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:
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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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
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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.… Read more »
BTW I love the term ‘glottic fascination’! Might borrow that…
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… Read more »
Nathan,
The only program I know for sure has EMS physicians in the field is U. Pitt. If listeners know of others, please comment.
Nathan if you don’t have any luck at home feel free to come and see us – http://nswhems.wordpress.com
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… Read more »
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… Read more »
Gosh, I would love to hear from some folks involved or knowledgeable about the Princess Di situation as well.
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… Read more »
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
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… Read more »
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
seven years later, incredible. thanks scott. and dr reid
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