Friday, June 18, 2010

Muddying The Waters of C-Spine Stabilization Even More

From EMS1:

Link to the original article.

Prove It: Extrication Collars Cause Internal Decapitation

By Kenny Navarro

 The Scenario
 The Review
 What It Means for You

The Scenario
Medic 3 responds with the fire department to a reported motor-vehicle collision at a busy intersection. Two patients are present on the scene; both were front seat passengers in a car versus telephone pole collision. The seat-belted driver is walking around, has no complaints, and no evidence of traumatic injury. The second patient was not wearing his seat belt at the time of the impact and is sitting in the vehicle.

Inspection of the vehicle reveals a broken area in the windshield that approximates the shape and size of the patient’s head. The patient is a male, age 42, who is conscious and alert with multiple lacerations on the forehead. Bleeding appears controlled. The patient denies loss of consciousness, complains of mild neck pain, but is able to move all extremities. The remainder of the physical exam is unremarkable.

One of the firefighters enters the back seat of the vehicle and maintains the patient’s head in a neutral position with manual in-line stabilization. The paramedic measures and selects an appropriately sized extrication collar and applies it to the patient’s neck. The rescue team successfully removes the patient from the vehicle, secures him to a long backboard, and places him in the ambulance.

The patient remains conscious and alert with a Glasgow Coma Score of 15. The patient’s blood pressure is 130/86 mmHg, the pulse is 90 bpm, and the respiratory rate is 14 bpm. The head-to-toe exam is unremarkable for trauma except for the lacerations to the forehead. En route to the hospital, the patient begins complaining of a tingling sensation in the arms and legs and increased discomfort in the neck.

Emergency department X-rays do not discover evidence of cervical fractures, although the patient continues to have worsening paresthesia. Magnetic resonance imaging (MRI) reveals significant disruption of the upper cervical ligaments and an atlanto-occipital distraction.

Back at the station, the medics wonder if application of the extrication collar may have made the situation worse, since the tingling only began after spinal motion restrictions occurred. The shift duty officer assures them that they performed exactly as protocol dictated and that without the collar, the injury could have been much worse.

The Review
Article: Ben-Galim, P., Dreiangel, N., Mattox, K. L., Reitman, C. A., Kalantar, S. B., & Hipp, J. A. (2010). Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of Trauma Injury, Infection, and Critical Care, [Epub ahead of print].

Using fresh whole human cadavers, investigators from the Spine Research Laboratory at the Baylor College of Medicine in Houston examined the effects that spinal motion restriction devices have on a destabilized cervical spine (Ben-Galim, Dreiangel, Mattox, Reitman, Kalantar, & Hipp, 2010).

None of the cadavers had previous cervical spine injuries or abnormalities. The research team placed the cadavers in a refrigerated state until the effects of rigor mortis subsided and then warmed the specimens to room temperature. Previous investigations demonstrated a high correlation in vertebral movement between room temperature whole cadavers and asymptomatic live humans (Brown, Reitman, Nguyen, & Hipp, 2005; Subramanian, Reitman, Nguyen, & Hipp, 2007).

In this study, researchers focused on the first and second cervical vertebrae. The first cervical vertebra (C1, otherwise known as the atlas) forms a ring of bone upon which the skull (more specifically, the occiput) rests (Marieb, 1989).

The atlas rests on the axis, which is the second cervical vertebra (C2). A small bony protuberance called the odontoid extends from the body of the axis into the opening of the atlas alongside the spinal cord. Under normal conditions, connecting ligaments and other tissues limit movement of these vertebrae.

However, damage to those ligaments, as might occur during traumatic injury, permits abnormal movement or allows the skull to separate from the spinal column, a condition known as internal decapitation (Brown, Reitman, Nguyen, & Hipp, 2005). Most patients who suffer this type of dissociative injury die almost instantaneously (Bucholz & Burkhead, 1979), although the literature describes dozens of survivors (Anderson, Towns, & Chiverton, 2006).

Two previous investigations of fatal atlanto-occipital injuries describe complete disruptions of the supporting ligaments, with and without associated fractures (Bucholz & Burkhead, 1979) (Ben-Galim, Sibai, Hipp, Heggeness, & Reitman, 2008).

For this investigation, the researchers replicated this type of upper cervical spine injury by leaving the muscles intact but surgically transecting the supporting ligaments. In addition, the team fractured the odontoid at its base.

Using a standard EMS spinal immobilization protocol that included manual stabilization, the team applied a commercially available and properly sized extrication collar. Researchers obtained before-collar and after-collar fluoroscopic images in the first four cadavers. The five remaining cadavers received before and after computed tomography (CT) scans. Researchers then measured the degree of distraction or separation between C1 and C2.

In every cadaver, proper application of an extrication collar resulted in abnormal separation between these two vertebrae. The mean of the average distance was 7.3 mm with a standard deviation of 4.0 mm. In effect, application of an extrication collar in these cadavers resulted in separation of the head from the spinal column.

What It Means for You
There are approximately 12,000 new cases of spinal cord injury in the United States every year (National Spinal Cord Injury Statistical Center, 2010). The most common cause is motor-vehicle collisions, which account for almost half of the injuries. Patients who survive often face devastating physical immobility and a lifetime of related health issues.

Since the birth of the modern emergency medical service system, training programs stressed the need for proper application of cervical collars to safeguard against the possibility of further damage during movement to the hospital.

This direction is in spite of the absence of proven benefit from spinal immobilization (Domeier, Frederiksen, & Welch, K. 2005). Quite to the contrary, researchers have demonstrated that rigid spinal immobilization procedures can result in tissue necrosis (Cordel, Hollinsworth, Olinger, Stroman, & Nelson, 1995), increased intracranial pressure (Dunham, Brocker, Collier, & Gemme, 2008), reduced pulmonary function (Bauer & Kowalski, 1988), and even death (Papadopoulos, Chakraborty, Waldron, & Bell, 1999).

Although the results of this study add to the collective knowledge about the harm that cervical collars can create, one must be careful about making false assumptions about the results.

Extrapolating the results from an investigation involving specific research conditions to a much larger population involves a concept known as generalizability. Some conclusions are easily generalizable across a broad spectrum of conditions while others are not.

For example, suppose an observer (or researcher) watched cars travelling on a road for a period of a month. At the end of the study period, the observer saw 5000 people driving on the right-hand side of the road. The observer might conclude drivers operate their vehicles in that right hand lane.

However, those results are not generalizable to all drivers everywhere. We are all aware that drivers in some other countries operate their vehicles on the left side of the roadway.

The cervical collar study examined only one specific type of injury, namely atlanto-occipital dissociative injuries. In the general population, these injuries are rare and almost uniformly fatal at the moment of impact (Cooper, Gross, Lacey, Traven, Mirza, & Arbabi, 2010).

Motor vehicle collisions and falls can produce many other types of cervical injuries. No convincing data demonstrates similar degrees of distraction in other cervical injuries as the result of rigid extrication collar application.

Therefore, one cannot reliably conclude that application of cervical collars will produce dangerous spinal cord stretching in ALL patients with cervical injuries.

Another limitation that also addresses the issue of generalizability is in this study’s use of cadavers. Cadavers lack muscle tone. Normal muscle tone provides a considerable degree of stabilization in upper cervical spine injuries (Ben-Galim, Sibai, Hipp, Heggeness, & Reitman, 2008).

It is possible that this inherent stabilization limits the separation between C1 and C2 in conscious patients with this type of dissociation injury including those with extrication collars applied. However, it is reasonable to assume that the lack of muscle tone in cadavers mimics the reduced tone found in patients rendered unconscious from the trauma or from subsequent rapid sequence induction procedures.

Although the International Trauma Life Support guidelines warn against the prehospital application of in-line traction during stabilization procedures (Augustine, 2008), field application of cervical collars appears to produce distraction or stretching of the spinal column in some patients.

While this study does not mean that EMS should abandon the use of cervical collars, it does suggest the need for a reevaluation of the risks and benefits of the currently accepted practices for cervical spinal immobilization.

Medical directors must ensure that field providers utilize proper restraining techniques, including choosing appropriately sized collars. In addition to the dangerous distraction for some patients with normal use, cervical collars that are too large for the patient or those strapped too tightly around the neck may worsen distraction by pushing the head even farther away from the trunk (Ben-Galim, Sibai, Hipp, Heggeness, & Reitman, 2008).

Perhaps future research will lead to an evidence-based redesign of cervical collars or the realization that collars are no more effective than rolled-up blankets used decades ago.

Anderson, A. J., Towns, G. M., & Chiverton, N. (2006). Traumatic occipitocervical disruption: a new technique for stabilisation. Case report and literature review. Journal of Bone and Joint Surgery British Volume, 88, 1464-1468.

Augustine, J. J. (2008). Spinal trauma. In J. E. Campbell (Ed.), International trauma life support for prehospital care providers (6th ed., pp. 161-182). Upper Saddle River, NJ: Pearson Education.

Bauer, D. & Kowalski, R. (1988). Effect of spine immobilization devices on pulmonary function in the healthy nonsmoking man. Annals of Emergency Medicine, 17, 915-918.

Ben-Galim, P., Dreiangel, N., Mattox, K. L., Reitman, C. A., Kalantar, S. B., & Hipp, J. A. (2010). Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of Trauma Injury, Infection, and Critical Care, [Epub ahead of print].
Ben-Galim, P. J., Sibai, T. A., Hipp, J. A., Heggeness, M. H., & Reitman, C. A. (2008). Internal decapitation: survival after head to neck dissociation injuries. Spine, 33, 1744-1749.

Brown, T., Reitman, C. A., Nguyen, L., & Hipp, J. A. (2005). Intervertebral motion after incremental damage to the posterior structures of the cervical spine. Spine, 30, E503–E508.

Bucholz, R. W. & Burkhead, W. Z. (1979). The pathological anatomy of fatal atlantooccipital dislocations. Journal of Bone and Joint Surgery, 61, 248-250.

Cooper, Z., Gross, J. A., Lacey, M., Traven, N., Mirza, S. K., & Arbabi, S. (2010). Identifying survivors with traumatic craniocervical dissociation: A retrospective study. Journal of Surgical Research, 160, 3-8.

Cordel, W. H., Hollinsworth, J. C., Olinger, M. L., Stroman, S. J., & Nelson, D. R. (1995). Pain and tissue-interface pressures during spine-board immobilization. Annals of Emergency Medicine, 26, 31-36.

Domeier, R. M., Frederiksen, S. M., & Welch, K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Annals of Emergency Medicine, 46, 123-131.

Dunham, C. M., Brocker, B. P., Collier, B. D., & Gemme, D. J. (2008). Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit, Critical Care, 12. Retrieved May 17, 2010, from,

Marieb, E. N. (1989). Human Anatomy and Physiology. Redwood City, CA: Benjamin/Cummings.

National Spinal Cord Injury Statistical Center. (2010). Spinal cord injury facts and figures at a glance. Retrieved May 16, 2010, from

Papadopoulos, M. C., Chakraborty, A., Waldron, G., & Bell, B. A. (1999). Exacerbating cervical spine injury by applying a hard collar. British Medical Journal, 319, 171-172.

Subramanian, N., Reitman, C. A., Nguyen, L., & Hipp, J. A. (2007). Radiographic assessment and quantitative motion analysis of the cervical spine after serial sectioning of the anterior ligamentous structures. Spine, 32, 518-526.

The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned.

Link to the original post.

Friday, June 11, 2010



In an ambulance, you spent a good portion of your life with your partner. In my service, I would spend 12 hours a day in the ambulance with the same person, for 7 out of 14 days. That’s 25% of my life. Being a partner in an ambulance is, in some ways, a closer relationship than marriage. My wife would work days and I usually worked nights. We would see each other for a few minutes in the morning, when I was getting home and she was leaving for work, and then a few more minutes at night, when the reverse was happening. But at work, I’d say hello to my partner and then spend 12 continuous, unbroken hours with him or her, talking with them, listening to each other’s music, smelling their food and seeing their face. With my partner, we would respond to crises throughout our entire shift. Our exasperation with stupidity would peak simultaneously, our adrenaline would flow together during life-or-death emergencies, our boredom at times would cascade into a common pool of ennui. You eventually get to know your partner’s quirks and pet peeves; you not only know, but understand what drives them; you even become personally acquainted with details you’d never imagine you’d know of another person, like what their farts smell like. The old saying goes “an experience shared is twice as sweet.” When you’re sharing those experiences in an ambulance responding to medical emergencies day in and day out, it has an effect more powerful as a shared experience than any sunset, dessert, wedding or vacation spot could ever hope to have. And unless your spouse, family or significant other is also in EMS (God help you if they are) EMS partners may well rank as of the most unintentionally intimate relationships human society has ever created.

Therefore, it behooves me to describe your partner. If you have been in EMS for years, no doubt you will recognize some of, if not all, the partners you have had. If you are new to the field, here’s an idea of what to expect in your nascent career.

"The Great Partner”

This is the person whom you should never expect to be paired with. In the extremely unlikely circumstance that you are, you will quickly come to appreciate this individual. He or she will have far more than a passing knowledge of EMS. You will be impressed with their knowledge of the profession and the care they deliver to your patients. You will be able to handle a complicated scene with them and know exactly what you and they need you to do and barely speak a word about it to each other. He or she will drive the ambulance carefully, not throwing you around the back of the truck. Alternately, he or she will thank you for a good ride when it was your turn to drive. You will both happily agree on the same place to get lunch. Your relationship will make it a pleasure to come to work, you’ll look forward to your time together and take mental notes of each others’ medical techniques. If something needs to be done and you can’t handle it all yourself, like triaging a multiple-casualty scene or calling in a report to the ER while you’re busy doing CPR, you will confidently delegate that task to your partner and you will not have to worry about them fucking it up. You will enjoy each others’ company even outside of work and be friends with their family. Once administration gets wind of how well you get along with your partner, you will immediately be split up... at which point you will find yourself with one of the following.

"The Talker”

This person will never stop talking. When you come to work and hope for an easy shift, the patients may be compliant with your wishes, but your Talker partner will continue to prattle on about their latest argument with their spouse, their patient they had last week who had a hangnail, their credit card bill, their kids, their trip to Cleveland, their mother, their child, their burger on a soggy bun from the drive-thru last week, their hairdo, their review of some movie you’ve never heard of and what they saw on TV last night. You will fall asleep at some point during your shift and when you wake up, your partner will still be yammering on uninterrupted, oblivious to your absence during your nap. You will be delayed from taking the next call because you had to go find your partner who was busy telling the emergency room doctor about the condition of someone’s clothes on an emergency run they handled last year.

If you’re not partnered with the Talker, you may find yourself with...

“The Chick That Thinks They’re Hot”

This will be a female, obviously. She is at best a mediocre EMT. She might be able to adequately apply a cervical collar and long spineboard, maybe even a bandage. But when you ask her why she thought it was necessary to spineboard the atraumatic grandfather with chest pains, she will thrust out her boobs at you, then make a quick turn on her heels so you can get a view of her glorious ass as she goes to make up the stretcher, or herself. Any coherent answer when asked about her erratic actions on the scene will not be forthcoming. Years after being at your EMS service, she will still not be able to adequately explain the mechanics behind CPR, she will still interpret a 12-lead EKG exactly as the EKG machine interprets it, and will she be not able start an IV under the best of circumstances. But... she will... um.... uh.... Dude! Check out those tits!

"The Paragod"

A close relative of the Chick That Thinks She’s Hot, the Paragod can be a male or female and has been everywhere, seen everything and knows everything there is to know about EMS. Even though he or she is known for jumping in the driver’s seat despite it being their turn to take the patient, the Paragod will insist that whatever their actions were on scene were the best possible actions to take, even if they deliberately stabbed the patient in the eyeball with an IV needle. This partner has responded to every possible permutation of anything that could ever go wrong with a human body, and the Paragod will fabricate a story to back up their claims. The Paragod responded to the World Trade Center on 9/11 and saved every survivor; they personally, physically carried the President of the United States to their ambulance when he was injured or unconscious; they wrote the medical protocols that some country with nuclear weapons uses in their EMS services. If you question the Paragod on why he licks sterile equipment prior to inserting it into a patient’s body, he will sneer down his nose at you, point to his advanced-level patch on his uniform, and say, “When you get one of these, then you can ask about why I do something.” The Paragod will be recognized when you find yourself daydreaming of actual plans to assassinate your partner.

“The Eternal Newbie”

This poor soul will have been at your service for twenty years, but every day will be their first day on the job. You will marvel that in twenty years, he or she will still not have picked up on the proper way to apply a nasal cannula, or splint a fracture, or read a map, or figure out the best way to get to the hospital. You can play dumb and offer your partner helpful advice, even though he or she far outranks you in seniority, to which he will reply “Oh yeah, I knew that! I must’ve had a brain fart.” This will be the same response he offers even if you call him out twenty times a day. Alternately, you can become insanely angry at their idiocy, jump and scream and insult them, to which your partner will give you a doe-eyed look that says ‘I have no idea what you’re talking about.’ Defeated, you will curl up into a metaphorical fetal-position (if not a literal fetal-position) and wonder how your partner ever passed his EMT exams, let alone made it through twenty years at the same EMS service.

“The Actual Newbie” (AKA “Ricky Rescue”)

Sooner of later, you will be partnered with the “new guy.” He or she will be fresh-faced and eager to save the world. Your partner will shout with joy when he turns on the lights and sirens. This eager beaver will lie on the radio, saying that your crew is miles closer to a “good call” than the crew that was actually dispatched. Ricky Rescue will shout driving instruction over the PA system to cars in front of your ambulance. He will become sullen and morose during slow periods between calls. He will become sullen, morose and angry when your emergency call is not some horrible trauma scene, such as when the gunshot call you were dispatched to actually turns out to be a little old lady with arthritis in her feet. He will drive 120 miles per hour to get to a motor vehicle accident, probably causing a few more accidents along the way. He will want to perform every procedure that an EMT can possibly perform, but will balk when you ask him to write the report. If it is Ricky’s turn to make up the stretcher and clean the back of the truck after a call, it will not be done. You will recognize the Actual Newbie/Ricky Rescue because he will show up to work on his first day wearing every possible accoutrement ever made with the label “Tactical,” including tactical flashlight, tactical knife, tactical boots, tactical window punch, tactical trauma shears, tactical baseball cap and tactical underwear.


The Crispy partner will most likely be your first partner, a paramedic that was burnt-out since before you could spell “EMS.”. He or she will find no joy in his job and will do his or her best to bring you down into his or her bitterness. Every call will be a horrible waste of time to your partner, no matter how dire the circumstances were that caused EMS to be summoned, and no matter how significant a difference you make in the patient’s life and existence. Any call, no matter how serious or trivial, will be met with an angry “harrumph.” Be prepared for objects to be thrown around the cab of the ambulance when dispatch assigns you a call. Be prepared to slink away silently when the Emergency Department staff questions your partner about any of his actions or non-actions while transporting a patient, because your Crispy partner will launch into a frustrated diatribe describing the need or lack of need for whatever it was the staff was asking about. You will recognize Crispy as you approach his ambulance; there will be cracks in the windshield on his side of the ambulance from clipboards or computers hurled viciously onto the dashboard during his bouts of anger over getting assigned a call. One point to remember (to your advantage or disadvantage): in his eyes, YOU are the Newbie/Rickie Rescue, no matter how long you’ve been at your service.

“The Family Guy”

This person will wear out the battery of their cell phone several times a day. They will be on the phone all throughout your shift together as they talk about “family issues.” You will hear your partner’s side of the conversation all day as they argue with their spouse, discipline their children, fight with the cable guy doing work at the house, chat with various contractors regarding the lowest bid for work to be done on the house, whine to their lawyer about paying child support and during slow times at work, you partner will describe in nauseating detail all the goings-on in his or her family dynamic. After a week or two with the Family Guy, you will know all about their spouse and children in ways you don’t know your own spouse and children.

“The Walking Crisis”

The Walking Crisis never has a good day. Every day, no matter how benign the calls are, will be “the worst day ever.” The patients might have a minimum of problems, be extraordinarily cooperative with your partner and yourself, and thank you profusely for your service, maybe even offer you some food or drink, yet your partner will find something wrong with the call. “Oh my God, that was awful!” you partner will exclaim after every EMS run. If you enquire why they found the call so stressful, they will respond by elucidating some vague, unlikely, unobservable possibility, the repercussion of which invariably result in their suspension, firing, revocation of their certification and possibly jail time. Often the Walking Crisis will overlap with the Family Guy, as their “horrendous” job description spills over into their home life. Your partner will spend their time between EMS calls talking on the phone with family members about worst-case outcomes in whatever circumstances their family is in. “Junior got an A in math? Jesus Christ, I thought he wanted to be an artist! This will never work out!” your partner will say.

“The Slut”

The Slut will be recognized the first week of orientation. The Slut can be male or female. By the end of the first week, the Slut will have had sex with at least one fellow employee, often that employee will be his or her field training officer. If the Slut is a female, after six months of her employment, most of the male employees will obliquely refer to her skills at sexual prowess. There will be whispered references to her as “The Suction Device,” “The Bottomless Pit,” “The Sperm Bank,” “The Freak,” and other crass but recognizable names. If the Slut is a male, a meaningful fraction of the female employees will be taking maternity leave within a year of his hiring. The Slut may or may not be a good EMT, but to many of the people who make that determination, their professional skills will likely not matter much.

“The Gay”

You will find an extraordinary percentage of your EMS co-workers are gay. This can have both advantages and disadvantages. If you are a gay male and your partner is a gay male, your chances of getting laid just went up, as is also the case if you are both gay females. If you are a straight male partnered with a gay female, you can both have a good time ogling the attractive females that you encounter during your shift, and the crew with the gay male/straight female can have the same fun pointing out attractive males to each other. The disadvantages can be a problem, though. The Gay, if they are too horny, promiscuous, or opportunistic at work, can acquire the gay version of the label “The Slut” among that portion of the work community. If two gay males or females from EMS become an item, they run the risk of the dreadful “Family Guy” problems (and label) as a result of the shrieking drama that can be so endemic to gay relationships. Further, your straight co-workers will get endless fun pointing out the ongoing spectacle between you and your co-worker boyfriend or girlfriend.

“The Social Butterfly” (AKA "The Silent Treatment")

The Social Butterfly will usually be on his or her cell phone, texting updates to Facebook, Twitter, MySpace and various other social networking sites. Actually responding to EMS calls will be a chore, as actual EMS work tends to distract them from texting their boyfriend, girlfriend, or 3rd-grade classmates. Expect little in the way of conversation from the Social Butterfly; somehow actually interacting with another human being (you) is far too cumbersome an activity compared with the instant gratification and massive life-affirmation they receive when someone “likes” thier Facebook status (“OMG, my partner is so lame! He actually wants to TALK to me WTF?!!”).

“The Fighter”

The Fighter will be related to the Walking Crisis. Paranoid at every turn, your Fighter partner will call for police backup for every 2-month-old with a fever. The Fighter will manage to get into a difficult situation on a call with a patient who is completely alone and unresponsive. Be prepared to apply restraints to every patient because “They’re combative!” according to your partner. Even if you are not partnered with the Fighter, you will hear them on radio asking for another crew to help with the the “uncooperative” patient. The patient could be an arthritic little Grandma who offers you some of the chocolate chip cookies she baked earlier; somehow the Fighter will press assault charges on her when she reaches to give your partner a hug.

“Driving Miss Daisy”

Miss Daisy has an infinite number of personal errands to run. Don’t be fooled by the nomenclature “Miss” Daisy; this partner can just as easily be a “Mister.” It is unthinkable to Mister or Miss Daisy to run personal errands on their day off, while they’re off the clock. Be prepared to visit their mother, shop for groceries, stop off at the electric and water company so Miss Daisy can pay their bill, purchase their hardware at the Home Depot, pick up their kids from school in the ambulance, give friends a ride home from the bar in the ambulance and attend some school class in between calls. Miss Daisy will never make and/or bring her own lunch, so you will be meeting her boyfriend, girlfriend, spouse or other family member so lunch can be delivered to Miss Daisy while on duty. Note that the closest location that the friend can meet you and Miss Daisy is clear on the other side of town, as far away from your dispatch-assigned location as you can possibly be. Do not be surprised when Miss Daisy asks YOU to inform dispatch why you are forty miles from where you were expected to be when dispatch assigns you a call.

“Sleeper Cell”

Not unlike Miss Daisy, the Sleeper Cell will have personal duties to perform that probably should have been done on their time off. However, the duties will fall under only one category - sleep. This partner will do their best to sleep during their entire shift. You will wonder what activities could possibly be so exhausting that your partner actually falls asleep while attempting to intubate a non-breathing patient. The moment your stretcher is made up and secured back in the ambulance after a call, you partner will be stretched out on it, with “Zzzz’s” almost visible on their snoring breath.With some partners, the cause of their sleep deprivation isn’t too hard to find - the narcolepsy may be secondary to his off-duty antics being “The Slut.” Possibly, the partner schedules too much abuse during her time off as she cooks, cleans, sends the kids to school, and runs her errands on her days off (the Family Guy?) then looks forward to napping in the ambulance. You can recognize the Sleeper Cell easily - you will be responding to a call, lights and sirens blaring, potholes jostling the ambulance to the point that your heads are actually making contact with the ceiling but your partner is snoozing away, undisturbed, oblivious to the fact that your ambulance overturned upside-down just now.

“The Soldier of Fortune”

This die-hard ex-military person will sneer in the face of danger, insult you for calling for backup when six big guys attempt to shoot you with pneumatic spearguns and steal your ambulance, and will be packing a firearm somewhere on his person. Every conversation will start with “When I was in the military...” This partner will regale you with war stories (literal stories of genuine war). The Soldier of Fortune will actually purchase “Soldier of Fortune” magazine and point out articles, insisting you read the review of the latest X-10 Kill-o-Matic weaponry. No situation in your experience is as awful a crisis as “This one time, in the military...” The Soldier of Fortune will spend his time off engaging in re-enactments of the Civil War or collecting unlikely weaponry, like a catapult or a guillotine. Do not engage such a person in conversation, it can only end badly.

“The Partner of Questionable Hygiene”

This partner will be recognized the moment you climb into the ambulance. You will imagine that the previous crew, while cleaning, had missed some foul turd that a patient had left behind. You will inspect the ambulance for the cause of the aroma. Unsuccessful, you will fall into a deep depth of depression as you slowly begin to realize that the stench emanates from you partner - the partner who you will not only have for the rest of your shift, but have just been assigned to work with permanently. Bring extra tissue paper to wipe your eyes and blow your nose as the irritants of his personal gasses fill your ambulance. If you lower the window in the ambulance, they will raise it again, claiming he or she is “too hot” or “too cold,” as your partner seals you into your personal corner of stink-hell. There are advantages to the Partner of Questionable Hygiene. When you have a patient on your stretcher, if you fart, it will be easily attributed to your partner. Conversely, your patient may have an episode of uncontrollable, explosive, stinky, diarrhea incontinence on your stretcher, in which case the smell will be unnoticeable, obscured as it is by your partner’s personal odor. Recognize this partner when fellow employees anonymously present him or her with a basket of personal hygiene products, including, but not limited to deodorant, soap, shampoo, laxatives, tampons, Gas-X, Febreeze, laundry detergent and cologne.

“The Princess and the Pee”

Not necessarily a female, the Princess cannot, under any circumstances, get their hands dirty. Should a stray drop of blood, urine, vomit or bodily fluids mar their perfect uniform, the Princess must go home immediately and will most likely file a personal injury report. The Princess will arrive at work with her makeup perfectly applied, his hair immaculately coiffed. Any object or patient heavier than a newborn baby will require backup for lifting assistance. If the patient is actually a newborn baby, your partner will be unable to touch it, “in case it throws up or poops.” The Princess is a delicate winter blossom, unaccustomed to the hysteria that frequently accompanies emergency medical calls. Such hysteria paralyzes the Princess and they cannot possibly be expected to function when there is “drama” going on. Starting an IV or bandaging a wound is outside their scope of fragility. The Princess cannot ever be expected to get so physically close to an actual patient so as to assess vital signs or use a stethoscope.

"Mister Clean"

Mister Clean has an extraordinary need to keep the ambulance sterile. Probably diagnosable with obsessive-compulsive disorder , he or she will spend a large portion of their paycheck on cleaning items for the ambulance. Whatever cleaning equipment your company provides will be far inadequate for their needs. Mister Clean will have a large bin chock full of bleach, Windex, scrubber pads, Armor-All, sponges, brushes, brooms, mops, a vacuum cleaner and anti-bacterial soap. They may keep their own pressure washer machine to scrub the outside of the ambulance. At least once a shift or more often, this partner will launch into a cleaning frenzy to scrub, polish and straighten every item in the ambulance. When you look under the hood at the engine, the caps for brake fluid, radiator coolant, windshield washer fluid and oil will have colorful hand-made labels identifying each. Your eyes will frequently burn as the ammonia and bleach mixes during their cleaning fits. You dare not leave lunch leftovers anywhere as they will be thrown away the moment your partner finds them idle. Mister Clean will stare at the drop of the patient's blood that fell on the floor, transfixed, mesmerized at the fantasy of cleaning it up. Should you offer to help clean the ambulance, your hand will be slapped away when you reach for Mister Clean's stash of supplies, in the fear that you might disrupt the meticulous organization of their precious paper towels.

Thanks for reading! Hopefully you’ve found a little light to brighten your day. As you climb into your ambulance for another shift with your partner, I want you to ask yourself not only “Which one are they?” but also “Which one am I?” (And if I missed any partners out there, please describe them in the comments!)

Onward and upward.

Tuesday, June 08, 2010

IV Tips From the IV King

IV Tips From the IV King

Lots of times at work, others call me to start IV’s on patients who are “hard sticks.” I’m usually successful. Many doctors and nurses acknowledge that if I can’t get an IV on a patient, they need to put in a central line. I’m not boasting about my prowess with the needle, Lord knows there are days when I can’t hit the broadside of a barn with a 22 gauge. But I want to share some tips to help you, dear IV-sticker, to make your job easier and become your own IV king or queen.

I won’t go into the basics of IV-sticking. If you’ve read this far, you already know the basics of how to stick an IV into a patient. Let’s work on getting better at it. There’s lots of different “hard sticks” out there: diabetics, IV drug abusers, frail little old people, children, babies, cardiac arrest patients, CHF-ers and so on. Their veins may blow, they may be very deep and invisible, or very tiny. These tips will help on all those.

One of the first and most helpful things you can do to be a better sticker is to brush up on your knowledge of the vascular system, particularly the veins. “But everybody’s veins are different!” I hear you screech. True, everyone’s different, but we all have two arms, two legs, a stomach, a heart and a brain and they’re generally located in the same place between individuals, right? Our veins are no different. We all have a radial vein, an ulnar vein, a brachial vein, a cephalic, basilar, saphenous and external jugular and they all are placed in more or less the same location in our bodies. Sometimes you have to do a “blind stick.” If you know where a particular vein should be located, it will help in hitting that vein, rather than just sticking the needle into any old patch of skin and hoping. You may have to dig around a bit to get the flashback. Move the needle slowly so you don’t pierce through the vein. Remember that veins follow the bone, and everywhere in the body, the NAV rule applies- Nerve, Artery, Vein. Aim the tip of your needle a little lateral to a pulse point and you should find the vein. I also find that while the initial needle stick is painful, after a minute or two of digging around, the pain almost disappears, thanks to our amazing sympathetic nervous system. So don’t feel that you are torturing your patient if it takes a while to find the vein.

Some patients are severely edematous. The swelling makes it impossible to distinguish the feeling of a palpated vein from edematous tissue. With these patients, remember the veins will be deeper under the swollen tissues. Don’t be afraid to stick your needle in at a steeper angle than usual. Your flash chamber may fill up with interstitial fluid rather than blood, so if you feel like your in the vein but there’s no blood in the chamber, pull your needle out and see if the catheter bleeds. If you keep everything aseptic, you can reinsert your needle into the catheter and keep trying if you didn’t get it. Just be cautious of tearing the catheter with the needle. If you feel any resistance reinserting the needle, pull the whole thing out & start again.

People with tiny veins are another challenge. Yes, everyone likes to use big ol’ honking 16 and 18 gauge catheters. But Grandma with the tiny spider veins won’t be able to take that. I know you learned that big, long catheters can infuse more fluid and could show me the math to prove it. But in real life, a well-placed 22 gauge can infuse just as fast as a 16. So to hit Grandma’s tiny little veins, use a small needle. Feel free to poke one of the varicose veins just under the skin. Make sure you’re very gentle as you pierce. Often the vein will form a hematoma at the insertion site. If it does, don’t give up yet; keep advancing the catheter and infuse a little fluid. If it doesn’t expand the hematoma when you push the fluid, you can use the IV. Another tip is to insert the needle bevel-down when poking a small or fragile vein.

Some IV-stickers freak out when they have to stick kids. People - it’s not that hard! Kids whine less than adults do. And kids have young, strong veins. Please don’t use a crappy little 24 gauge catheter just because the patient is a child. 24 gauge catheters are too small to support their own weight. I’ve stuck 16 gauges in 2 year-olds with no problem. Kids generally have a fair amount of adipose tissue that can hide the veins, but use the same principles of anatomically finding a vein and you’ll be fine. Scalp veins are commonly used on kids and kids often have great foot veins. Remember, you can use any vein in the body for an IV. Don’t get stuck in the thinking of using only arms for IV’s.

Speaking of which, if you can’t use an arm for an IV for whatever reason, look up the arm towards the shoulder. Frequently patients with terrible arm veins will have terrific veins on their shoulders and upper chest. True, you can’t use a tourniquet, so the lack of pressure in the vein may not give you a flashback. But if the catheter bleeds when you pull out the needle, you’re golden. On those crazy-looking sideways veins, just make sure you stick in the direction that’s most towards the heart and you’ll get it in the right direction.

Lots of folks have valve-y veins. When the valve senses the foreign body of the catheter, they tend to clamp shut and you won’t be able to advance your catheter. If the vein is relatively straight and strong, use the needle to pierce through the valve, making sure to keep the tip within the lumen of the vein. It may take a surprising amount of force, but remember, it the valves are that strong, so is the vein. Don’t be chicken.

Lots of EMS services use the EZ-IO (intraosseous needle) on cardiac arrest patients as their first line of access. Call me old-fashioned, but you can’t beat a good IV, especially on a code. Folks, at least try to get an IV on a code. You’ll be surprised at how easy it is. The lack of vascular tone usually makes the veins engorge with blood so they stand out yelling “stick me, stick me!” The whole purpose of ACLS and IV access is to get the patient back, and if they regain a pulse, they’ll be in the hospital for a while. Your IV will remain in use for days, helping the patient recuperate. If you stuck an IO in, it’ll get pulled before the patients gets to the ICU. Please try to get an IV.

One last tip - EMS people, your IV’s fall into two extremes by the time the patient gets to the floor in the hospital. Either they A) last forever and are great for infusing fluids and drawing blood or they B) need to be pulled prematurely because they get infected. Please start your IV’s as aseptically as possible. Yes, I know the thinking “you can always give them antibiotics.” However, antibiotics don’t always work. Antibiotics also contribute to resistant infectious organisms. Also, insurance companies don’t pay for treatment of iatrogenic infections, you and I do. If you’re going to start an IV, do it right.

Thanks for reading, and good luck!