This post, detailing my reflections on clinical retrieval medicine, is the fourth in a series recording my reflections on the twelve months I spent working for Sydney HEMS1 in prehospital and retrieval medicine. The first post covers medical education – you can find it here2. The second covers human factors – you can find it here3. The third covers clinical lessons from retrieval medicine – you can find it here4.
In a follow-on from post three, this post is about the clinical lessons I’ve learned during my year of prehospital and retrieval medicine. As someone with subspecialty training in Paediatric EM, managing paediatric patients is definitely in my comfort zone (something for which I’m very grateful), but there was still plenty to learn about the paediatric patient in the prehospital environment.
I also treated my first patients with drowning – three to be exact. Although drownings do occur in the UK they are not seen as commonly in inner-city EDs as they are in Australia, probably due to both geographical and climate differences as well as the plethora of swimming pools in NSW. Drownings present some unique challenges which are worth thinking about as they are significantly more common than snake and spider bites (I didn’t see any of those!).
The reflections in this post cover lessons learnt about paediatric prehospital care, drowning and some other critical care odds and ends.
Part Four – Clinical Retrieval Medicine: Paediatrics, Drownings, Ketamine and Intubation
Kids get sleepy when they bang their heads
We tend to know this but usually the sleepy period has passed by the time they turn up in hospital. We miss out on how unnerving it can be when the child is totally zonked after a bang on the head and a big cry. It still doesn’t mean that there is pathology there though.
The sleepiness is particularly noticeable if you give them analgesia (on one job the child had been given a generous dose of intranasal fentanyl – yes, that will make you more sleepy). A key lesson for me when called to another child with a minor head injury and “altered conscious level” (asleep) was that you can still be an ED doc in the prehospital world – I was able to provide a head injury assessment in the home and head injury advice as I would have done in-hospital and save the family the time and effort of an ED attendance for what was essentially a minor head injury.
Not only are paediatric ETTs small, they are SHORT
During my year I intubated a couple of paediatric patients. These were, thankfully, uneventful experiences but it is worth taking the time to be familiar with your equipment. We know in our heads that paediatric ETTs are squashable and dislodgeable but this becomes very relevant when we are using small ETTs in adult patients with airway compromise. At one point we intubated an adult with a size 5.0 ETT (I was totally ready for front of neck access which I thought was completely inevitable – have never been happier to be wrong) and although this worked brilliantly, we couldn’t readily fit the ETT over an adult bougie – and the problem with using a paediatric bougie is the length. Even with an uncut size 5.0 ETT you might struggle to maintain control of the bougie tip once the ETT is through the cords as there’s just not much to hold onto.
Remember deadspace in your circuit
When tidal volumes are tiny (i.e. in small children), deadspace in a ventilator circuit can preclude effective ventilation – you may remember anaesthetic colleagues’ preference for Mapleson F circuits for bag ventilation in kids (Ayres T-piece). Lots of great resources on this from our anaesthetic colleagues: Paediatric anatomy, physiology and the basics of paediatric anaesthesia from Anaesthesia UK is an excellent start, then have a look at this to revise the differences in Mapelson circuits. If you are going to use a mechanical ventilator, you should be aware of its own deadspace and consider whether the tiny tidal volume will actually allow gas exchange.
PEEP is your friend
This is true for paediatric patients and adult patients but especially for drownings. Consider that there is a lot of fluid in the lungs, either due to direct aspiration or early inflammation. Your go-to PEEP of 5 cmH2O may not be enough – don’t be afraid to increase if oxygenation is a challenge (it is likely to be)
Do you need an NGT?
Paediatric patients have often swallowed lots of air which can make invasive ventilation difficult – gastric decompression will make things easier. The same is true of patients who have drowned or near-drowned – water swallowing is common and decompressing the gastric contents may improve ventilation. It’s probably worth considering an NG for paediatric patients or drowning patients you are intubating pre-hospital (and in-hospital, for that matter).
ECMO CPR – what an amazing concept!
Sydney is currently recruiting patients to 2CHEER 5. Obviously we need to wait for published data but I am struck by how relatively quickly ECMO is considered for the resuscitation of patients here, compared to the UK. The ECMO-CPR guys are doing incredible stuff – if you’re interested, read more here with this FOAM resource: LearnEcmo.com
It’s hard to assess burns in darkness…
Actually, it’s hard to assess a lot of prehospital injuries in darkness. What is obviously a small or insignificant burn in the light of the ED resus room might not have been so obvious out in the dark and the pouring rain. The opposite is also true! In one particular case I really doubted myself on the severity of the burns the patient had (in the dark, in the rain) but decided to intubate anyway.
…But humanitarian reasons for intubation are legitimate
And my justification to myself for intubating that burns patient was for humanitarian reasons – i.e. it was kind. As it turned out the patient needed escharotomies in the burns centre we took them to, so it was a good decision – but in a similar way, be kind to your prehospital colleagues who need to make decisions with even less information than we have in the ED.
Not everyone loves ketamine
If you are using ketamine for analgesia, pat yourself on the back – it’s pretty great. But please consider small dose of midazolam to smooth the effects even if you’re using subdissociative dosing – some patients will defy you by dissociating anyway and not everyone loves it!
If the patient goes crazy on ketamine the answer is generally MORE KETAMINE. Once you’re on the edge of the K-hole and the patient is hard to manage or having an awful time, further ketamine will usually get you over the agitation by dissociating them completely. It’s not what we aim for if we are just treating pain but safety is also an issue for you and your colleagues.
But don’t forget the simple stuff
That said, it’s all too easy to just drug our patients if they get a little lively. Remember that simple touch can provide great reassurance and I managed to avoid additional ketamine for a patient who was otherwise pain controlled by holding his hand. It stopped him from waving his arms around in the stretcher and calmed things down beautifully.
Ideal care isn’t always achievable
Sometimes you won’t be able to deliver the care you’d ideally like to because everything in prehospital care is about balancing the patient’s needs about what you can reasonably deliver where you are. We made a decision not to intubate a patient who had rapidly dropped his conscious level as we landed on a hospital helipad but instead transferred him straight into ED. There were a number of reasons behind that decision; staff, equipment, lighting and the fact that it was very cold outside.
It’s good to talk
Talking about your view during laryngoscopy makes everyone calmer. In the ED in Australia the CMAC is the laryngoscopic weapon of choice but I still like to hear the intubating clinician talk about what they can see. This is a cultural norm at Sydney HEMS – we describe what we can see (or can’t see) including a POGO – percentage of glottic opening. Sharing that very specific mental model means that for the high-stress intervention everyone is on the same page. If you are supervising someone junior intubating and they aren’t giving that information, you can ask for it – “what can you see?” will often prompt exactly the response you are after.
It’s still good to talk
If you’re not intubating, you can perpetuate the cycle of calm. Providing regular reassurance on SpO2 during someone else’s intubation attempt makes everyone calmer and I do this routinely in the ED and outside it – “you have plenty of time, the sats are still 100%” in a calm voice reassures the person focused on the airway that you genuinely have an overview of the whole patient where they are task-focused.
What’s the blood pressure?
For most inter-hospital transfers, I’d ensure there was an arterial line in situ. They can provide wonderful reassurance… until you lose the trace in the back of an ambulance/helicopter/aeroplane. Take the time while on terra firma to correlate a non-invasive BP with your arterial line in case you lose it – then you should have an idea whether you can rely on your non-invasive monitoring until you are back on solid ground rather than messing about with aspirating, flushing, zeroing and all those rather distracting trouble-shooting tasks.
Peripheral noradrenaline can save your ass (and the patient’s)
Of course in an ideal world we’d run our pressors centrally, but central access is time consuming and can be very difficult. Most patients can tolerate single strength noradrenaline running peripherally for a period of time – again, this is a judgement call between urgency and clinical concern, but remember that it is an option and don’t be afraid to use it if you need to.
Next post in this series: leadership lessons.
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