Tag Archive: transfer


PHARM: Dr Minh Le Cong’s blog

Filed Under: General Practice, Specialist Tips, Uncategorized by Casey Parker — Leave a comment
May 24, 2012

Dr Minh Le Cong has finally found his own home and settled down with a nice new blog called Prehospital and retrieval medicine PHARM.

This is a high quality blog looking at all things to do with transfer and prehospital care of the sick patients in remote parts of Australia.

Minh is mildly obsessed with all things airway, psychiatry and critical care.  My type of guy!

If you are interested in this stuff then go to the site prehospitalmed.com

FYI there is a discussion podcast between Minh, myself and Dr Tim of the KI-Docs blog about all things to do with remote care, education and training.

Check it out.

Casey

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C-spine Trauma: in a town with no CT

Filed Under: Critical care / ICU, Emergency, Pearls and Pitfalls, Useful Evidence by Casey Parker — 3 Comments
March 12, 2012

I worked for 4 years in a town with no CT (but plenty of beer) – and it is fair to say that the protocols for managing C-spine trauma were often makeshift.  Logistics rather than clinical acumen often determined who got a CT rather than ‘just’ clinical exam and a set of plain films.  But…. why should my patient get less than gold-standard care – just because of geography?   I realize this is a bit idealistic, but when it comes to life-long disability – do we really want to take that risk?

Now in recent months there has been a lot of posting and banter about C-spine trauma on the popular medical blogs / podcasts.  So I thought I would trawl through the literature and come up with a pragmatic protocol for those of us who work in CT-isolation, or where it is not available 24/7.  Amusingly here is a hot debate about whether you need to MRI patients with pain and a normal CT – Yep, true!  We are not even close to that debate in regional Australia!

The logistics of distance mean that I break (‘scuse the pun) C-spine trauma into 3 main groups:

  1. The minor trauma – these are the patients whom you can clear with clinical history, exam and NO imaging is required.
  2. The fuzzy middle group: they cannot be cleared on clinical grounds for whatever reason, or they have failed the clinical clearance. Yet, they remain asymptomatic, have no high risk features –  your “gestalt” is that they are probably OK.
  3. The major trauma: these patients are high risk – based on the mechanism of injury, associated injuries or the presence of neurology suggestive of a cord injury

I will try and explain how I think each of these should be managed based on my reading of the recent evidence, the reality of rural practice and a measure of common-sense.  If you want to get some great background and refresher in anatomy I have a few suggestions for your valuable time:

OK, without further waffling – lets analyse these 3 groups and try to cook up a rough protocol for each.
In some ways this should be the easiest group – but is also the one that causes the most frequent consternation!
Clearing a C-spine is one of those moments in medicine when you just have to trust your call. This is especially true in the bush – if you decide not to clear them – you are probably committing them to a long transfer strapped to a spinal board: uncomfortable and expensive!
So how do you clear a C-spine clinically? Here is how I do it – I use MDCalc’s Canadian C-spine tool – but be warned – you have to use it properly. These rules are derived and validated by following the protocol to the letter – if you do not follow the protocol as described you cannot achieve the same sensitivity. The Canadian C-spine seems to be better than the NEXUS rule (NEJM, 2003) – but you must have an alert, sober, orientated and cooperative patient – so a lot of our customers are self-excluded! Scot Weingart describes an interesting combination of the 2 rules.
As the receiving doctor in a CT+ town – I really want to know that the patient has had a proper attempt at C-spine rule clearance – otherwise we are squandering valuable flight resources and irradiating unnecessarily.
This group includes the people whom you cannot clear clinically as they are too drunk, disorientated, in pain, etc to qualify for a clear Canadian C-spine rule PLUS those who have failed the rule – ie. they have tenderness, pain on rotation, are too old etc.
So according to the rules they get “imaging”.  Easy: off for a set of plain films, right?  well maybe not such a great idea.
A good number will have sub-adequate views, and then you need to ask – what is the sensitivity OR the negative predictive value of plain films for C-spine injuries…?  Well they are not so great – in fact the term ‘suck’ has been used to describe them!
This series from the Journ. Trauma 2009 showed a sensitivity of plain films c/w CT for serious injury of less than 50% – that is worse than a coin toss!
However, some protocols continue to advocate plain films as a ‘screen’ for fracture in the lower-risk groups.  I guess this means the patient who so nearly passed the clinical clearance test (eg. were just 65 years old only, had transient pain…) But it is a small group – so the role of plain films is vanishing rapidly.
So in summary – there are not many patients we can reliably clear with plain films if you follow the evidence and guidelines as written.
Therefore if you are in a CT-less town, and have one of these patients – you probably should transfer for a CT.  If you think they are low-end risk, and have a good set of films then it is a judgement call on your part.  Traditionally we have cleared patients on this basis – but is it still the standard of care?
This is really the easiest group to decide upon. Sure, the toughest to manage, but the easiest to make a call on C-spine imaging.
If you have a patient with a high-energy mechanism, bony tenderness, neurological signs or major injury (esp head) then you need not bother with plain films. These patients need transfer – not imaging. This is the scenario where you want to get them to a trauma centre ASAP – probably for more than their neck injury. Taking them through the Xray Dept, moving them 3 or 4 times – for a series of images will add little to your management! Assume they have an unstable injury and manage them appropriately. If you are wrong – great, if you are right – then you have done the right thing!
Finally a quick note on C-Spine collars
  • Rigid C-Spine collars are omnipresent in ED trauma patients, they are almost like religious artifacts – there is a lot of belief in their powers, but is there the evidence to back them up??
    • The Journ Emerg Med 2012 published an article by Holla which looked at healthy people and the effect of collars – basically they did not actually immobilize any more than the padded boards / straps and decreased mouth opening.
    • There is no hard evidence to say they actually decrease neurological injury / improve outcomes.
    • We all know they are a pain, ill-fitting and your worst enemy when trying to intubate!
    • So here is my take – immobilisation is good, collars are window dressing.  If you really want to keep the neck still – provide good analgesia and anti-emesis, supervise the patient closely (esp. if they are drunk, head-injured etc), they will need a nurse / doc by the bedside constantly to do this right!
    • If you use a collar  and it is causing problems: pressure, pain, airway obstruction or really making the patient hostile – then take it off and keep a close eye on them.  Prima non nocere.
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Managing Traumatic bleeding: how can we apply the evidence in smaller hospitals?

Filed Under: Anaesthetics, Critical care / ICU, Emergency, Pearls and Pitfalls, Pharmacology, Useful Evidence by Casey Parker — 1 Comment
October 23, 2011

OK after Clinical Case 031 I was inspired to go out and slog through the literature and try to discover what is “best practice” for traumatic bleeding, then try and work out what is important, what we can do in small or remote hospitals and what is just too expensive / difficult / marginal or plain impossible to do in the bush.  There was a great review in Critical Care last year by Rossaint et al – Updated European Guidelines - so I have used this as a starting point.  Also a review by Curry et al looked at similar data / trials.

So I spent time going over the evidence, and came up with the post below.  The evidence is there, so you can read it for yourself, however, there is no evidence for my opinions – that you can decide for yourself.  As always – I have tried to keep it simple, my brain being the filter for your reading pleasure!  I have given each “recommendation” a grade from A to F (A = gotta do it,\; C = maybe useful; and F = ‘don’t go there’…)  So here it is….it is big, apologies!

This is an A1 recommendation. In patients who are either unstable or have an identified source of bleeding – they need an operation as soon as possible. Time is vital to outcomes.  Let me repeat – if you know where the blood is leaking from – plug it ASAP – do not resuscitate in lieu of intervening with a procedure.

So for the small centres – this means getting into an OT as soon as you can, less time in ED and less fiddling with resuscitation efforts prior to surgery. If you work in a town without a surgeon – then mobilising retrieval early is important. I have on a few occasions arranged for a surgeon to be flown in with the crew to operate prior to transfer.

If your patient responds well to initial resuscitation measures – then you have time, but it should be clear that they need to get to a place where they can get an urgent operation ASAP

We have all been through ATLS or EMST and learned about primary and secondary surveys. What I will say is that there is not much evidence to suport this strategy, but it is universal and you have to do it. However, doing the classic ABCs doesn’t really help you when it comes to the reality of big bleeding patients – the evidence has moved on a bit.

Your initial clinical assessment should answer the following questions:

  1.  mechanism: is this a significant injury? eg. energy of blunt impact, penetrating abdo or thoracic trauma, head injury with any change in GCS.
  2. Pattern of injury:  is this a cluster of injuries, rather than a single overt lesion.  Along with mechanism, the presence of a cluster of injuries should get you worried.
  3. Patient’s physiology / obs / general presentation:  the obs are helpful, but can be normal despite significant bleeds, especially in fit, young people.  You can use the ATLS guide to shock, but know it can be wrong
  4. Response to initial resuscitation – for me this is more useful than the absolute numbers.  The ATLS folks divide these into: rapid responders, transient responders and minimal / non-responders.  You get the idea – give a bit of fluid and watch closely – are you winning?  A pragmatist’s approach to shock – I love this concept – use it every day in my practice.

If you have a patient presenting in shock after trauma and it is unclear as to where the bleeding is coming from then you have to find it fast. If you find it – then you are in the position to intervene.

Resuscitation without identifying the source can waste valuable time. In reality the resus and investigation happen in parallel ideally.

So what investigations? they are guided by you initial assessment, but empirical CXR, pelvis and FAST scanning are mandatory.  The evidence discusses DPL (diagnostic peritoneal lavage) but in my world this is not done – maybe if you have a surgeon with experience, but a FAST is hard to beat when you look at the numbers.  Image anything else you find on you secondary survey.

Shock is defined as tissue hypoperfusion, and this does not equate to the blood pressure. [There is a whole other post coming up on this concept!]

So what measures tissue hypoperfusion? at this stage, serum lactate is your most evidence-based test.  Base deficit is also used with less evidence to support it – but in my hospital they both spit out on the same gas analysis – so use both.  Beware the youngish, sweating / spewing chap with a normalish BP and high lactate – he is on his way to crashville.  [See this article on 'Cryptic sepsis']

I was taught to aim for a low normal ET CO2, but the evidence now suggests this is wrong. The Guidelines recommend normocapnea.

Hyperventilation is associated with poor outcomes (even in brain-injury) including increased mortality, decreased cardiac output and all round badness.

The vent strategy is essentially the same strategy the ARDS Net folks came up with for lung injured patients. The recipe is – low tidal volume (eg. 6 ml/kg IBW), higher RR to keep the minute volume up and clear CO2, and add PEEP to maintain open airways and titrate to oxygenation.  See my case on postop PEEP++ for an example of this strategy.  I now use this on all my intubated patients (even elective gallbags) -unless they have COPD / bad asthma / obstruction.

The evidence shows that using Hct alone is about as good as tossing a coin in the air! It is a poor predictor of volume lost or prognosis. I think you can put Hb in the same basket. It is good to know and use serial assessments, but it is just a part of your more global assessment.

Not a lot of evidence. But it makes sense to try and detect coagulopathy early by testing for it. Of course clinical observation of bleeding and knowing how much fluid / blood has been given can allow you to anticipate ACoTS before the lab can tell you the numbers are bad. The studies did not show much benefit but we should probably check the INR, APTT, platelets and fibrinogen levels. In my practice – I start giving FFP, etc before the labs go bad in the big bleeders – I think this is because – (1) it makes sense to get ahead of the game and (2) the lab can be slow, over an hour to get some results – too late usually.  So if your lab wants confirmation of coagulopathy before the take the FFP out of the freezer – you need to have a ‘meeting’ and change this!

The future includes thromboelastography – this is basically a test of clot strength.  This is used to guide treatment with a variety of coagulation factors – but don’t hold your breath in the regional hospitals – this is still a long way off!

There are some bleeds that need something simple done.

(1) arterial bleeding from and extremity. There is a growing body of evidence from the military showing the safety and improved mortality of torniquet use. See my previous post on Life AND Limb

(2)  Pelvic fracture stabilisation. This depends on where you are and what you have got – but a bed sheet tied around the trochanters is infinitely better than nothin’.  If you have a purpose designed pelvis binder-  then better.  For most small hospitals, that is as good as it gets.  The goal is to make the pelvic volume as small as possible by reducing the injury.

Embolisation seems to be the done thing if you have an angio suite at your disposal.

If you have not heard of this concept before – it basically consists of 3 stages:

(1) Brief ‘resuscitative laparotomy’ – control active bleeding, remove contamination, pack the abdomen and get out

(2) Off to ICU for resuscitation and normalisation of the acidosis, hypothermia and coagulopathy. Optimise fluid status and ventilatory management.

(3) Return to OT for a definitive fix of the injuries / closure of wounds.  This may be hours to days later depending on the injury

There are no RCTs to support this but a lot of retrospective data supports it – it is the new standard of care for the severe end of the trauma spectrum – especially those who have significant acidosis, coagulopathy and low core temp at the outset.

Here we run into some controversy / uncertainty in the literature. What fluid, how much, targets of resus?

Which fluid?  Crystalloids remain the first line.  Most trauma patients now get them en route to the ED.  However, there is evidence showing a direct survival relationship between the volume of crystalloid and mortality.  So if you use them I think it is as a bridge to getting some blood ready.  In my experience too many crystalloids are given in an attempt to get the BP up to unnecessary heights (We are treating our own pulse, rather than the patient’s!)

Which crystalloid – well CSL, Ringer’s etc are good if you patient is acidotic.  See Emcrit’s Acid-base lectures on this.  Saline seems popular – but why? I don’t know, tradition?  It doesn’t make sense in terms of acidosis management – makes it worse not better!

Hypertonic saline (7.5% + dextran) is the new concept here – smaller volumes, and has been used extensively on the Mid-East battlefields.  Watch this space…

Blood products – packed red cells, FFP in my hospital  - these are the mainstay of volume resuscitation in severe trauma.  How to use them – well the Guidelines suggest a target of Hb = 70 – 90 g/L.  However if you are doing a “sympatholytic” resuscitation or “controlled volume / permissive hypotension” then you titrate the fluids to the BP – aiming for a MAP above 65.  Yes, I said 65, which is same as 75/60, or about 80 systolic for round numbers.  This seems low to those of us who trained in Anaesthesia, but that is what the evidence says!

How much?  Well – enough, and just that much – until you can get control of the bleeding source(s).  As above target is MAP > 65.  If you can measure other markers of preload eg. IVC collapse or SVV maybe you can titrate to those as well?  Not sure of the evidence here…

An important caveat to this:  if you have a head-injured or spinal cord patient – then you need a higher target SBP – you probably want to aim for triple figures here [100+]

Ratio of RBCs to FFP (+/- platelets)?  This is a tricky question.  The evidence for RBCs and FFP is much better than adding platelets into the mix, fortunately most small hospitals don’t keep platelets – so the decision to not use them is very easy!  Lots of retrospective, registry analysis of the RBC:FFP ratios has been done.   1:1 is popular, however the dust seems to settle with a ratio somewhere between 1:2 and 1:3 giving the best outcomes.  In the reality of rural practice you have already given at least 4 bags of red before the first FFP is thawed, so I aim for a 1:1 after the FFP is available – the ratio then eventually approaches 1:1 as you give more and more volume, and if you stop early then they probably were not as sick as you thought?  No evidence, just bloody-minded pragmatism.

Calcium has many jobs to do, and in bleeding it has a crucial role in: inotropy, coagulation factors and avoiding citrate toxicity in massive transfusion.

Calcium can be given as CaCl, or Ca-gluconate.  Basically the Ca++ in CaCl is immediately available, but harsh on the veins.  Ca-gluc is cleaved by the liver to release into the plasma ionised Ca++. In severe shock you might want to go with CaCL as hepatic metabolism might be impaired.

The goal is to get the ionised Ca++ level up to around 1.0 mmol/l, acidosis does reduce the available Ca+.

The evidence for the infusion of platelets is not as good as FFP. There are studies showing improved survival if the ratios infused were better than 1:5. In most small hospitals it is a non-argument – they are just too hard to store and not gonna get used frequently enough to justify the expense. If you are giving platelets the recommendation is to aim for a level of 50, or maybe 100 for the brain-injured.

These contain a variety of clotting factors – but importantly they are the only real source of fibrinogen in modern practice. (although FFP has fibrinogen also). This should be used if you show a low fibrinogen level.  This might be viable in small places – though does it add more than just giving more FFP?

PCC is a combo of the vit K dependent factors, protein C and S. It is stored for a good period and doesn’t need cross matching – so it is easy to use. It is expensive, but the in vivo testing(in animal models) shows it is effective for reversing coagulopathy of trauma – better than FFP in ‘mildly hypothermic pigs’.  Not just for those on warfarin. There is a theoretical risk of thrombotic events – so use some mechanical prophylaxis to prevent DVT.  There are a few small trials and reviews: Critical care, and Euro Journ Anaesthesiology.

I think this is viable in the smaller hospitals – easy to store, use and has effects.  I think I might pester the accounting department about this….

This is really controversial. rFVII is super- expensive and hasn’ really passed the evidence-in-practice test from what I can see. It seems to be down the bottom of all the algorithms, and hear this – you need to have all your ducks in a row before using it – make sure the other factors are all replenished, the big vessels are tied and your Ca, fibrinogen and pH are all sweet. For me this is likely not enough bang for my buck in a small centre.

This is not a drug for trauma. Full stop. If you have a bleeder with known vWF problem then you might talk to a Haematologist about it.

CRASH-2 was a huge trial that looked at IV tranexamic acid for trauma. And it showed a mortality benefit – only a small one though – ~ 1.5%.  It was safe though – so not much downside.  Did not reduce the volume of blood required – so may not help you in the instant…

Caveats – you have to use it early.  Get the initial bolus in ASAP then you have a slow 8 hour bag to run in at your leisure.  For me this is now something I do in my hospital – it is cheap and pretty easy.

Watch out for upcoming trials in obstetric bleeding – might be another string to our bow there too!

Sorry folks – it was a marathon of mostly my ramblings and I am asking you to take my word on all of that – but the evidence is not very clear in this field – there are many ways to “resuscitate an exsanguinating cat”.  I would love to hear your questions and comments – so I know if this is total gibberish or if you think it might apply to your place.  Hit me on the comments.

Casey

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Dr Le Cong – the Medical Blogshere’s most promiscuous lecturer

Filed Under: Emergency, Pearls and Pitfalls, Pharmacology, Psychiatry, Uncategorized, Useful Evidence by Casey Parker — 2 Comments
September 4, 2011

Dr Minh Le Cong (RFDS) is possibly the most promiscuous blogshere lecturer out there – he pops up on all the best sites!

After playing the field at Emcrit and LITFL, he is back on Broome Docs this week covering our favourite topic – Psych sedation and retrieval.  This is his presentation to the Australian Aeromedical Society at Burswood in Perth, Western Australia last week.

Minh has sent me the link for the download as it is a big file – too big for this little blog.  So if you need a dose of Minh / ketamine check out his lecture at:

https://rcpt.yousendit.com/1214000281/1d760fcd7988cbbb786f1c799a58272a

It takes a bit to download, but is well worth it.  Then if you haven’t read my recent case on the topic – check it out @ Livin’ the Ketamine dream.  Minh tells me it is the first ketamine-based transfer of psychosis in WA, and might be the shape of the future if you follow Minh’s data from Queensland.

Enjoy

Casey

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Clinical Case 024: Livin’ the ketamine dream

Filed Under: Anaesthetics, Clinical Cases, Emergency, Psychiatry, Useful Evidence by Casey Parker — 4 Comments
August 27, 2011

If you are new to Broome Docs, then you might have missed my mild obsession with Acute Psychiatric Sedation.  (GO back and read the posts from earlier 2011 to get the background and some tricky cases to ponder.)

Last night I had my first opportunity to put Dr Minh Le Cong’s secret weapon (ketamine) into action.  I had a large, schizophrenic patient who was very agitated and due to fly in an hour on the RFDS.  The patient had good going sleep-apnoea, a thick neck, big belly and a history of aspiration pneumonia during a previous sedation-gone-wrong.  This is one of those scenarios where you can make a bad situation worse without trying too hard.  So how did I manage this?

  1. Communication.  Get on the phone and make a plan with the flight crew.  We decided to try and avoid intubation if possible, this patient had a lot of co-morbidities and would not do well with a day or two on the blower.
  2. Team huddle.  Organise your own team, make it clear what the plan is and what plans B, C etc are.
  3. Move to the light => we moved the patient into the Resus area, fully monitoring (including ETCO2) and had the airway gear all ready to go
  4. Sedation.  Titrated sedation is the only way to go.  Give a dose and watch for a bit – chronic Psych patients have a wide range of tolerance to various drugs – so don’t just use a pre-formatted recipe – you have to give a bit and observe response, then repeat. As previously stated – I do not see why a Psych sedation should be done in a low-acuity area, where we would never do procedural sedation for a surgical problem.
  5. Change the plan if plan A is not great.  This patient got quite deep with 4 mg of midazolam and required a nasalpharygeal airway.  So I changed the plan – ketamine.  This worked well – RR went up a bit, patient  was tranquil and allowed us to site another IVC and an IDC with minimal fuss.
  6. Bedside vigil.   You need to be nearby to monitor this patient – you cannot give drugs and wander off to other areas.  I stayed around and actually went with the patient to the airstrip to ensure the plan was working.  Maybe once we are all more familiar with these agents in practice we can relax a bit, but for now I plan to keep my eye on them.

At the end of the night all was well. The patient was sedated, but rousable, moving herself on the stretcher.  Nobody got punched or spat upon.  The RFDS crew seemed happy and her numbers remained perfect throughout.

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A Bridge Over Troubled Waters – part 2.

Filed Under: Anaesthetics, Clinical Cases, Emergency, Psychiatry by Casey Parker — 1 Comment
July 17, 2011

Here is the gripping conclusion to the Extreme Psych transport that we heard about from Dr Minh in PArt 1 of “A Bridge Over Troubled Waters?”

It is fair to say that Dr Minh and I have similar but slightly differing views on this difficult and hazardous topic.  So here is Minh’s conclusion to the story and his appraoch on the transfer of agitated patients.

As always, Dr Minh’s references and talks are available at the bottom of the blog if you want to know more.  Enjoy – over to Minh….

 

Hi folks. This is the second and final instalment to this case. Where did we leave off? Dilemma? What to do with this involuntary psychiatric patient , intubated in a island hospital without any ICU facilities for the next 8+hours?

There are only two real options. Leave him intubated whilst awaiting retrieval. Or extubate him and observe his behavior whilst awaiting retrieval. It was decided after some discussion to leave him intubated with the GP anaesthetist and nurse in the hospital operating theatre. ALL NIGHT!

Some of my retrieval colleagues have argued that it is riskier to extubate an agitated patient and then try to reintubate again. I admit there is some truth in that but I believe the patient should be given the benefit of the doubt and be allowed a period of observation before embarking on the decision to use intubation and anaesthesia as a form of chemical restraint. The zero tolerance approach to risk in this patient group is inappropriate and violates the legal and ethical principle of least restrictive means that underpins all mental health acts of Australia.

The story gets more complicated. The intubated patient now develops hypotension from presumed sepsis secondary to suspected pulmonary aspiration syndrome. I am not fully aware of all the clinical details that lead to this diagnosis but the patient was commenced on an adrenaline infusion which did correct the hypotension. He was transferred by RFDS the next day but due to more delays not until late in the afternoon. In the end the saga ended the next day after 40 hours of intubation, when the ICU doctor extubated the patient who happily went off to the mental health unit albeit with a sore and hoarse voice having no signs of pulmonary aspiration at all!

Since this unfortunate episode this same patient has been retrieved again in pretty much the same situation. It happened only 3 weeks ago and I spoke to the same treating psychiatrist about how it all went down this time. The difference this time was that we deliberately avoided intubation from the outset as a method of restraint and oral sedation was emphasized at the beginning of the retrieval process. The retrieval team used IV ketamine sedation to good effect and he was happily dropped off to the Cairns Emergency Department as opposed to the ICU!

Primum non nocere, folks!

Dr Minh Le Cong, RFDS Qld

 

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A Bridge over Troubled waters?

Filed Under: Clinical Cases, Emergency, Pearls and Pitfalls, Pharmacology, Psychiatry by Casey Parker — 4 Comments
July 5, 2011

Hi All

As a special treat we have a case from Dr Minh Le Cong, my favorite flying doctor.

Minh is superkeen when it comes to all things involving Psych transfer and sedation.  Check out the research and resources he has shared in the links at hte bottom of the Blog.

Anyway, this week Minh has delivered his first installment on the topic – crazily complex logistics of getting a Psych patient out of the Torres Strait to Cairns.

Forget “planes, trains and automobiles” this is more like choppers, ferries and fixed-wings!  Minh describes the logistics of providing a safe “bridge over troubled waters” for these people in remote tropical far-north Queensland.  Proving he is the Art Garfunkel of Psych transfer….

Check out the link below to Minh’s case.  Enjoy, as always – comments welcome.

Casey

Extreme Psych Transfer

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Lessons Learned from TC George, Part II

Filed Under: Uncategorized by Casey Parker — Leave a comment
July 3, 2011

This is the  TC George evacuation, from the perspective of Dr Sebastian Rubinzstein-Dunlop, who was at the time my “Reg” at Karratha.  Seb has put together his recollections and learnings from the day.  Dr Seb has now returned to the NW after doing a few years of training in critical care and is a Broome Doc.

So, take it away Seb:

Going a few yrs back (2007), I was the PGY3 who joined you on the chopper going out to the mine site which was devastated by TC George.  I was super keen and super short on experience when it came to management of the critically ill patient let alone retrieval medicine.  On the day the cyclone hit I was a spare set of hands as my remote clinic had been cancelled.  In the genial nature of hospital management, it was decided that I was therefore to be the sole Dr going out to the devastated mine camp irrespective of my lack of experience…  Thankfully as my senior colleague, you saw the slight deficiencies of this plan and suggested that you should also attend the scene which was agreed to.
As you remember, it was a scene of utter devastation when we came in to land; it was as though the dongas (living quarters) had been thrown around like match boxes.  Whilst you and the nursing team triaged the scene, my main role became to transport patients into Port Hedland.
I took a lot away from the experience; a few that have stuck in my mind are summarised below.
1. B.I.G intraosseous instruments can fail.  We were struggling with IV access on a severely head injured patient and had to resort to I.O access.  Upon activating the BIG (as per the formal instructions) it jammed and then activated when I tried to unjam it whereupon it shot the metal needle across the room!!  In the end, I sterilised the needle somewhat with chlorhexidine and then used a hammer belonging to one of the workers to insert (hammer) it into the patient’s proximal tibia.  It worked but it certainly isn’t a technique I have considered using again!  In regards to I.O access, I have since used the I.O drill with good success and have steered clear of the B.I.G device.  I would be interested in other people’s comments.

2. Never put a syringe filled with an important drug in your pocket
I have never repeated this “newby” mistake again.  On one of the chopper flights with an intubated, ventilated head injured patient, my last dose of muscle relaxant was conveniently drawn up in a syringe in my pocket.  The patient was behaving beautifully on the oxylog until Port Hedland landing strip came into view whereupon he began to fight the ventilator.  When I reached for the Vecuronium I found a rather empty syringe and a very wet pocket..  So, my patient who had been stable during the entire flight was handed over in a less stable state which never looks good (“I swear, he was great until a few minutes ago…”).

3. Pre pack your IV cannulae packs
On the ground we struggled through the Parry packs to find the gear to put in IVC’s rapidly in multiple patients.  Since then I have prepacked small snaplock bags with; alco wipe, IVC x2 (16 + 18 G), bung, tape, 10ml NS, 10ml syringe).  We found the normal opsite dressings inadequate for securing cannulae in wet or diaphoretic patients and preferred large amounts of tape.

4.  We are ready to go!!
We were waiting on the ground in Karratha for what seemed like an eternity to get a formal go ahead from FESA to board the chopper and head out to the mine site.  Much of this time was not only due to the obvious need to ensure that the site was safe to approach but also negotiations about who was to go on the flight (medical, police, FESA volunteers) and how much equipment the chopper could take.  Without wanting to be too critical of what is obviously a very difficult situation to manage and coordinate, I still feel that it would have been very beneficial to do things differently.  My thought is that, once the scene was declared safe, a small contigent should have been sent out to rapidly assess the situation and what needed to be prioritised.  I think that this team should have been comprised of a senior police officer, a FESA representative, a Dr and a nurse.  This would have saved alot of critical time in the end.  I would be really interested to hear from those of you with more field experience in regards to this issue.

Please, feel free to comment on your experiences in similar situations.  Big thanks to Dr Seb R_D, always a lot of fun to work with and I learn a lot from his experience now!

Casey

Twitt
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Lessons Learned from TC George

Filed Under: Anaesthetics, Emergency, Pearls and Pitfalls, Specialist Tips by Casey Parker — 8 Comments
June 27, 2011

On Thursday 8th March 2007, Tropical Cyclone George crossed the coast just north of Port Hedland, it was a large, catgory 5 cyclone and it was unusual as it maintained its intensity for 100s of km inland where it struck Indee station and the Fortescue Metals Group Rail Village  (FMG RV1).  The destructive winds wreaked havoc in the work camp at RV1 and destroyed a number of the transportable “donga” units used to house the workers. The image below was taken from the helicopter as we approached the camp, the building in the foreground that has been flatttened was the Medical / First Aid post – so this created a unique logistical challenge!  See the story below. For more pics / maps see the BOM Site report into Cyclone George

I was actually the Night Shift Doc in Karratha the night TC George hit Hedland – we were on Yellow alert for the impending cyclone, and as is usual – it was quiet – cyclone protocol means a curfew for the locals – so it was a good night, plenty of sleep for all.   I arrived at the Karratha hospital for handover in the AM and there were a number of Admin-type staff wearing yellow vests – not a good sign.  We had been asked to form a team to fly into the camp and evacuate the injured in helicopters commandeered from the local gas company.  Time was critical – so we grabbed the Parry packs, all the pre-packed gear we have in store and headed off to the airport – 2 docs (myself and Dr Seb R-D – my registrar) and 3 nurses.  We were joined by a crew of volunteer SES workers, 2 policemen and the local St John’s ambo vollies.

The brief was vague – at least 1 dead, one critically head-injured and about 25 – 30 other injuries.  Port Hedland airport was out of action and RFDS could not land nearby.  We sat through a weirdly boring helicopter safety briefing whilst our brains turned over the possibilities!  Then there was a bit of argy-bargy with the Police and other agencies about who should go in and what gear we should take.  Interesting how people’s priorities are set by their perspective – one Police officer wanted to take a box of 50 body bags…mmmmm, maybe not a high priority!  After a bit of ‘negotiation’ we took off and saw just how much water a cyclone can dump – the desert looked like a swamp overnight!

About a mile out of the camp we could see the debris of buildings scattered over the desert.  Landing was a bit scary – still gusts up to 100 kph!  We landed a good 10 hours post impact so the workers had moved all the injured to – the cool rooms of the kitchen block – they were the strongest standing buildings!  There was not much lighting, the walls were damaged / off and the floor was wet. The Pilbara sun had come out and it was getting humid.  We were taken straight to the man with the head-injury, stepping over the other injured people.  For me, this was worrying – am I focusing on one at the expense of the other potentially bleeding patients?

The critical man had been struck in the head by debris and then been lucid, apparently helping other victims.  He then became drowsy and LOC.  He had a large temporal scalp injury and had been vomiting – blood in the airway.  Breathing but was gurgling secretions, no suction available.

At this point we decided to divide the team – triage the other patients whilst we tried to stabilize A, B and C in the critical man. This is the time where you just have to trust your team – one cannot do all, you need a team to divide and conquer.

I won’t bore you with the next 10 hours of what seemed like constant chaos at the time, but here are a few choice moments and lessons learned from working in an extreme environment with little resources.

Our patient had lots of blood in the airway and we had no good suction. As soon as you slide in the laryngoscope blade the bulb is coated in blood and all looks dark! My tip – have 3 or 4 laryngoscopes at hand and use the first few to find the landmarks, suck what you can then quickly replace the blade with a new, fresh one to light up the cords

My mate was struggling to get an IV in this patient – and I needed Sux to get the airway in. So we went for the intraosseous gun into the tibia. Unfortunately the gun didn’t go right through the cortex…Doh! So he asked for a hammer – being a mining camp, a large hairy man brought in a 2 foot sledge hammer! This has to go down as one of the more surreal moments in my career. There was Seb attempting to ‘tap’ in an IO needle with a massive tool. In retrospect we could have gone for the IM or SL injection. But it worked!

After tubing and stabilising the head-injured man we had a dilemma – we needed to get him out ASAP, but that would mean one of the team leaving and using precious resources before we really knew how bad the rest were. So as the senior Doc, I decided to send the more junior Doc out with the severe patient and stay behind to sort the rest. Don’t know if this was the right call, but we had to decide quick. Seb did a great job after a 2 minute tutorial in ventilating the head-injured patient. (Note: never keep the muscle relaxant in your top pocket.)

So the next challenge – sorting out 20 odd patients with a range of injuries / symptoms – all roughly as bad as one another, no obvious crashing patient. A bit tricky to allocate triage… We sorted them into – ‘spinal precautions’ vs. ‘walkers’ as a good number had mechanisms and symptoms that suggested spinal injury. We immobilised those with ?spinal injury and then triaged the others. More helicopters were incoming – so we had to decide who to send next.

Light – we take this for granted in our bright, white hospital environs. Having to work in the dim light of a commercial cool room was an eye-opener! Get the patients into a well lit area, this sounds obvious, but it takes some doing in the real world of a disaster. However, it makes all the other work so much easier. So many cues we take from visual information when clinical exam is all you have to go on in the field.

I wanted to get IV access into anyone who looked like they might have a risk of bleeding – just in case. However, puting 2 large-bore IVs into 20 people is not as easy as you might think, especially when you are crawling in the dark and have to jump over people to get to others. We ED docs take the IV trolley for-granted. It is really tricky to carry enough gear to do all this in quick time and safely dispose of the sharps. My Tip: pre-pack specimen bags with all the gear you need for 2 drips. Take it to the “bed”side and have a small sharp container in the other hand. This might sound obvious, but it took me an hour to figure it out!

So you have put in 40 IVs into 20 patients and you want to give fluids. You have no way of documenting or recording how much fluid each patient has received. So here is what you need: 1 magic marker. You just write a big “1″ on the first bag, then when you change the bags you write “2″ on the next bag…. This sounds simple, too simple for our huge doctor brains, it really beats trying to remember the ins and outs of 20 people! This trick is so simple I have taken it back to my ED / anaesthetic practice. When you are doing a big case, or a massive transfusion – it is gold, at a glance you can look and see where you are up to.

So how do 3 nurses keep an eye on 20 odd patients scattered around a wrecked building? They can’t – this is what I observed. I was keen to keep up frequent pulse / BP / RR etc on the injured, so that we might detect occult bleeds / shock etc early in the injured. But that takes serious manpower. So I thought we could enlist the help of the un-injured folk who were there trying to help. I line each patient up with a “buddy” and gave instructions to stay and feel the pulse, watch for new symptoms / distress – and let us know if anything changed. Sounds like a good idea? Maybe not. I think I underestimated the effect this trauma had on the workers. I think half an hour later and about 50% of the “buddies” ha all excused themselves – they were not coping

There was one chap – fit looking guy who was not in the original group of “patients”, he admitted to a few bangs and scrapes. He had a few episodes of syncope towards the middle of the day. I was sure he was probably bleeding or worse. We have him IV fluids and kept a close eye on him, flew him out on the next transport…. he turned out to have a coincidental chronic leukemia with a Hb in his boots. I certainly didn’t pick the anaemia clinically, and in the context wasn’t looking for it!

Of the serious blunt trauma – there was a chap with a left upper quadrant injury / left flail chest. To look at he had a crushed left lower rib-cage. I got to him and put in IVs, gave some morphine for pain, and got a quick medical history. This guy was lucky – he had had his spleen removed a year prior for what sounded like a low platelet count. I could have kissed him – I was sure he was gonna have a splenic injury when I saw his chest, he did well from a lung point-of-view.

So after working solid for a few hours in a hot, sweaty, stressful situation we all get a headache, and a burning desire to pee. Not sure about you , but I don’t think straight with a full bladder and moderate dehydration. If you are in this scenario – pee and drink – you have to do it. I think I kept putting it off for paranoid ideas that I would leave for a minute and something bad would happen!

One woman was killed prior to our arrival, she was crushed by a building. Once the dust had settled on the injured, I was asked to certify her death by the Police in attendance. I was surprised as to how meaningful this act was to the other survivors. Not sure if it gave some “finality” to the other victims or in some way validated the grief they were feeling. The disaster courses always talk about resource allocation – don’t waste time on the unsalvageable – but I think there is a place for this once the situation is under some control. No evidence for this as usual, just my gut-feeling

So those are my “pearls” from TC George.  I would love to hear what you have to say, and hear your war stories and what they have taught you.   Dr Seb R-D has returned to be my Reg once again and I will be posting his lessons from this day soon.

Back to Sepsis soon

Casey

Twitt
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Clinical Case 015: Septic Surprise

Filed Under: Clinical Cases, Emergency, General Practice, Internal Medicine, Obstetrics by Casey Parker — 7 Comments
June 17, 2011

I have been busy learning all this week, so not much new material.  Fortunately Dr Ray Gadd out of Qld has sent me a ripper case of sepsis for you to mull and consider.    I know Ray is a keen Broome Docs reader – so let him know what your thoughts are on this case via the Comments area, we all learn from shared ideas!  I love this case because it is a true representation of the resources available to us in remote communities.  The case is definitely not “textbook” – but it is real!

Today’s case is food for thought, I will use it as a basis for some upcoming posts on Sepsis.  Over the coming weeks I hope to put together some Sepsis Resources which I reckon can make the diagnosis and management of sepsis in small / remote hospitals much easier and bring the standard of care for these super-sick patients up to a similar level they would get in any tertiary ED.

So – without further ado – Here is Ray’s case :  Septic Surprise (Apologies it is in PowerPoint – takes a bit to download)

Twitt
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