Australian retrieval medicine guru and Flying Doctor Dr Minh Le Cong sent me a copy of the ‘Prehospital Anaesthesia and Airway management Syllabus 2012’ that he’d authored, a thorough and evidence-based approach to airway management for practioners involved in pre-hospital care and critical care transport.
In the surgical airway section, Minh describes the use of ultrasound as an adjunct to the identification of the cricothyroid membrane. It includes this image of Minh ultrasounding his own neck in his office.
I couldn’t help but be distracted by an object on his desk, which on closer inspection, appears to be a rubber chicken.
I emailed Minh to find out about that chicken. He replied:
..even I did not pick that my rubber chicken was visible in the shot!
A great tip from an ex SAS soldier…always carry a rubber chicken into high stress, high risk situations. You would be surprised how well it works in defusing high tension, arguments and standoffs as well as personally allowing you to take a moment and ground yourself when the shit is flying.
The chicken comes with me, along with my king vision, portable USS and Leatherman Multitool and head torch.I used all of those items recently on the same patient!
Minh Le Cong
Medical Education Officer
RFDS Queensland Section
What are the essential items you have with you on every shift? Is your list anything like Minh’s Retrieval Toolkit?
A recent study highlights the need for uniform standards of outcome data collection in Helicopter Emergency Medical Services (HEMS) in Great Britain and aero-medical retrieval services in Australia. Suggested patient outcome measurements by Britsh and Australian air medical respondents to the survey included:
Mortality versus TRISS predicted mortality
APACHE/ TRISS predicted mortality versus actual mortality.
KPIs from a national body. Mortality in isolation is not a useful marker of quality
Clinical KPIs provided there is a reliable method of data collection
Interventions performed by doctors that contribute to patient mortality/morbidity.
Background Performance outcome measures are an essential component of health service improvement. Whereas hospital critical care services have established performance measures, prehospital care services have less well-established outcome measures and this has been identified as a key issue for development. Individual studies examining long-term survival and functional outcome measures have previously been used to evaluate prehospital care delivery. There is no set of standardised patient outcome measures for Helicopter Emergency Medical Services (HEMS) in the UK or Air Medical Services (AMS) in Australia. The aim of this study is to document the patient outcome measures currently in use within British HEMS and Australian AMS. Methods This is an observational study analysing point prevalence of practice as of November 2009. A structured questionnaire was designed to assess the method of routine patient follow-up, and the timing and nature of applied patient outcome measures. Results Full responses were received from 17/21 (81%) British services and 6/7 (86%) Australian services. The overall response rate was 82%. Conclusions HEMS in Britain and Australian aeromedical retrieval services do not have uniform patient outcome measures. Services tend not to follow-up patients beyond 24 h post transfer. Patient outcome data are rarely presented to an external organisation and there is no formal data comparison between surveyed services. Services are not satisfied that the data currently being collected reflects the quality of their service.
For a whole bunch of reasons, patients with ST-elevation myocardial infarction who undergo interhospital transfer for primary percutaneous coronary intervention may not meet the required 90 minute door-to-balloon time. In a new study of patients transferred by helicopter, only 3% of STEMI patients transferred for reperfusion met the 90-minute goal. Should this result in an increase in the use of fibrinolysis at non–percutaneous coronary intervention hospitals?
STUDY OBJECTIVE: Early reperfusion portends better outcomes for ST-segment elevation myocardial infarction (STEMI) patients. This investigation estimates the proportions of STEMI patients transported by a hospital-based helicopter emergency medical services (EMS) system who meet the goals of 90-minute door-to-balloon time for percutaneous coronary intervention or 30-minute door-to-needle time for fibrinolysis. METHODS: This was a multicenter, retrospective chart review of STEMI patients flown by a hospital-based helicopter service in 2007. Included patients were transferred from an emergency department (ED) to a cardiac catheterization laboratory for primary or rescue percutaneous coronary intervention. Out-of-hospital, ED, and inpatient records were reviewed to determine door-to-balloon time and door-to-needle time. Data were abstracted with a priori definitions and criteria. RESULTS: There were 179 subjects from 16 referring and 6 receiving hospitals. Mean age was 58 years, 68% were men, and 86% were white. One hundred forty subjects were transferred for primary percutaneous coronary intervention, of whom 29 had no intervention during catheterization. For subjects with intervention, door-to-balloon time exceeded 90 minutes in 107 of 111 cases (97%). Median door-to-balloon time was 131 minutes (interquartile range 114 to 158 minutes). Thirty-nine subjects (21%) received fibrinolytics before transfer, and 19 of 39 (49%) received fibrinolytics within 30 minutes. Median door-to-needle time was 31 minutes (interquartile range 23 to 45 minutes). CONCLUSION: In this study, STEMI patients presenting to non-percutaneous coronary intervention facilities who are transferred to a percutaneous coronary intervention-capable hospital by helicopter EMS do not commonly receive fibrinolysis and rarely achieve percutaneous coronary intervention within 90 minutes. In similar settings, primary fibrinolysis should be considered while strategies to reduce the time required for subsequent interventional care are explored.
Reperfusion Is Delayed Beyond Guideline Recommendations in Patients Requiring Interhospital Helicopter Transfer for Treatment of ST-segment Elevation Myocardial Infarction. Ann Emerg Med. 2011 Mar;57(3):213-220
I don’t have full text access to the Journal Pediatrics, so I’m not sure what I make of this small randomised trial comparing two types of blood pressure monitoring during paediatric transport: BACKGROUND The “golden-hour” concept has led to emphasis on speed of patient delivery during pediatric interfacility transport. Timely intervention, in addition to enhanced monitoring during transport, is the key to improved outcomes in critically ill patients. Taking the ICU to the patient may be more beneficial than rapid delivery to a tertiary care center. METHODS The Improved Monitoring During Pediatric Interfacility Transport trial was the first randomized controlled trial in the out-of-hospital pediatric transport environment. It was designed to determine the impact of improved blood pressure monitoring during pediatric interfacility transport and the effect on clinical outcomes in patients with systemic inflammatory response syndrome and moderate-to-severe head trauma. Patients in the control group had their blood pressure monitored intermittently with an oscillometric device; those in the intervention group had their blood pressure monitored every 12 to 15 cardiac contractions with a near-continuous, noninvasive device. RESULTS Between May 2006 and June 2007, 1995, consecutive transport patients were screened, and 94 were enrolled (48 control, 46 intervention). Patients in the intervention group received more intravenous fluid (19.8 ± 22.2 vs 9.9 ± 9.9 mL/kg; P = .01), had a shorter hospital stay (6.8 ± 7.8 vs 10.9 ± 13.4 days; P = .04), and had less organ dysfunction (18 of 206 vs 32 of 202 PICU days; P = .03). CONCLUSIONS Improved monitoring during pediatric transport has the potential to improve outcomes of critically ill children. Clinical trials, including randomized controlled trials, can be accomplished during pediatric transport. Future studies should evaluate optimal equipment, protocols, procedures, and interventions during pediatric transport, aimed at improving the clinical and functional outcomes of critically ill patients. Enhanced Monitoring Improves Pediatric Transport Outcomes: A Randomized Controlled Trial Pediatrics. 2011 Jan;127(1):42-8
More National Trauma Databank analysis coming out in favour of helicopter transport: this time looking at interhospital transfer:
Background: Helicopter transport (HT) is frequently used for interfacility transfer of injured patients to a trauma center. The benefits of HT over ground transport (GT) in this setting are unclear. By using a national sample, the objective of this study was to assess whether HT impacted outcomes following interfacility transfer of trauma patients.
Methods: Patients transferred by HT or GT in 2007 were identified using the National Trauma Databank (version 8). Injury severity, resource utilization, and survival to discharge were compared. Stepwise logistic regression was used to determine whether transport modality was a predictor of survival after adjusting for covariates. Regression analysis was repeated in subgroups with Injury Severity Score (ISS) ≤15 and ISS >15. Results: There were 74,779 patients transported by helicopter (20%) or ground (80%). Mean ISS was higher in patients transported by helicopter (17 ± 11 vs. 12 ± 9; p < 0.01) as was the proportion with ISS >15 (49% vs. 28%; odds ratio [OR], 2.53; 95% confidence interval [CI], 2.43-2.63). Patients transported by helicopter had higher rates of intensive care unit admission (54% vs. 29%; OR, 2.86; 95% CI, 2.75-2.96), had shorter transport time (61 ± 55 minutes vs. 98 ± 71 minutes; p < 0.01), and had shorter overall prehospital time (135 ± 86 minutes vs. 202 ± 132 minutes; p < 0.01). HT was not a predictor of survival overall or in patients with ISS ≤15. In patients with ISS >15, HT was a predictor of survival (OR, 1.09; 95% CI, 1.02-1.17; p = 0.01). Conclusions: Patients transported by helicopter were more severely injured and required more hospital resources than patients transported by ground. HT offered shorter transport and overall prehospital times. For patients with ISS >15, HT was a predictor of survival. These findings should be considered when developing interfacility transfer policies for patients with severe injuries. Helicopters Improve Survival in Seriously Injured Patients Requiring Interfacility Transfer for Definitive Care J Trauma. 2011 Feb;70(2):310-4.
Flying Doctor Minh Le Cong describes the profile and success rates of emergency endotracheal intubation conducted by the Queensland Royal Flying Doctor Service aeromedical retrieval team, comprising a doctor and flight nurse. It would be interesting to know how many more patients have been added to the registry since this was submitted. An important contribution to the literature in retrieval medicine.
Objective To describe the profile and success rates of emergency endotracheal intubation conducted by the Queensland Royal Flying Doctor Service aeromedical retrieval team comprising a doctor and flight nurse.
Method Each intubator completed a study questionnaire at the time of each intubation for indications, complications, overall success, drugs utilised and deployment of rescue airway devices/adjuncts.
Results 76 patients were intubated; 72 intubations were successful. None required surgical airway and three were managed with laryngeal mask airways; the remaining failure was managed with simple airway positioning for transport. There were two cardiac arrests during intubation. Thiopentone and suxamethonium were the predominant drugs used to facilitate intubation.
Conclusion Despite a low rate of endotracheal intubation, the high success rate was similar to other aeromedical organisations’ published airway data. This study demonstrates the utility of the laryngeal mask airway device in the retrieval and transport setting, in particular for managing a failed intubation.
Flying doctor emergency airway registry: a 3-year, prospective, observational study of endotracheal intubation by the Queensland Section of the Royal Flying Doctor Service of Australia Emerg Med J. 2010 Sep 15. [Epub ahead of print]
Those interested in learning more about this registry, including how often capnography was used, more information about the asystolic arrests, and whether they tried a blind digital intubation, can check this link to a presentation about the registry.
Intercostal catheters can kink, obstruct, or get pulled out. These hazards are greater during transport of the patient. Critical care and retrieval medicine doctors in Queensland, Australia (where many people are having a bad time right now) have invented an elegant alternative: using a cuffed tracheal tube in the pleural space instead. It can be attached to a Heimlich valve.
They even used a bit of science to demonstrate its effectiveness, by creating pneumothoraces and haemothoraces in sheep and comparing the tracheal tube with a standard intercostal catheter (ICC).
The method for insertion is simple:
Breach the pleura
Insert a 14 Fr Cook intubating bougie into the thoracic cavity
Railroad a 7.0 mm internal diameter tracheal tube (ETT) into the chest cavity
Inflate the cuff
Retract the tube until resistance is felt.
Remove the ETT connector
Attach a Heimlich valve
The results of the comparison are convincing: ‘The ETT proved faster to insert for both sheep. This was likely because it did not require suturing. Both the ETT and the ICC were comparable in draining blood. It was noted that neither tube was particularly effective when the haemothorax was positioned ‘side-up’. When turned ‘side-down’, both tubes successfully drained blood. Despite having multiple drainage ports, the ICC required more manipulation and was noted to kink. Conversely, the ETT with a single lumen and a Murphy eye, was stiffer and drained a similar amount of blood without the catheter having to be milked.’
Proposed advantages of this method include:
More portable equipment
Provides kit redundancy
Does not require suturing
Avoids operator trauma from any sharp edges such as a fractured rib. (No attempt was made to place a finger into the chest cavity in the ETT group).
Allows for a smaller incision
Less trauma to the insertion site
Might also offer a back up, when conventional equipment has been exhausted.
The authors graciously note that both Portex and Cook have developed ICC kits that now go some way in supporting the original idea behind this study. These include flexible introducers (Portex) and guidewire insertion technique (Cook). Appraisal of the endotracheal tube as an alternative to the intercostal catheter Emerg Med Australas. 2010 Dec;22(6):573-4
Data from the England and Wales Paediatric Intensive Care Audit Network on children (aged 16 years or younger) admitted to 29 regional paediatric intensive care units (PICUs) between 1 January 2005 and 31 December 2008 were analysed in a retrospective cohort study to assess the effectiveness of the specialist retrieval teams.
The type of transferring team (specialist or non-specialist) was known for 16 875 cases and was specialist in 13 729 (81%). Compared with children transferred to PICUs from within the same hospital, children transferred from other hospitals were younger (median age 10 months vs 18 months), more acutely ill (mortality risk 6% vs 4% using the Paediatric Index of Mortality), needed more resources (such as invasive ventilation, vasoactive drugs, renal replacement therapy, extracorporeal membrane oxygenation and/or multiple-organ support), had longer stays in the PICU (median 75 h vs 43 h) and had a higher crude mortality (8% vs 6%). On multivariable analysis after adjustment for case mix and organisational factors, the risk of death among interhospital transfers was significantly (35%) lower than among intrahospital transfers. With similar analysis, the times spent in PICU did not differ significantly between these two groups. When the type of transferring team was considered, crude mortality was similar with specialist and non-specialist teams, although the children transferred by the specialist teams were more severely ill. On multivariable analysis, the risk of death was 42% lower with specialist team transfer.
These findings appear to confirm the value of specialist retrieval teams. Why children transferred from other hospitals did better than children transferred to the PICU in the same hospital is not explained. Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study Lancet. 2010 Aug 28;376(9742):698-704
In the United Kingdom, The Academic Department of Military Emergency Medicine at the Royal Centre for Defence Medicine produces Clinical Guidelines for Operations on behalf of Surgeon General under the direction of Defence Professor of Emergency Medicine.
These guidelines, last updated in May 2010, are available on line here:
**UPDATE JUNE 2011** I have received correspondence that this document is now out of date. The link is however still active and the document makes for interesting reading.
Can cardiotocography be applied in the pre-hospital setting? French physicians assessed its feasibility in 145 patients enrolled during 119 interhospital transfers and 26 primary prehospital missions.
Their physician-staffed ambulance teams included 19 emergency physicians and one anaesthetist.
Interpretable tracings were obtained for 81% of the patients during the initial examination, but this rate decreased to 66% during handling and transfer procedures. Only ground EMS transportations were included in the study. For 17 patients (12%), the monitoring led to a change in the patient’s management: an acceleration of chronology of prehospital management in 5 cases, a decision to directly admit the patient to the operating room for immediate cesarean section in three cases, a change in hospital admission in three cases, an adaptation or implementation of tocolytic treatment in six cases, and placing the patient in the left lateral decubitus position or oxygen administration in three cases. Fetal monitoring in the prehospital setting J Emerg Med. 2010 Nov;39(5):623-8