Prehospital Chest Tube Thoracostomy

[Guest]

Sounds like Heaven to me!

When you put it that way,your not wrong, over regulation can lead to confusion as you may clearly see, through those bifocals that is...te he!

[kevkei]

Great come back Alberta! Kudo's to you, you saw my heart transplant and raised with an Alberta Occupational Competencies Profile (AOPC). I still think that your bluffing. The poker hand is not over though. The shame is that the AOCP has little to no relevance in the Province. It's not used in the teaching colleges, the emergency services, by the licensing college, or by the physicians that direct Alberta's medics. It's a working document that is finding its way into the fireplace. Think of it like a wish list letter to Santa that never quite made it to the north pole.

Proof of this is the Alberta Health & Wellness Standards for Regulated Ambulance Equipment and Supplies (also found on the web) that mentions the need to stock booster cables, a bed pan, urinal, portable O2, cold packs and an advanced airway kit for just such an occasion. I missed seeing the arterial line adapter, the central venous catheter, the selection of chest tubes, the pulmonary catheter, and even the pericardiocentesis needle. It's not a wish list, but a Provincial law. The previously noted intensive care items are not on the Calgary, Edmonton, Canmore, Lethbridge stock orders. Their not given to the EMS services from the regional governments or the associated hospitals. Are the medics purchasing the equipment on their own accord? That's just wrong. And if your getting paid less than the Ontario wages of 85K annually to do this stuff your getting robbed.

Take a few moments to re-consider Squints posts. He's probably been doing the job in a multiplicity of capacities when you were just a toot. He has nothing to prove, but just words of experience knowing the health and EMS system in Alberta. He's possibly even pretty well connected at the College as well. I hear the CEO & Registrar position is open, he sounds more than qualified to take that.

Does your employer and directing physician know that your ready and able to perform pericardiocentesis? You could be deemed as being overqualified to work in Alberta EMS.

Any questions?

Boy, from a person in Ontario you seem to know your stuff about Alberta. As well, since you and Squirt know each other so well, I'd almost say you were the same person. As for the comments about doing a pericardialcentesis, you are correct regarding wanting to have people properly equipped to do the job. That said, if you have a patient that clinically presents to having a tamponade that is going the route of being one of the 98% mortality statistic group, is it going to hurt to attempt to intervene to become one of the 2% of survivors? Consider the risk vs benefit scenario. There is always more than one way to skin a cat.

I will concede that it is a very invasive procedure but if you have an injury and a mechanism together in a patient that might benefit (live vs die) from it as a temporary measure, what is the harm? I'm not talking about doing this in an otherwise healty person, using alligator clips to confirm contact with the myocardium, it should be considered as a last resort. Kinda like a needle decompression in a tension pneumo. You know, TENSION, as opposed to a simple pneumo. If I have a patient that is hypotensive, decreasing LOC and all the other fluff and puff from obstructive shock, I'm not supposed to decompress? Again, I'm not comparing this to a simple pneumo where you have time to do a AP CXR, you base it on clinical presentation (heaven forbid we assess our patients and treat them as such)

As for the AOCP document, the teaching institutions have been teaching to that level and ACP has been examining at that level since Feb 2004. Are you familiar with the current gap training?

Have you had a read of the Alberta Health and Wellness Medical Control Guidelines (provincial protocol) relating to pericardial centesis in mechanical shock? It is indicated in Section II / Medical Guidelines and Drug information /- Shock/Trauma Emergencies / Mechanical Shock pp 85

- all EMR and BLS assessments and treatments should have been done prior to the following:

-Auscultation of chest breath sounds symmetrical and present; yes/no

-Yes- Suspect cardiac tamponade- JVD, narrowing pulse pressures, trachea midline, muffled heartsounds (Becks triad)

-Consider: PATCH to physician re: Pericardiocentesis

Could you please provide me with something to substantiate that pericardiocentesis is NOT within the skill set of the Alberta EMT-P other than a bunch of threats and verbal diarrhea? And, how is it that the AOCP document is nothing but making it's way into the fireplace? So I guess that the fact that I know and am friends with the editor of the document and his extensive research comparing the ACOP with the NOCP to see how we meet (sans EXCEED) it, means nothing? Perhaps you should forward your concerns to the Continuing Competency Program Coordinator continuingcompetence@collegeofp

aramedics. and bring them up with him.

Regarding the vacancy of the CEO/ Registrar, would it take much to be more qualified than the interim/acting CEO (former President B.C)?

Squirt and Letterman, does Squirt by chance have the initials of W.M?

[Guest]

Great come back Alberta! Kudo's to you, you saw my heart transplant and raised with an Alberta Occupational Competencies Profile (AOPC). I still think that your bluffing. The poker hand is not over though. The shame is that the AOCP has little to no relevance in the Province. It's not used in the teaching colleges, the emergency services, by the licensing college, or by the physicians that direct Alberta's medics. It's a working document that is finding its way into the fireplace. Think of it like a wish list letter to Santa that never quite made it to the north pole.

Proof of this is the Alberta Health & Wellness Standards for Regulated Ambulance Equipment and Supplies (also found on the web) that mentions the need to stock booster cables, a bed pan, urinal, portable O2, cold packs and an advanced airway kit for just such an occasion. I missed seeing the arterial line adapter, the central venous catheter, the selection of chest tubes, the pulmonary catheter, and even the pericardiocentesis needle. It's not a wish list, but a Provincial law. The previously noted intensive care items are not on the Calgary, Edmonton, Canmore, Lethbridge stock orders. Their not given to the EMS services from the regional governments or the associated hospitals. Are the medics purchasing the equipment on their own accord? That's just wrong. And if your getting paid less than the Ontario wages of 85K annually to do this stuff your getting robbed.

Take a few moments to re-consider Squints posts. He's probably been doing the job in a multiplicity of capacities when you were just a toot. He has nothing to prove, but just words of experience knowing the health and EMS system in Alberta. He's possibly even pretty well connected at the College as well. I hear the CEO & Registrar position is open, he sounds more than qualified to take that.

Does your employer and directing physician know that your ready and able to perform pericardiocentesis? You could be deemed as being overqualified to work in Alberta EMS.

Any questions?

Letterman:

Beside the fact that you appear to have a finger or two on the pulse of Western Canada EMS and its political progress as well, this is very good news to hear as many Paramedics in Western Canada pay little stead, or give due credit to the advancements of Eastern Canada. You express yourself as if you are very experienced, perhaps a recognized CCP? A position of envy, in fact the statement re:(The Alberta EMT-P has adopted the theory of the national CCP but doesn't include the practical (yet).) could this statement validate that Alberta is not as Advanced as they are lead to believe?

I certainly wish I had some of those "things" you talked about in my kit bag but I can't afford them nor the Law suits.

Quote by Alberta's expert?: Hmmmm, apparently you aren't familiar with the Alberta Occupational Compatency Profile (AOCP) and how we are leaps and bounds ahead of the NOCP document.

In Fact the NOCP document historically proceeds the AOCP document...AHMMMM.

Letterman: Your clear understanding and interpretation in regards to the "actual legislation" and the "reality" not the Crystal Ball approach that we have recently observed. In regards to the future of advancement for EMT/PCP and additional skill sets of Symptomatic relief these are NOT implemented by the vast majority of operators, nor have they received approval by Medical Directors in Alberta, the Jury may be out for some time, the idea of EMTs pushing IV drugs is a reportable offense I think but I could be wrong here as well?

Perhaps a *paste/post* of the Local signed protocols in this individuals area would be the proof now needed.

Quoting Letterman: (Does your employer and directing physician know that your ready and able to perform pericardiocentesis?)........I too am awaiting a reply to this question, Where is the BEEF?

The evidenced based studies concerning the realistic/legal application in the field treatment of Pericardiocentesis has been disregarded buy my Alberta associate, not only yourself but a many other VERY experienced providers that are still monitoring this forum...you know the ones the individuals that my Alberta associate eludes to as supporters of his credibility, and dogmatically refuses to admit.... this speaks volumes.

Paramedic Letterman, sincerest apologies for my junior compatriot's comments, I hope you will not believe that all of Alberta's Fine ACP er Paramedic's behave in this manner.

Blue Sky's

Calm Air

[kevkei]

Letterman:

Beside the fact that you appear to have a finger or two on the pulse of Western Canada EMS and its political progress as well, this is very good news to hear as many Paramedics in Western Canada pay little stead, or give due credit to the advancements of Eastern Canada. You express yourself as if you are very experienced, perhaps a recognized CCP? A position of envy, in fact the statement re:(The Alberta EMT-P has adopted the theory of the national CCP but doesn't include the practical (yet).) could this statement validate that Alberta is not as Advanced as they are lead to believe?

I certainly wish I had some of those "things" you talked about in my kit bag but I can't afford them nor the Law suits.

Quote by Alberta's expert?: Hmmmm, apparently you aren't familiar with the Alberta Occupational Compatency Profile (AOCP) and how we are leaps and bounds ahead of the NOCP document.

In Fact the NOCP document historically proceeds the AOCP document...AHMMMM.

Letterman: Your clear understanding and interpretation in regards to the "actual legislation" and the "reality" not the Crystal Ball approach that we have recently observed. In regards to the future of advancement for EMT/PCP and additional skill sets of Symptomatic relief these are NOT implemented by the vast majority of operators, nor have they received approval by Medical Directors in Alberta, the Jury may be out for some time, the idea of EMTs pushing IV drugs is a reportable offense I think but I could be wrong here as well?

Perhaps a *paste/post* of the Local signed protocols in this individuals area would be the proof now needed.

Quoting Letterman: (Does your employer and directing physician know that your ready and able to perform pericardiocentesis?)........I too am awaiting a reply to this question, Where is the BEEF?

The evidenced based studies concerning the realistic/legal application in the field treatment of Pericardiocentesis has been disregarded buy my Alberta associate, not only yourself but a many other VERY experienced providers that are still monitoring this forum...you know the ones the individuals that my Alberta associate eludes to as supporters of his credibility, and dogmatically refuses to admit.... this speaks volumes.

Paramedic Letterman, sincerest apologies for my junior compatriot's comments, I hope you will not believe that all of Alberta's Fine ACP er Paramedic's behave in this manner.

Blue Sky's

Calm Air

Well, I fall to my knees in envy at your superiority :? I have quoted two sources and provided a link that can be researched by anyone, both of which substantiate that the performance of a pericardiocentesis is indeed within the skill set of the Alberta EMT-P. Other than anecdotal huffing and puffing and posturing, you have not provided any data or resources to support your position. Please provide me the "legislation" that supports your position.

Where have I suggested that this is something that is, or should be, performed on a regular basis? Where have I suggested that we all go out and look for someone to needle in the heart? I was simply suggesting that it is something included in our skill set (as is currently intracardiac drug administration, not to suggest it is ever used). I'd hope that you would be willing to think outside of the box enough that in a patient with a positive mechanism, clinical presentation and extremis (such as traumatic cardiac arrest), with no other options available to you, you might consider doing something that might help actually save a life.

Have I claimed it has a high success rate? Have I suggested it is something that will always be effective? Even if it is effective in 1% of patients with an existing tamponade, is that 1 patient in 100 not worth it? I guess that as a last ditch effort you will sit with your hands in your pockets while you debate the merrits and validity of trying something that might actually work.

Oh, by the way, you can also tell my patient from a month ago that had two holes in his left ventricle from a central stab wound that performing a thoracotomy in the ER is contraindicated because of the extremely low (1-2%) overall success rate. Because he got to walk out of the hospital and hug his daughter again less than two weeks later, I guess it was a good thing that the surgeon thought he was worth the risk despite the fact he was a statistic.

[Guest]

kevkei

Hmmm, lets see, yes we carry the commercially available Cooks Cric Kit, which is an actual #6 sized trochar that is cuffed. In the absence of having this, it is a scalpel and shortened #6 ETT (sounds like a surgical [initiation of an incision] cricothyrotomy [incision through the skin and cricothyroid membrane] to me)? What does "pseudo surgical tracs" mean? Either is is surgical or it's not. Perhaps you could define the medical term that I am stumbling for.

Most pleased to provide information to you sir/lady, A surgical trachostomy typically refers to that of a procedure most akin to the O.R or sometimes preformed in an ICU, it requires one to be a rather skilled surgeon, the patient is sedated, typically with narcotics, benzo's and or paralytic drugs and now quite vogue to use Propofol, area is cleaned with anti-infectives. Surgical sterile procedure is used, (although sterility is not guaranteed) typically NOT an emergent but elective procedure. The Surgeon, dependent on situation and indications for said procedure, usually the 3 to 5 tracheal ring is land-marked a cut is made using cautery or scalpel, dissecting the area very carefully as not lacerate an artery (Thyroid) have observed a few blood baths with a tiny opps! Then once the tip of the ETT is located and a hiss of air is heard/observed, spreaders are used to allow entry of a Trachostomy tube, Portex has less of an Infection rate than a Shiley, due to inner cannula retaining secretions, tube is secured and CXray to assure correct placement. This is an abbreviated version, sorry getting late.

Now you may observe that the emergent situation of a Cricothroid puncture is LIKE or PSEUDO, the use of the scalpel is not surgery just a "poke" to make a pathway, sometimes it is advantageous to twist the scalpel to provide improved access to introduce a Catheter (whatever that service prefers) my unsolicited preference is the introduction of a wire, (retrograde intubation technique) this was demonstrated to me by a ex military PA, and is a very good alternative to those that may have difficulty or are needing some time in the OR. I have found the NU TRACH dilator system very time consuming in a Shot gun facial insult. My preference is the portex mini Trach, its sweet piece of Kit.

As for trans tracheal high pressure ventilation off an improvised wall outlet @ 50 psi. well you may want to attempt it but I will not simply use a BVM, as this far less potential to kill.

Since were on the topic, Naso tracheal blind intubation......search for the Baltimore study......really scary stuff there.

OR I may just be pretending to know about Airways too!

squint

[Dustdevil]

Most pleased to provide information to you sir/lady, A surgical trachostomy typically refers to that of a procedure most akin to the O.R or sometimes preformed in an ICU, it requires one to be a rather skilled surgeon, the patient is...

True enough, but apparently irrelevant. I don't recall Kevkei saying anything about tracheostomy. Not all surgical airways are tracheostomies, and he didn't imply they were.

[kevkei]

OR I may just be pretending to know about Airways too!

squint

Apparently because you don't seem to be able to differentiate the difference between a tracheostomy (which would be a surgical procedure done in the O.R, whice I have not yet claimed that we do) and a cricothyroidotomy (which obviously we do do). In the initiation of a crichothyroidotomy, I guess that you "stab" through the skin initially as opposed to making a vertical incision. I'd expect more from an RRT.

In the initiation of a crichothyroidotomy, I guess that you "stab" through the skin initially as opposed to making a vertical incision.

That aside, I've yet to see an effective rebuttle to the questions I have asked in the last few posts.

[Letterman]

'Alberta',

Are we arguing semantics here with Squint? Stab... vertical incision... Instead of defending yourself with the argument at hand, you are reverting to discrediting with terminology. That's rather cheap. The surgeon who taught me suggested two transecting 'slices' into the cricothyroid membrane and then blunt dissection 'southwards' (meant as inferior) with the index finger. Go figure he meant an incision. Layman's terms. Watching him demonstrate it, I knew what he meant. Hearing what Squint said, and knowing how it's done, I knew what he meant. Terminology... I would prefer you arm wrestle with squint rather than try and discredit him by semantics. You'll loose.

The bottom line were arguing what is appropriate in the prehospital field. There is a line between inserting an oropharyngeal airway and doing brain surgery. The line is doing what is appropriate for the best interests of the patient with the appropriate skills that can be maintained with a considerable amount of competency. I am not sure when your Province resembled the streets of LA or Detroit, and there is not one prehospital location in Canada that can rationalize the performance of pericardiocentesis. The skill can not be maintained! I will agree to chest tubes. Having dealt with hemothoraxes on occasion, a 14 gauge cath (and even a 12 gauge 8 inch chest needle cath) will become clogged. In the instances where travel time to a hospital is greater than 1 hour from the time of decompression, a chest tube in the prehospital field 'may' be appropriate. I recall a retrospective chart audit study from Calgary in the mid 90's that indicated that there was a lot of cric's being done in the field. This was because the percentage of successful intubations were in the 70% range. Medics thought to needle their patients verses reverting back to basic life support methods of a good face seal and effective ventilating. Was the low success rate due to poor problem solving or the ability to needle cric when needed? This is why pericardiocentesis and intracardiac meds are way outside the ability and scope of the paramedic in 'our' prehospital setting to do it with a degree of success. In or near an urban setting, a chest tube is not appropriate as needle decompression works effectively to buy the time that is necessary until someone who is trained for surgical techniques is available. Chest tubes in the aeromedical environment is not only appropriate but mandatory due to the expansion of gases at altitudes.

Let's not get outside our respectable abilities as paramedics. We are not surgeons. A plethora of skills are inappropriate in the prehospital field, and to recognize this shows due respect for the patient not wanting to practice skills on them just because we can. I would like to ask where you would draw your line with what skills are appropriate and responsible in the prehospital Field but fear the reply of you doing surgery in your ambulance.

We can argue the skillset that you have mentioned and noted on paper with endless replies. Fact is... outside of critical care aeromedicine, its not done on the street. Dreaming in your private time is one thing, leading others along thinking that your dreams have come true is another.