Implementing Tourniquet Conversion Guidelines for Civilian EMS and Prehospital Organizations : A Case Report and Review.

Since the first documented use of a tourniquet in 1674, the popularity of tourniquets has waxed and waned. During recent wars and more recently in Emergency Medical Services systems, the tourniquet has been proven to be a valuable tool in the treatment of life-threatening hemorrhage. However, tourniquet use is not without risk, and several studies have demonstrated adverse events and morbidity associated with tourniquet use in the prehospital setting, particularly when left in place for more than 2 h. Consequently, the US military's Committee on Tactical Combat Casualty Care has recommended guidelines for prehospital tourniquet conversion to reduce the risk of adverse events associated with tourniquets once the initial hemorrhage has been controlled. Emergency Medical Services systems that operate in rural, frontier, and austere environments, especially those with transport times to definitive care that routinely exceed 2 h, may consider implementing similar tourniquet conversion guidelines.

Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport.

OBJECTIVE: Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit. METHODS: This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist. RESULTS: Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation. CONCLUSION: The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.

Takotsubo Cardiomyopathy Syndrome in Critical Care Transport: A Case and Critical Review.

Takotsubo cardiomyopathy syndrome, or simply takotsubo syndrome (TTS), is a form of stress cardiomyopathy thought to be caused by excess catecholamines in association with physical or emotional stress. Providers should maintain a high index of suspicion for TTS in patients with symptoms of acute coronary syndrome, acute decompensated heart failure, substernal chest pain, or dyspnea. However, TTS is a diagnosis of exclusion, and patients should initially be evaluated and treated for other causes, such as acute myocardial infarction. Critical care transport crews may encounter patients with TTS during their primary presentation, before diagnosis, or after the formal diagnosis is made in the catheterization laboratory. Therefore, crews should be familiar with unique aspects of the pathophysiology, diagnosis, and management of TTS. This article presents a case and provides a critical review of TTS for critical care transport clinicians.

Management of Postpartum Hemorrhage in Critical Care Transport.

Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.

Management of Hantavirus Cardiopulmonary Syndrome in Critical Care Transport: A Review.

In 1993, the Southwest found itself staring down a disease then known as "unexplained adult respiratory syndrome." During the outbreak, 12 of 23 known patients died. What we now recognize as hantavirus cardiopulmonary syndrome still remains a rare and deadly disease. Although no cure exists, modern supportive techniques such as extracorporeal membrane oxygenation have increased survival among these patients. Early diagnosis has become the primary factor in patient survival. The initial presentation of hantavirus is similar to acute respiratory distress syndrome, necessitating a high index of suspicion to afford the patient the best chance of survival. Diagnosis is further complicated by prolonged and nonspecific incubation periods making it difficult to pinpoint an exposure. Familiarizing oneself with common clinical presentations, diagnostic strategies, and testing is the best way to increase patient survival. Because hantavirus has a predilection for rural areas, transport to a tertiary facility is paramount to provide the resources necessary to care for these complex patients. Rapid sequence intubation, although common in airway-compromised patients, could prove fatal in the setting of the severe hemodynamic instability found in hantavirus cardiopulmonary syndrome. Anticipation of significant pressor use and fluid administration could likely mean the difference in patient mortality during transport.

Management of Acute Upper Gastrointestinal Bleeding in Critical Care Transport.

Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients. In addition, we present a novel method of continuous balloon pressure monitoring of balloon tamponade devices that is applicable to the transport environment.

Initiation of Invasive Arterial Pressure Monitoring by Critical Care Transport Crews.

Noninvasive blood pressure monitoring is convenient in the prehospital setting, but its use in the critically ill patient should be carefully considered given documented inaccuracies. Countless therapeutic patient interventions are based on blood pressure parameters, and the prehospital paramedic, nurse, and physician should strongly consider the use of invasive blood pressure monitoring, especially during critical care transport. Radial artery cannulation for arterial blood pressure monitoring is a safe and effective procedure that can reasonably be performed in the prehospital setting by both physicians and nonphysicians. Critical care transport teams should consider clinical guidelines that outline indications and training to safely implement this as a clinical skill.

Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport.

Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.

Compliance and Attitudes of Critical Care Transport Providers Regarding a Prehospital Rapid Sequence Intubation Checklist.

Human factors engineering innovations, such as checklists, have been adopted in various acute care settings to improve safety with reasonable compliance and acceptance. In the air medical industry, checklists have been implemented by different teams for critical clinical procedures such as rapid sequence intubation. However, compliance and attitudes toward these human factors engineering innovations in the critical care transport setting are not well described. In this institutional review board-exempt, retrospective review of checklist usage, we assessed rapid sequence intubation checklist compliance and surveyed providers with 5 questions based on Rogers' theory of diffusion of innovation to examine why or why not there was compliance. Our results indicated that compliance with checklist implementation was excellent. The survey questions were consistent with process improvement factors that enhance the spread and acceptance of innovation.

FINGER: A Novel Approach to Teaching Simple Thoracostomy.

For decades, most prehospital clinicians have only been armed with needle thoracostomy to treat a tension pneumothorax, which has a significant failure rate. Following recent changes by the US military, more ground and air transport agencies are adopting simple thoracostomy, also commonly referred to as finger thoracostomy, as a successful alternative. However, surgical procedures performed by prehospital clinicians remain uncommon, intimidating, and challenging. Therefore, it is imperative to adopt a training strategy that is comprehensive, concise, and memorable to best reduce cognitive load on clinicians while in a high-acuity, low-frequency situation. We suggest the following mnemonic to aid in learning and retention of the key procedural steps: FINGER (Find landmarks; Inject lidocaine/pain medicine; No infection allowed; Generous incision; Enter pleural space; Reach in with finger, sweep, reassess). This teaching aid may help develop and maintain competence in the simple thoracostomy procedure, leading to successful treatment of both a tension pneumothorax and hemothorax.

Impella in Transport: Physiology, Mechanics, Complications, and Transport Considerations.

Cardiogenic shock (CS) represents a spectrum of hemodynamic deficits in which the cardiac output is insufficient to provide adequate tissue perfusion. The Impella (Abiomed Inc, Danvers, MA) device, a contemporary percutaneous ventricular support, is most often indicated for classic, deteriorating, and extremis Society for Coronary Angiography and Intervention stages of CS, which describe CS that is not responsive to optimal medical management and conventional treatment measures. Impella devices are an evolving field of mechanical support that is used with increasing frequency. Critical care transport medicine crews are required to transport patient support by the Impella device with increasing frequency. It is important that critical care transport medicine crews are familiar with the Impella device and are able to troubleshoot complications that may arise in the transport environment. This article reviews many aspects of the Impella device critical to the transport of this complex patient population.

Accuracy and Reliability of a Disposable Vascular Pressure Device for Arterial Pressure Monitoring in Critical Care Transport.

OBJECTIVE: Arterial catheterization is a commonly performed procedure in intensive care units to guide the management of critically ill patients who require precise hemodynamic monitoring; however, this technology is not always available in the transport setting because of cumbersome and expensive equipment requirements. We compared the accuracy and reliability of a disposable vascular pressure device (DVPD) with the gold standard (ie, the transducer pressure bag invasive arterial monitoring system) used in intensive care units to determine if the DVPD can be reliably used in place of the traditional pressure transducer setup. METHODS: This study was a single-center, prospective, observational study performed in the adult intensive care unit of a large academic university hospital. A convenience cohort of hemodynamically stable, adult critically ill patients with femoral, brachial, or radial arterial catheters was recruited for this study. The Compass pressure device (Centurion Medical Products, Williamston, MI) is a disposable vascular pressure-sensing device used to assure venous access versus inadvertent arterial access during central line placement. The DVPD was attached to an in situ arterial catheter and measures the mean intravascular pressure via an embedded sensor and displays the pressure via the integrated LCD screen. Using a 3-way stopcock, the DVPD was compared with the standard arterial setup. We compared the mean arterial pressure (MAP) in the standard setup with the DVPD using Bland-Altman plots and methods that accounted for repeated measures in the same subject. RESULTS: Data were collected on 14 of the 15 subjects enrolled. Five measurements were obtained on each patient comparing the DVPD with the standard arterial setup at 1-minute intervals over the course of 5 minutes. A total of 70 observations were made. Among the 15 subjects, most (10 [67%]) were radial or brachial sites. The average MAP scores and standard deviation values obtained by the standard setup were 83.5 mm Hg (14.8) and 81.1 mm Hg (19.3) using the DVPD. Just over half (51.4%) of the measurements were within a ± 5-mm Hg difference. Using Bland-Altman plotting methods, standard arterial measurements were 2.4 mm Hg higher (95% confidence interval, 0.60-4.1) than with the DVPD. Differences between the 2 devices varied significantly across MAP values. The standard arterial line measurements were significantly higher than the DVPD at low MAP values, whereas the DVPD measurements were significantly higher than the standard arterial line at high MAP values. CONCLUSION: The DVPD provides a reasonable estimate of MAP and may be suitable for arterial pressure monitoring in settings where standard monitoring setups are not available. The DVPD appears to provide "worst-case" values because it underestimates low arterial blood pressure and overestimates high arterial blood pressure. Future trials should investigate the DVPD under different physiological conditions (eg, hypotensive patients, patients with ventricular assist devices, and patients on extracorporeal membrane oxygenation), different patient populations (such as pediatric patients), and in different environments (prehospital, air medical transport, and austere locations).

Force of Habit: Developing Situation Awareness in Critical Care Transport.

Situation awareness (SA) is a vital cognitive skill for high-stakes, high-hazard occupations, including military, aviation, and health care. The ability to maintain SA can deteriorate in stressful situations, exposing patients to dangerous errors. The literature regarding how to best teach SA techniques is sparse. This article explores specific techniques to promote and maintain SA in dynamic clinical environments using principles derived from cognitive psychology, neuroscience, and human behavioral and organizational research. The authors propose strategies to help individuals and teams to develop ingrained, subconscious behaviors that can help to maintain effective SA in high-stress environments. Situation awareness (SA) is critical in high-stakes circumstances, such as the resuscitation of critically ill or injured patients. Exploratory research in psychology, neuroscience, human factors engineering, and to a lesser extent health care has led to a deeper understanding of what SA is and how it can be measured. Unfortunately, little is known about how we can adapt training in order to more consistently create behaviors that heighten SA during dynamic, high-stakes clinical events. In this article, the prevailing theory of SA is reviewed, and the evidence for evaluating it in medicine is presented. In addition, the authors draw from the fields of neuroscience and cognitive psychology to suggest some strategies that can develop effective behaviors that promote SA in resuscitation.

Psychological Skills to Improve Emergency Care Providers' Performance Under Stress.

Stress experienced by emergency medical providers during the resuscitation of critically ill or injured patients can cause cognitive and technical performance to deteriorate. Psychological skills training offers a reasonable and easily implemented solution to this problem. In this article, a specific set of 4 performance-enhancing psychological skills is introduced: breathe, talk, see, and focus. These skills comprise breathing techniques, positive self-talk, visualization or mental practice, and implementing a focus "trigger word." The evidence supporting these concepts in various domains is reviewed and specific methods for adapting them to the environment of resuscitation and emergency medicine are provided.

The 5 T's: Applying Cognitive Science to Improve Prehospital Medical Education.

Although research on effective teaching methods exists, the application of this information in prehospital medical education is limited. Applying lessons from the realms of cognitive psychology and neuroscience, prehospital educators can enhance their ability to teach. One such concept is the theory of cognitive load. Understanding this theory can reduce the mental strain placed on learners and allow educators to best accomplish long-term learning success, defined as "far transfer" of material to novel contexts. Thus, we propose 5 concise strategies gleaned from cognitive science literature: Tell a story, Time, Technical elements, Think novelly, and Testing and recall (referred to as the "5 T's"). Each strategy is grounded in research and applicable to medical education. Increased educator awareness and use of these strategies garners the potential to transform prehospital medical education.

The Effect of Critical Task Auto-failure Criteria on Medical Evaluation Methods in the Pararescue Schoolhouse.

BACKGROUND: Medical training and evaluation are important for mission readiness in the pararescue career field. Because evaluation methods are not standardized, evaluation methods must align with training objectives. We propose an alternative evaluation method and discuss relevant factors when designing military medical evaluation metrics. METHODS: We compared two evaluation methods, the traditional checklist (TC) method used in the pararescue apprentice course and an alternative weighted checklist (AWC) method like that used at the U.S. Army static line jumpmaster course. The AWC allows up to two minor errors, while critical task errors result in autofailure. We recorded 168 medical scenarios during two Apprentice course classes and retroactively compared the two evaluation methods. RESULTS: Despite the possibility of auto-failure with the AWC, there was no significant difference between the two evaluation methods, and both showed similar overall pass rates (TC=50% pass, AWC=48.8% pass, p=.41). The two evaluation methods yielded the same result for 147 out of 168 scenarios (87.5%). CONCLUSIONS: The AWC method strongly emphasizes critical tasks without significantly increasing failures. It may provide additional benefits by being more closely aligned with our training objectives while providing quantifiable data for a longitudinal review of student performance.

Motion compensated cone-beam CT reconstruction using ana priorimotion model from CT simulation: a pilot study.

Objective. To combat the motion artifacts present in traditional 4D-CBCT reconstruction, an iterative technique known as the motion-compensated simultaneous algebraic reconstruction technique (MC-SART) was previously developed. MC-SART employs a 4D-CBCT reconstruction to obtain an initial model, which suffers from a lack of sufficient projections in each bin. The purpose of this study is to demonstrate the feasibility of introducing a motion model acquired during CT simulation to MC-SART, coined model-based CBCT (MB-CBCT).Approach. For each of 5 patients, we acquired 5DCTs during simulation and pre-treatment CBCTs with a simultaneous breathing surrogate. We cross-calibrated the 5DCT and CBCT breathing waveforms by matching the diaphragms and employed the 5DCT motion model parameters for MC-SART. We introduced the Amplitude Reassignment Motion Modeling technique, which measures the ability of the model to control diaphragm sharpness by reassigning projection amplitudes with varying resolution. We evaluated the sharpness of tumors and compared them between MB-CBCT and 4D-CBCT. We quantified sharpness by fitting an error function across anatomical boundaries. Furthermore, we compared our MB-CBCT approach to the traditional MC-SART approach. We evaluated MB-CBCT's robustness over time by reconstructing multiple fractions for each patient and measuring consistency in tumor centroid locations between 4D-CBCT and MB-CBCT.Main results. We found that the diaphragm sharpness rose consistently with increasing amplitude resolution for 4/5 patients. We observed consistently high image quality across multiple fractions, and observed stable tumor centroids with an average 0.74 ± 0.31 mm difference between the 4D-CBCT and MB-CBCT. Overall, vast improvements over 3D-CBCT and 4D-CBCT were demonstrated by our MB-CBCT technique in terms of both diaphragm sharpness and overall image quality.Significance. This work is an important extension of the MC-SART technique. We demonstrated the ability ofa priori5DCT models to provide motion compensation for CBCT reconstruction. We showed improvements in image quality over both 4D-CBCT and the traditional MC-SART approach.

Emergency Reflex Action Drills and the Problem with Stress.

Clinicians involved in the care of critically ill patients are often exposed to demanding and stressful situations that require immediate action. Evidence suggests that human performance can be significantly diminished when multiple stressors and stimuli are present. Humans have developed conscious and unconscious methods of dealing with this type of cognitive overload in various high-risk occupations, but these coping methods have not necessarily been structured and adapted to the provision of emergency medical care. Emergency reflex action drills (ERADs) are derived from available evidence in specific domains (e.g., airway management) and develop automaticity of critical skills which engender quick, effective, and reproducible performance with minimal cognitive load. These are pre-planned, practiced responses to specific, high-demand and time-sensitive situations. This article outlines the psychological, cognitive, and behavioral effects of stress that affect performance and necessitate development of ERADs. It also reviews the scientific underpinnings behind how humans have adapted cognitive behavioral techniques to manage under high-stress situations. Finally, this article recommends the adoption of these cognitive tactics via ERADs to enhance clinical practice and provides an example in the context of airway management.

Effectiveness of and Adherence to Triage Algorithms During Prehospital Response to Mass Casualty Incidents.

Mass casualty incidents (MCIs) can rapidly exhaust available resources and demand the prioritization of medical response efforts and materials. Principles of triage (i.e., sorting) from the 18th century have evolved into a number of modern-day triage algorithms designed to systematically train responders managing these chaotic events. We reviewed reports and studies of MCIs to determine the use and efficacy of triage algorithms. Despite efforts to standardize MCI responses and improve the triage process, studies and recent experience demonstrate that these methods have limited accuracy and are infrequently used.

An analysis of the regional heterogeneity in tissue elasticity in lung cancer patients with COPD.

Purpose: Recent advancements in obtaining image-based biomarkers from CT images have enabled lung function characterization, which could aid in lung interventional planning. However, the regional heterogeneity in these biomarkers has not been well documented, yet it is critical to several procedures for lung cancer and COPD. The purpose of this paper is to analyze the interlobar and intralobar heterogeneity of tissue elasticity and study their relationship with COPD severity. Methods: We retrospectively analyzed a set of 23 lung cancer patients for this study, 14 of whom had COPD. For each patient, we employed a 5DCT scanning protocol to obtain end-exhalation and end-inhalation images and semi-automatically segmented the lobes. We calculated tissue elasticity using a biomechanical property estimation model. To obtain a measure of lobar elasticity, we calculated the mean of the voxel-wise elasticity values within each lobe. To analyze interlobar heterogeneity, we defined an index that represented the properties of the least elastic lobe as compared to the rest of the lobes, termed the Elasticity Heterogeneity Index (EHI). An index of 0 indicated total homogeneity, and higher indices indicated higher heterogeneity. Additionally, we measured intralobar heterogeneity by calculating the coefficient of variation of elasticity within each lobe. Results: The mean EHI was 0.223 ± 0.183. The mean coefficient of variation of the elasticity distributions was 51.1% ± 16.6%. For mild COPD patients, the interlobar heterogeneity was low compared to the other categories. For moderate-to-severe COPD patients, the interlobar and intralobar heterogeneities were highest, showing significant differences from the other groups. Conclusion: We observed a high level of lung tissue heterogeneity to occur between and within the lobes in all COPD severity cases, especially in moderate-to-severe cases. Heterogeneity results demonstrate the value of a regional, function-guided approach like elasticity for procedures such as surgical decision making and treatment planning.