All posts by TheTraumaPro

Prehospital Lift-Assist Calls

Here’s something I was completely unaware of until just a few years ago. A number of 9-1-1 calls (quite a few, I am told) are made, not for injury or illness, but because the caller needs help getting back into bed, chair, etc. It is also common that prehospital providers are frequently called back to the same location for the same problem, or a more serious one, within hours or days.

Yet another study from Yale looked at the details of lift-assist calls in one city in Connecticut (population 29,000) during a 6 year period. The town has a fire department based EMS system with both basic and advanced life support, and they respond to 4,000 EMS calls per year.

Here are the factoids:

  • Average crew time was about 20 minutes
  • 10% of cases required additional fire department equipment, either for forced entry or for assistance with bariatric patients
  • About 5% of all calls were for lift-assist, involving 535 addresses
  • Two thirds of all calls went to one third of those addresses (174 addresses)
  • There were 563 return calls to the same address within 30 days (usual age ~ 80)
  • Return calls were for another lift-assist (39%), a fall (8%), or an illness (47%)

Bottom line: It looks to me that we are not doing our elderly patients any favors by picking them up and putting them back in their chair/bed. Lift-assist calls are really a sentinel event for someone that is getting sick or who has crossed the threshold from being able to live independently to someone who needs a little more help (assisted living, etc). Prehospital personnel should systematically look at and report the home environment, and communities should automatically involve social services to help ensure the health and well being of the elder. And a second call to the same location should mandate a medical evaluation in an ED before return to the home.

Reference: A descriptive study of the “lift-assist” call. Prehospital Emergency Care 17(1):51-56, 2013.

The Lucas CPR Device And Pregnancy

A reader posed an interesting question last week: can you use the Lucas chest compression device in a pregnant patient?

The official company answer is “no.” Obviously, this is one those areas that is tough to get research approval on, and the number of pregnant patients who might need it is very small. So basically, we have little experience to go on.

That being said, the reality is that prehospital agencies can and do use it for these patients on occasion. There is only one published case report that I could find (see reference below). The thing that makes using this device a little more challenging is that, to optimize blood pressure, late term pregnant patients need to have the uterus rolled off of the vena cava. This means tipping the patient to her left. 

As you can see from the picture above, the design of the Lucas makes this a bit difficult. However, it can be done, either by tipping the board the patient is on or wedging something under the right side of the back plate.

And as always, make sure that you adhere to your local policies and procedures, or have permission from your medical director to use this device in this particular situation.

Reference: Cardiac arrest and resuscitation with an automatic mechanical chest compression device (LUCAS) due to anaphylaxis of a woman receiving caesarean section because of pre-eclampsia. Resuscitation 68(1):155-159, 2005.

Autotransfusing Blood Lost Through The Chest Tube

Autotransfusing blood that has been shed from the chest tube is an easy way to resuscitate trauma patients with significant hemorrhage from the chest. Plus, it’s usually not contaminated from bowel injury and it doesn’t need any fancy equipment to prepare it for infusion.

It looks like fresh whole blood in the collection system. But is it? A prospective study of 22 patients was carried out to answer this question. A blood sample from the collection system of trauma patients with more than 50 cc of blood loss in 4 hours was analyzed for hematology, electrolyte and coagulation profiles.

Here are the factoids:

  • The hemoglobin and hematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable

Bottom line: Although shed blood from the chest looks like whole blood, it’s missing key coagulation factors and will not clot. Reinfusing it will boost oxygen carrying capacity, but it won’t help with clotting. You may use it as part of your massive transfusion protocol, but don’t forget to give plasma and platelets according to protocol. This also explains why you don’t need to add an anticoagulant to the autotransfusion unit prior to collecting or giving the shed blood!

Related post: Chest tubes and autotransfusion

Reference: Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011.

How To See The Unseeable: The Answer

Yesterday I posed a scenario where the surgeon needed to see an area of an open abdomen (trauma laparotomy) that could not easily be visualized. Specifically, there was a question as to whether the diaphragm had been violated just anterior to the liver, just under the costal margin.

Short of putting your head in the wound, how can you visualize this area? Or some other hard to reach spot? Well, you could have an assistant insert a retractor and pull like crazy. However, the rib cage might not bend very well, and in elderly patients it may break. Not a good idea.

Some readers suggested breaking out the laparoscopy equipment and using the camera and optics to visualize. This is a reasonable idea, but expensive. Shouldn’t there be some good (and cheap) way to do this?

Of course, and there is. Think low tech. Very low tech. You just need to see around a corner, right. So get a mirror!

Every OR has some sterile dental mirrors lying around. Get one and have your assistant gently hold the liver down while you indirectly examine the diaphragm. Since you’re probably not a dentist, it may take a minute or two to get used to manipulating the mirror to see just what you want. But if you can manage laparoscopic surgery, you’ll get the hang of it quickly.

And if you need more light up in those nooks and crannies? Shine the OR light directly into the abdomen, then place a nice shiny malleable retractor into the area to reflect light into the area in questions. Voila!

Bottom line: A lot of the things that trauma professionals need to do in the heat of the moment will not be found in doctor, nurse, or paramedic books. Be creative. Look at the stuff around you and available to you. Figure out a way to make it work, and make $#!+ up if necessary.