Fire-EMS Brain Training

Continuing discussion of patient who crash, this time discussing acute changes in mental status. Happy Holidays! JY

Discussion of the rest of the abdominal organs, spine, and pelvis. Also a short discussion of what doctors can do at scenes to help expedite care once the patient reaches the hospital. Thanks.

This is a primer on Traumatology starting with pre-hospital and moving through the small intestine (no pun intended). At the beginning and the end is a recording I found of when I played baritone sax with the McDonald’s Tri-State Jazz Ensemble in 1979. Not bad for a bunch of high school kids. JY

I discuss a typical severe GSW to the abdomen and chest. This is part 1 describing the actions during the initial surgery where damage control is necessary. Part 2 next week will describe what to do during the second operation. I have also put in my thoughts about the priorities for these patients in the pre-hospital setting.  Also a tune from the CD I made with Tom Jolly in the 90's. Thanks for listening. JY

I discuss the evaluation and treatment of patients who present with hyperurgent head injuries (blown pupil) and hyperurgent abdominal injuries (positive FAST and hypotension). We'll go over my decision tree and algorithm for treatment. This will help pre-hospital providers understand the urgency in these patients and the need for rapid transport.  Thanks for listening. JY

We discuss hypotension and shock. Recognition, therapy, decision making, and some new developments in fluids and goals of resuscitation. A little original music I wrote for my daughters at the beginning and end. Thanks for listening. JY.

Discussion of causes, signs, symptoms, and treatments of sepsis and septic shock for the pre-hospital and hospital provider. A little original gospel sax at the beginning and end. Hope you find it useful. JY

A discussion of when to call for help, and how to respond. Also, what we need to do in medicine to better define our core competencies and abilities. A little of my sax playing at the beginning and end. Be safe, JY

A discussion of using war games and cognitive simulation to better prepare you and your team for new situations. Also a discussion of active shooter MCI and the importance of communication with the hospital in these situations.

I'm a great believer in scenario training for pre-assessments and for release assessments. Here are some tips for getting the most out of the sessions and when you encounter a subject who is having problems.

Podcast with guest Assistant Chief Bob Brown from Albemarle County Fire Rescue going over the response to a MVC MCI.

Tactical thinking Can the air get into the trachea? Can the air in the trachea get into the lungs? Do the lungs work? Can the air get in? Open the airway Use an adjunct to open the airway Oral, nasal, fingers if necessary Obstructions Suction Get large objects out, but be careful not to push them farther in (dont blindly sweep) Hold large tissue defects open to allow air passage Remember the tongue is the most likely item to obstruct Bag mask technique Remember do not push the mask down on the face causing the tongue to obstruct Try not to blow vomit into the airway, if you hear noisy respirations you need to suction, or might need to get a definitive airway Can the air get from the trachea into the lungs? Problems Large obstructions Mucus plugs, blood, teeth Transections of trachea Huge neck SQ emphysema When ventilating neck looks like its expanding with each breath Air comes back out of mouth with each ventilation Perforation of trachea with airway device Mass in neck Symptoms of tracheal transection Must get airway, less important to treat perforation If you can maneuver tube past perforation, do that, and we'll worry about perforation later. Do whatever you need to do to get airway, most things can be fixed Do the lungs work? Massive aspiration Unable to get sats up despite good airway (color change, see tube pass through cords) Very important - in hyperurgent situation, if all data looks like tube is in, do not pull it out until you have ruled out other things. You may not get that airway back. Pneumothorax Dart chest, or chest tube Remember need to keep path open or with positive pressure pneumo will reaccumulate quickly Hemothorax Not much can be done pre-hospital Hemothorax should not cause tension situation Other lung should function normally Darting will not help Only chest tube will help Airway Should be prepared for surgical airway at every intubation I have seen normal intubations turn into catastrophes that requires surgical intervention - you can not predict when it will happen... At the least, someone should have their hand on a Knife Tube Tracheal hook (or crich kit) When the sats are dropping, you do not want to be tearing apart bags, or sending people back to the unit to get equipment Better idea - if you have time, get the airway in the back of the unit Lighting Better bed height Better suction Can run if you need to In my opinion, you should try to do EVERYTHING in the back of the ambulance (you are one step closer to the hospital if things go south) Crich (you dont do traches in the field) Make sure you find the cricothyroid membrane It is VERY easy to think you are in the right place when you are not In some patients it is higher that it looks, in some lower Procedure Find thyroid cartilage FIRST (gull winged cartilage) Move down until you feel first tracheal ring (will usually be prominent) then slide finger up and in to space between first tracheal ring and thyroid cartilage In some people, this space may be small, but it can be widened. Tube If you dont have a tracheostomy tube, use an ETT The ETT should be one entire size smaller than you would use endotracheally In the average adult, I will use a 6.0 ETT for a crich It is better to get a smaller tube in than be unable to get a bigger tube in You can usually vent through anything down to a 4-4.5 tube in an adult, and even then you will probably do fine with pO2, the pCO2 may rise but who cares, its short term. I recommend an NG tube as a guidewire if you are not using a crich kit You need to know which NG tube you need and it should be readily available, or taped to the ETT or trache It is OK to have one too small (a 12F will usually work)

This is the first episode in the series taking the listener from the 911 call all the way to definitive treatment in the hospital. This podcast concerns a cardiac patient and looks at things from the EMS perspective. Guest: Battalion Chief Chip Walker, Albemarle County Fire Rescue. Thanks for listening.