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Now displaying: October, 2019
Oct 12, 2019

This episode is a wrap up covering the highlights from the Tactical Trauma international conference on pre-hospital critical care and trauma. This conference emphasizes tactical medicine, with a panel of experts speaking throughout the 2 days.

0:10 – Introduction to day 2 wrap up

0:40 – Introduction of the panel

1:15 – Mike Abernethy wraps up his session as a moderator on Day 2. Takeaways include Michael Lauria’s discussion on the preoccupation with protocols and guidelines.

2:45 – Three basic concepts include speed, simplicity, and coordination of care. Tactical medicine boils down to how efficiently one can perform these three tasks using evidence based medicine. Take the lessons learned from the military medicine, and a lot of them can be applied to civilian EMS and in-hospital care.

5:30 – One thing to add, is being able to do the basics very well. These basic skills will lay the foundation for new advanced technologies and interventions.

7:00 – Discussion on Mike Klumpner’s talk on medical best practices at MCI’s. The phrase “Just because you can, doesn’t mean you should” is discussed among the panel members. Being able to look at these mass casualty events, their injuries, and intervention with simplistically is the key. An example here includes an anecdote regarding a vascular neck injury, and the ability to ask “Am I making a difference, or am I delaying definitive care?”

9:30 – The panel discusses the criticism of triage in an MCI setting during day 2. One example given is that during most MCI’s, the triage tags were not used including the Boston Marathon bombing, where triage had to ‘go out the door’. Another example is the way the walking wounded are huddled into a corner and sometimes forgotten, while they may be gravely injured as evidenced in the Manchester bombing.

11:40 – FDNY’s new triage protocols include any penetrating injuries between the clavicle and the pelvis are immediate red tags.

12:15 – Breakout sessions with LEO’s who discussed the medical care of the K9’s.

13:30 – The point on situational awareness with the K9 colleagues is discussed. This includes muzzling them early if gravely injured and in danger.

13:45 – Anesthesiology talks about how dogs have a fenestrated chest cavity, and its importance with a tension pneumothorax. The end result is that the resulting obstructive shock may be worse in dogs.

15:00 – Ketamine takes a hit when it comes to pain control with K9’s for multiple physiologic reasons. Morphine IM 30-50mg was preferred for K9 pain control.

15:35 – Currently, it is a felony in the USA to provide ALS to animals if you are not a veterinarian. Propositions for exclusions for EMS workers trained in animal care are in the works right now. One anecdote is during a NC MCI, kid pools were filled with ice for the explosives K9’s, drawing a parallel to firefighter rehabilitation.

18:05 – Psychosocial aspects when providing medical care is discussed along with PTSD learning points. While feelings of anger and hostility towards your patient may be natural, providers must be able to accept that and continue to give medical care.

19:35 – Learning points in PTSD. One interesting finding was that those with minor injuries who received early intervention developed worse PTSD when compared to those with severe or no injuries. This raises questions on mandatory Critical Incident Stress Management, and how it should always be voluntary.

21:05 – Best practices after tough calls in EMS. Debriefing, assessing for safety, and assuring readiness for the next job are the top priorities. Being able to spend time with your colleagues, who have been through similar experiences versus mandatory CISM is discussed as well.

23:15 – The longer people stay in lockdown during MCI’s, the more likely they are to develop PTSD. Data coming out is showing that school lockdowns are causing PTSD in pediatrics.

24:50 – ‘Just culture’ is discussed, as is the importance of making system level changes to prevent errors. Most of the time, it is organizational culture that leads to mistakes, and not just individual mistakes.

26:10 – No non-discoverable mistakes exist in EMS, as opposed to hospital-based medicine.

26:55 – Takeaways from afternoon lectures including penetrating trauma with Dr. Tom Koenig, tactical medicine in mass casualty events with Dr. Matthew Lengua, OB trauma, and blast injuries.

27:30 – Resuscitative hysterotomies in Finland, and other advanced procedures done quickly and in austere environments. Discussing the decision gap, which the is the time from when the decision to perform a critical procedure is made until when that procedure is performed.

33:30 – Advances in resuscitative hysterotomies and thoracotomies, and there are now clear indications for both. However, this does not mean that Top Cover should be eliminated.

34:00 – Takeaways from blast injuries and penetrating trauma, specifically to the head and neck region. Major points include how EMS Physicians can treat some of these patients in the warm zone with critical interventions.

36:00 – Learning points from the lecture on burn care, and the unpredictability of the burn patient. One takeaway is that due to the current school of thought, providers are over-intubating patients with harm. Studies have also shown that escharotomies performed outside of burn centers are often performed incorrectly and incompletely.

39:30 – Use of vehicles as a weapon of mass destruction has become more common recently. A takeaway is that the extent of injury tends to be worse when the attack is intentional, whether using vehicles or other weapons. Logistically, the scene tends to be complex as it generally encompasses are large area. The discussion is brought up again about how as medical personnel, we can empower and train the general public to help.

48:55 – Next steps include teaching our communities the basic skills that have been proven to save lives, and working together to minimize these threats in the future.

49:15 - Conclusion

Oct 12, 2019

This episode is a wrap up covering the highlights from the Tactical Trauma international conference on pre-hospital critical care and trauma. This conference emphasizes tactical medicine, with a panel of experts speaking throughout the 2 days.

 

0:10 - Introduction of the conference

0:45 – Introduction of the expert panel

1:25 – Reflecting on the Las Vegas Shooting. Description of the original triage station which was not setup for an MCI with major trauma. Severely injured patients were kept on scene for approximately 45 minutes, due to unknown location of gunshots being fired.

2:45 – A big takeaway from this session is to assign a civilian to each patient, as many are willing to help. This way there is someone watching every patient who could report on their overall status (ie. Doing well vs deteriorating), freeing up medically trained resources for the most critical patients. Included in this talk was a discussion in how to involve and empower bystanders, as the first responders may not be on scene within minutes.

4:30 – The concept of an “immediate threat vacuum” is discussed, and defined as a period of time where victims are not being treated by EMS. Currently, this remains an opportunity for improvement.

5:00 – Military success rests on the fact that everyone is trained on tactical casualty care, thus allowing that vacuum to be filled.

5:45 – Hemorrhage control for the bystander needs to continue to be emphasized. A major campaign in America is Stop the Bleed, which emphasizes basic bleeding control techniques for the general public. This has also raised awareness for bleeding control kits, which are now readily available in certain public locations (ie. Schools, airports) Link: https://www.stopthebleed.org

6:15 – Studies into casualties were not done until quite recently, where experts were able to analyze drills and incidents to create real timelines for casualties. It was found that victims were not surviving with current protocols, indicating a need for change. There is now widespread access to data regarding specific wounds and their prognostic factors.

7:15 – A reflection of the Pulse nightclub shooting shows that there may have been fatalities due to decisions that came under fire, as there was previously not much data available to study and prepare adequately.

8:00 – A quick discussion on how pre-hospital providers must be prepared for anything that can occur out of hospitals. There is a quick reminder that not all hot-zones are created equal, therefore every environment is different and professionals must train and adapt to this.

8:35 – Some internet searches have revealed that terrorists are using response tactics to learn and improve their terror plans.

9:30 – Brief reminder on how expanding on experience can come in the form of extensive training, along with length of service.

10:00 – Summary of Michael Lauria’s presentation on Emergency Action Drills. This is adapting the way we train to optimize response and link that to subsequent patient outcomes. One way is to look at how other fields train for high risk scenarios, such as the military and the aviation industry. This presentation looked at the medical side of training, and the opportunity for improvement in training

11:00 – Discussed here are the steps for developing ERADs. 1. Identifying time sensitive threats that need to be addressed first (ie. Massive exsanguination, difficult airway). 2. Looking to literature, and coming up with solutions to these threats. 3. Engraining those steps in our mind during training. This has worked well for other professions in their high-risk trainings (aviation, military combat). This shows the importance of training like you fight, so you can fight like you trained when it comes time for that initial reaction.

15:30 – Wrap-up of Mark Forrest’s preventable deaths by exsanguination. The presentation revisited the topics that had no research, including Hydrogel technology and others that need further research. The bottom line takeaway is stopping the bleed with basic techniques has been proven to save lives, while other technologies may be in the horizon.

17:12 – iTClamp use in head and neck trauma has been shown to be fairly effective in studies, while it performed poorly compared to CAT Tourniquet in the lower extremities. However, 7.5% of military wounds are above the neck and result in very high mortality. The iTClamp has shown success in these situations. One link to a study on animal models: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3786550/

18:05 – Brief update on Junctional hemorrhages. Multiple devices have been shown to be effective in the lab, however their field application has been limited by weight, time, training. SAM has seemed to be the most popular anecdotally. Wound packing and close monitoring is likely the most effective method at the moment.

18:50 – Dr. Kate Prior’s presentation on leadership in a team-based setting with Inclusive Leadership practice. A deeper anecdotal discussion regarding inherent bias in the team environment is discussed here as well.

21:30 – Discussion on the timing of intubation in hypotensive poly-trauma patient. Two main reasons prevailed, the instability that comes with induction, and the negative effects of ventilation.

22:10 – Discussion on the resuscitation of the bleeding pediatric patient. Using the adult knowledge in the pediatric patient, just changing based on weight has more evidence behind it now.

22:55 – Discussion on Damage Control Resuscitation. This depends highly on the setting, and resources available in that setting. Examples of this include consistent hypotension prior to trauma surgery, the use of whole blood, and following the blood pressures being less ideal than signs of perfusion and blood flow using ultrasound. One key point is that each person has a different shock tolerance, and predicting this is virtually impossible.

25:45 – Conclusion of Day 1 Wrap-up.

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