom based approach to what region to scan. While there are some limitations in their methodology, they reported no false-positives compared with available clinical data which is important. In addition, overall sensitivity was 85% (though it should probably be reported for each indication). Nonetheless, this study adds support to the feasibility of prehospital HEMS ultrasound and documents what findings may be value in the field. In several cases, management was altered, for example when pneumothorax was diagnosed then chest drains were placed.

Another study just published, prospectively evaluated the utility of lung ultrasound in non-trauma patients with dyspnea in a pre-hospital setting. They used a focused approach (as pictured below) to specifically identify potential causes of dyspnea. In 68% of cases, physicians reported lung US as a useful tool.

Imaging sites for rapid assessment of lung using ultrasound in dyspneic patients in prehospital setting

Imaging sites for rapid assessment of lung using ultrasound in dyspneic patients in prehospital setting

They required physicians to complete the exam within 5 minutes as not to delay scene times. Pneumothorax was accurately ruled out in all cases, while a large pericardial effusion causing hemodynamic instability was properly diagnosed though it was only drained once in hospital. You might imagine however that if the patient deteriorated en route that emergent pericardiocentesis would probably be the next intervention so identification would be important.

Algorithm for evaluation of dyspneic patient in the prehospital setting with ultrasound

Algorithm for evaluation of dyspneic patient in the prehospital setting with ultrasound in conjunction with imaging sites of above picture. 

I’m not sure how to interpret their results when they reported that additional management approaches were taken in 25% of cases as a result of US. Primarily diuretics were administered after US given the diagnosis of pulmonary edema. In our setting, we don’t carry furosemide so this doesn’t directly apply though if perhaps properly delineating between pulmonary edema and COPD would be useful as nitroglycerin vs. nebulizers could be emphasized in subsequent therapy.

I believe that most of the benefit of prehospital ultrasound is in the injured patient however, as we see, there is growing evidence that it can be used similarly to how it’s used within the emergency department and ICU.

References

1.  Eur J Emerg Med. 2010 Oct;17(5):254-9. doi: 10.1097/MEJ.0b013e328336ae9e. Prehospital ultrasound in emergency medicine: incidence, feasibility, indications and diagnoses. Hoyer HX et al.

2. Eur J Emerg Med 2012 Jun;19(3):161-6. doi: 10.1097/MEJ.0b013e328349edcc. Prehospital chest emergency sonography trial in Germany: a prospective study. Neesse A et al.