EMCrit Podcast 41 – Interview with Cliff Reid of RESUS.me

I was able to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff’s blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Cliff mentions the HEMS service in London. This amazing service sends a physician/paramedic team to the scenes of bad traumas by helicopter and response cars. A well done video is available on youtube:

The winner of the Toxicology Handbook is Jenny Mendelson. Yeah!!!

photo by Mad Scientist

Click Here to Play the Podcast

Play

You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode


Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 4 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. i must say i don’t really agree with doing all that stuff in the middle of the street. With such limited resources in the field, why waste more time there then necessary?

    • Lota,

      I think Cliff was talking about these advanced measures being done enroute to the hospital, rather than in the middle of the street. But hopefully Cliff will be checking out these comments and we’ll get a response direct from the source.

      Scott

      • Minh Le Cong says:

        HI Scott et al
        Firstly thanks for this engaging interview session with Cliff Reid

        In response to Lota’s comments , another way to reframe the question would be to consider if you, Scott, would think it a good idea to be getting on EMS trucks in New York and racing out to the scene to provide prehospital RSI etc or just keep doing what I assume you are doing now and waiting for the paramedics to bring the patient to your ED?
        If you watch a lot of the YouTube London HEMS retrieval footage, almost all of their prehospital intubations are done in the middle of the street or on some footpath.
        When transport times are short such as urban settings (mostly), I would argue there is little to gain by hanging around trying to do ED things in a non ED setting. INterestingly that Paramedic RSI study Cliff cited from MICA teams in Melbourne, Victoria demonstrated a statistically significant increase in cardiac arrest in the Paramedic group vs hospital group, albeit overall mortality was not increased. Their average transport time was 20-30 minutes and the HEMS patients were excluded from the study. SO in that study does prehospital RSI constitute a meaningful intervention if it induces more cardiac arrests enroute than waiting till you tube them in ED if your average transport time is <30 minutes?

        It is my belief that when transport times are longer you need to do more advanced stuff to stabilise the patient for transport.

        As for the LMA/SGA vs ETT debate in the prehospital setting, I find it surprising that Cliff is waiting on outcome data before he is willing to try out that strategy. Did he ask for outcome data before starting to perform prehospital RSI/ETI? I have done a number of LMA only ventilated aeromedical retrievals, albeit after failed intubations and if they are oxygenating well with good ETCO2 trace then what more do you want in a prehospital airway? Does that not constitute a meaninful intervention? I sometimes wonder if there is not a degree of airway snobbery in this whole debate!

  2. Scott Gallagher says:

    We’re moving away from ETTs and encouraging using only SGAs for our EMS service, specifically the King LT(D)-S airway.

    Couple of concerns:
    (1) EMS claims there is literature that quantitative CO2 is not accurate with the King airways. Wondered if anyone has read this? Is gastric air perhaps entrained and diluting measured CO2?
    (2) I still have concerns for suboptimal airway protection with the SGAs. Perhaps allowing paralytics, one attempt at ETT with wave-form CO2 confirmation, and then go straight to SGA if unsuccessful would the safer route as a compromise?

    Scott Gallagher, MD

    • Dr. Gallagher,

      I’m not aware of any such literature to your first point (and cannot find any of the same). If you have an adequate seal with the King, you won’t run into many issues with leaks. The largest failing I see is w.r.t. syringe size and the #4/5 Kings. Usually they are packaged with a 60cc syringe (or acquired separately), yet those two sizes require inflation volumes in excess of 60mL (60-90mL). I think its a learned response to just push the 60mL into the cuff and go from there.

      As for your second point, the only time we’re using a King is in cardiac arrest or as a difficult airway adjunct, as my service lacks RSI. Theoretically the LTS-D would allow an OG tube to be placed to mitigate the risks, but if you forgot to preload the OG tube you’re not likely to get it prior to insertion!

      If you are able to find the literature they are talking about I would love to read it as I am a large advocate for King airway usage prehospital.

      -Christopher

      • Scott & Chris,

        I too would love to see the articles your EMS folks are mentioning. I did a lit search and all I can find is this study:
        Acta Anaesthesiol Scand. 2005 Jul;49(6):759-62.
        Relationship between arterial and end-tidal carbon dioxide pressures during anesthesia using a laryngeal tube.
        CONCLUSION: This study suggests that for healthy adult patients mechanically ventilated via the LT, the PETCO(2) value reflects the PaCO(2) value as closely as when patients are ETT ventilated, allowing capnometry to be used to evaluate the adequacy of ventilation.

        which would indicate it is accurate. Only reasons that LTA would not get ETCO2 waves are inadequate placement or a leak. Even if there was gastric air admixture, there still should be waveform albeit with a lower CO2 level.

        Agree that there is still the question adequacy of airway protection. I think Chris is correct that gastric tube palcement goes a long way to reassuring me. Risk is passive regurg from gastric overinflation. Even passive gastric drainage makes this far less likely as pressure can’t build up.

        In the next few weeks I will be posting a discussion with Dr. Dan Cook who invented a new LMA with a gastric blocker tube. I think this may be the ultimate EMS airway ( I have no financial ties to this product or anyone).

        • Dr. Weingart,

          Looking forward to that interview! With a well placed King, the OG tube is likely not needed unless aggressive BVM ventilation was performed prior to its insertion. My own anecdotal experience is the King can be placed, with in-line ETCO2, in a comparable time to OPA+BVM in arrest situations. In these instances the gastric distension is negligible if not non-existent. The King LT-D or LTS-D is a no brainer in cardiac arrest.

          However as a part of Rapid Sequence Airway or backup airway I did find one study in which the LT-D showed a greater incidence of regurgitation [1]:

          “We observed regurgitation in 17% of all cases [ed: n=157], which, in the majority of patients, occurred prior to placement of the laryngeal tube. In the remaining seven cases, it remained speculative whether the observed regurgitation occurred before, during or after laryngeal tube placement. Nevertheless, six of these cases were associated with the use of the LT-D, which does not allow placement of a gastric drain tube.”

          In the OR a study comparing 6 methods of ventilation found a 13% rate (n=30) of hypopharyngeal pH dipping below 4 when using the LT [2]. This was comparable to all other supraglottic airways, but a much higher incidence than ETI. However, the authors note that this measurement is a potential limitation, but useful as a predictor of risk:

          “A limitation of our study is that our primary outcome was gastroesophageal regurgitation as detected by hypopharyngeal acid regurgitation rather than aspiration of gastric contents itself.”

          However, I still cannot find any negative studies related to the laryngeal tube and ETCO2 measurements.

          1. Schalk R, et al. Out-of-hospital airway management by paramedics and emergency physicians using laryngeal tubes. Resuscitation 81 (2010): 323-326.
          2. Khazin V, et al. Gastroesophageal regurgitation during anesthesia and controlled ventilation with six airway devices. J Clin Anes 20 (2008): 508-513.

  3. I’m glad the interview sparked discussion. What’s most heartening is that the debate is now about which advanced airway intervention EMS should be providing, rather than dismissing all pre-hospital interventions as a waste of time.

    Thanks for your points Minh.Here’s my response:
    “As for the LMA/SGA vs ETT debate in the prehospital setting, I find it surprising that Cliff is waiting on outcome data before he is willing to try out that strategy. Did he ask for outcome data before starting to perform prehospital RSI/ETI?”

    Yes, but at the time there wasn’t any. The reason I said I’d like to see more on RSA, as I explained on the podcast, is because I have no personal experience of it. I don’t like it when ‘experts’ comment on things outside their own experience, so I try no to. RSI is considered the gold standard way to protect and maintain the airway and ventilation. If I’m pharmacologically paralysing someone, shouldn’t I go for gold?

    ” I have done a number of LMA only ventilated aeromedical retrievals, albeit after failed intubations and if they are oxygenating well with good ETCO2 trace then what more do you want in a prehospital airway? Does that not constitute a meaninful intervention?”

    It sure does in my book, and it’s exactly what I’d do too in the event of a failed intubation if a crike wasn’t indicated.

    Regarding the MICA study – I share the concern about the arrests, which is mentioned in the paper’s discussion. My suspicion is that if they used an appropriate dose of ketamine as their induction agent there would have been fewer, and possibly none.

    As for intubating in the street rather than the ED…. The assumption is often that this causes delays. Although it may obviously cause a delay in getting to hospital, it may actually speed up time to various other meaningful interventions. For example, bringing a sedated, analgesed, intubated, cannulated patient in the ED might result in an earlier CT and neurosurgery than if the patient is brought in ‘fresh’. In both Sydney and London I’ve noted that pre-hospital RSI is done quicker and sometimes even more safely than in the receiving trauma centres. This might say more about those EDs’ systems of course but if we think about time to various meaningful interventions rather than ‘scene time’ the argument that some of these things should be left to the ED becomes weaker.

    I think these debates will continue for years because I don’t think they’re going to be resolved by research in the near future. I hope I’m wrong. In the mean time, keep it coming. No-one has all the answers and I always learn things from my paramedic and physician colleagues, particularly those who work in other systems.

    Cheers

    Cliff

    • Minh Le Cong says:

      Hi Cliff
      great comments thankyou. I must challenge you on this notion that RSI is gold standard in emergency airway management! Such a risky procedure should not be given the title of a gold standard without some form of rigorous scientific examination and debate.
      I assume you consider it gold standard as it protects against aspiration and maximises first pass success? You are a well read physician so can you show me the well controlled studies proving that RSI does indeed protect against aspiration? And if so what element of the RSI is crucial to the protection? Cricoid pressure? Or first pass success?
      IN light of that, if you paralyse someone to secure the airway, does it matter what airway you place as long as it provides adequate oxygenation and ventilation, perhaps even draining the stomach?
      RSI was never intended in the original descriptions to be performed outside of an OT/OR. Sure it has been well reported in other settings I admit that but does that mean it is the best we can do, the gold standard.
      To me a gold standard of emergency airway management is a procedure that is grounded in patient safety by maintaining oxygenation, a procedure that is simple to learn and teach and requires minimum skill to achieve good success. I don;t think it helps our prehospital practice to claim that RSI is the best we can do and stop trying to improve it.
      Scott has two excellent lectures on this whole idea of improving RSI : the awesome laryngoscope is a murder weapon and the DSI lecture on preoxygenation. He quite correctly says don;t be a gambler during your airway management in the critically ill or injured. There are a couple of elements of traditional RSI that I totally disagree with and no longer teach. One of my anaesthetic teachers told me the problem often in a difficuly airway is glottic fascination. We should not be bringing this fascination out into the street or the field .

      • Hi Minh

        Funny – I just blogged about an article on pre-hospital insertion of the Easytube – a bit like the Combitube – and the second sentence in the paper was ‘Endotracheal intubation (ETI) is currently the “gold standard” for airway management in a prehospital setting’!

        I think RSI is considered the gold standard in emergency airway management – you don’t have to look very hard to find this statement in multiple anaesthetic and emergency medicine sources. Whether it SHOULD be considered the gold standard you are of course entitled to question, and I love it when dogma is challenged.

        I think, if I understand you correctly, your point is about whether the possible (perceived if unproven) aspiration risk associated with a supraglottic airway is outweighed by the risk of providing RSI safely in a difficult environment, a point strengthened by the lack of robust outcome data in support of RSI. No-one knows the answer to this and the best approach for the patient will to some extent be dictated by the resources and skills of the EMS and environment they work in.

        To answer your questions: “I assume you consider it gold standard as it protects against aspiration and maximises first pass success? You are a well read physician so can you show me the well controlled studies proving that RSI does indeed protect against aspiration?”

        No, I can’t show you those studies.

        “And if so what element of the RSI is crucial to the protection? Cricoid pressure? Or first pass success?”

        I think it’s the cuffed tracheal tube that helps me ventilate my pre-hospital and interhospital retrieval patients with various combinations of pulmonary contusion, obesity, drowning/aspiration, ALI/ARDS, and so on. And the placement of that tube is easier and quicker using an induction agent and rapidly acting neuromuscular blocker.

        A point I think I made quite clearly in the podcast is what I would want for me or my family if I had a critically compromised airway and ventilation. In the light of what few data are out there and my clinical experience, I’d go for RSI by an experienced provider working within a rigorously supervised and audited system. Your interpretation of the limited literature and your own experience pushes you in a different direction. That should be cool with both of us.

        Thanks for your thought provoking discussion

        Cliff

  4. I’m a EM resident, prior Firefighter/Paramedic. I’ve been very interested in trying out a EMS physician response unit in my area. It would probably only be needed on 1% of calls, but in that area thats more than enough to keep one unit active 24/7. Outside of EMS fellowship programs it seems there isn’t a lot of interest or resources for this, which isn’t to say there aren’t areas that would benifit from it. I like the concept of “time to meaningful intervention” as a criterion, I get really tired of hearing “time to ED” when no one considers the patient’s status en route.

    If I don’t find a position stateside that allows active prehospital work (at least as part time for me) I would love to explore opportunities in the UK or S. Pacific!

    • Nathan,

      The only program I know for sure has EMS physicians in the field is U. Pitt. If listeners know of others, please comment.

  5. Nathan if you don’t have any luck at home feel free to come and see us – http://nswhems.wordpress.com

  6. Thanks for your excellent interviews and discussions! As one of the first ED-Doctors in Germany, prior Paramedic, I work today in-hospital as well as pre-hospital responding about 500 ems-calls a year as emergency physician in the field. Nationwide, pre-hospital emergency physicians (80 hrs. of training) respond to about 1.5 Mio. calls a year (“potentially life-threatening conditions”), but there is still discussion, wheter we need “Emergency Departements” and “Emergency Medicine” as a speciality or if we better continue to send the youngsters from medicine, neurology, ent, surgery, … to the ER. “Time to meaningful intervention” is here a problem of non-existing structurs for emergency care inside the hospital: “Want they don´t get on the streets, they will never get”.
    Nathan, feel free to come and see us!
    Thomas

    • Minh Le Cong says:

      Hi Thomas, great to hear from a German prehospital doctor. Cliff gave his views as a UK and Australian prehospital doctor…and I have given mine as an Australian prehospital doctor, albeit in a fixed wing air ambulance system.

      So Nathan, you can choose what experience you want to get depending upon what country you are keen to visit!

      I am intrigued by what you wrote, THomas, “What they don’t get on the streets, they will never get”

      Perhaps there are French prehospital doctors reading this forum, but could anyone comment on whether the statement that THomas wrote applied to Princess Diana in that Paris tunnel?

  7. Gosh, I would love to hear from some folks involved or knowledgeable about the Princess Di situation as well.

  8. Hi Minh,

    thanx for your comment. Transfering patients fixed-wing over longer distances is, of course, a different thing, my experience is from helicopter-, ambulance- and sea-rescue-calls.
    The tragic death of Lady Di was probably one of the most impressive incidences in the french-german-style emergency-systems and is still a wrinting on the wall for everyone supporting a “load-and-go”-strategy. But in the last years things changed: We learned to differenciate wheter pre-hospital treatment solves the problem of the patient or not. If you respond to unstable VT, there is no need to ran to the next hospital, you better stay “stay and play” and terminate VT in deep sedation.
    If you are called to a trauma case, you probably decide to “treat and go”.
    Last shift I was called to a 45-year gentleman, who had severe midface-trauma after an explosion and was initialy unconscious. When we arrived about 10 mins. after the event, he was awake, short of breath and was obviously going into an A-Problem. After a short AMPLE-history, monitoring, two large-bore i.v.-lines and preoxygenation, I decided to intubate him and did a RSI. After verifying tube position via capnograph, we transfered him by ambulance to a level-one Trauma-Center about 50km away. He reached the trauma-center 65min. after the call, the handover was not in the rescutation room, but directly for CT-Scan (CT in the ED), as he already got everything he needed at that time. CT-Scan revealed severe midface trauma, mild TBI and we all could see, that we would have lost the airway during transfer without intubation…
    “Treat and go” is probably the way to go. But: we do have good data, that only 60% of the pre-hospital ems-physicians are trained in RSI and perform it regularly! Failed intubation, unrecognised oesophageal intubation is rare, but still a problem.
    On the other hand, only about 10% of the german hospitals have interdisciplinary ED´s, staffed with senoir doctors, in about 90% of the hospitals we handover to a multidisciplinary team of youngsters, who also have little training in RSI! We doctors from the 10% re-organised ED´s work hard for a better in-hospital emergency management, every day as well as on a politcal and academical way and for the recognition of emergency medicine as a speciality.
    I really do favor physician-staffed ems and we can make a difference for severe trauma as well as for certain cardiac-cases, critical ill children, desasters, etc..
    The big thing is to have experts, not heroes on the streets!

    Thomas

    • Which part of Germany do you work in Thomas? It would be great to see your system in action. I understand the German pre-hospital HEMS network to be an excellent model, although as you say emergency medicine (as a specialty) in hospitals has taken a while to develop.

      Schöne Grüße aus Australien!

      Cliff

    • Minh Le Cong says:

      thanks Thomas
      I agree with you, .mostly. You did not really comment on the prehospital care of Princess Diana. As far as I understand it, she was intubated and ventilated post extrication by a prehospital doctor and managed to die from a massive left haemothorax 10 miles from a Level 1 trauma hospital. I understand that she arrested twice en route to the hospital and each time the ambulance was stopped so that CPR could be performed.

      I guess my point is that I consider patient location/environment to be important in deciding upon the treatment strategy. The fact that you are in Paris close to a major hospital should alter your decisions on management particularly when your ability to assess an injured patient is limited prehospitally

      As for your case of mid face fracture , I had a helicopter EMS retrieval doctor friend of mine recently present a primary retrieval case she did in which she attended the pilot of a light airplane crash into dense rainforest. He suffered a severe midface injury but was managed fine on the retrieval with only simple airway positioning.
      Why was he not intubated? because the retrieval required a 120ft winch into dense forest; the patient had to be stretchered 50 m from the crash site to the winch zone.; there were only 3 rescuers to lift the stretcher and intubating him would have meant an impossible task to move and winch him safely.

      Similarly what if your mid face injury patient was trapped in the rubble of a collapsed building from an earthquake like what has happened in Christchurch last week? getting someone out of an unstable building may be much harder if they are now intubated and relying upon someone else to support them

      Or you are in Afghanistan being shot at in the middle of the night, would you setup for RSI on your injured colleague with a midface injury? That might mean a death sentence for not only you but your colleagues as well.

      Prehospital interventions should indeed be meaningful, I agree. But they should also be taken within the context of the situation, environment and location of where you are providing that care. I agree with Cliff that the pathophysiology of trauma does not respect location but is only half the story in my view.

      as physicians we do need to respect location in making our decisions. the hard part of being an ‘expert” in prehospital care is deciding when NOT to intervene.

      I always find it remarkable that in ED/ICU settings we regard the “gold” standard of polytrauma care to be provided by a trauma team of ICU, ED , anaesthetics, surgeons etc. Yet somehow in prehospital doctor EMS we suddenly think sending one doctor and paramedic to a trauma patient is good enough? To me that is not the true sense of “bringing the ED to patient”!

  9. G´Day, Cliff!
    I work for a 500-bed teaching hospital in the north of of Germany, the city is called Wismar, right at the coast of the baltic sea, about 100km away from Hamburg.
    HEMS, physician-staffed EMS, Sea-Rescue, and the beginnings of an ED… you are welcome anytime!
    Greetings, Thomas

Trackbacks

  1. […] [Click here to read more and hear the podcast] […]

  2. […] Scott interviews Cliff Reid from the blog RESUS.ME, a prehospital-retrieval specialist and director of training for the New South Wales ambulance service. Cliff get’s down and dirty during the podcast, looking at pre-hospital airway management, gives insight into his blog, and has a rant about scoop-and-run vs stay-and-play in the prehospital setting. The LITFL team look forward to episode two. […]

  3. […] interviews Cliff Reid on Prehospital Airway Management and they discuss this […]

  4. […] this podcast, sourced from emcrit.org, Scott Weingart (ED Intensivist from New York City, founder of emcrit.org) and Cliff Reid (Great […]

Speak Your Mind (Along with your name, job, and affiliation)