Notes from Trends in Emergency Care 2009

Friday I spent the day at Gundersen Lutheran, attending a seminar on emergency medicine. They have this every year. I am definitely going to try to go again next year, as it was excellent!

Here are my notes from the day:

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Trends in Emergency Care 2009

Friday, November 6, 2009

Session I and II: Agricultural Trauma

Dan Neenan, Paramedic Specialist Manager

National Education Center for Agricultural Safety (NECAS)

Peosta, Iowa

This lecture focused on farm trauma that upper Midwest EMS personnel are likely to encounter. Farming is a hazardous occupation. OSHA law does not even apply to it unless a farm has 12 or more employees, and that leaves out most family operations. Farmers live on their farms, so there are usually children around, and the teenagers usually help, representing an undertrained work force. Plus there are the old farmers. Dad may have sold the family farm to his son, but you can't keep him off that tractor when there's work to be done, and while the son may have bought a new tractor with updated safety features, the one Gramps will want to use is the one he is most familiar with, the old one. Plus, they don't want to put too many hours on the new tractor. So he ends up doing the grunt work, running the Bush Hog or pulling stumps, with the older tractor. Farming also tends to be a solitary occupation, especially with the trend over the past 30 or so years of the wife having to work outside the home to provide steady income and, more importantly, insurance. So if she is gone to work, the kids are in school, and Dad gets hurt in the field, it could be hours before anyone even notices he is overdue and goes out looking for him. The Golden Hour of trauma is lost long before anyone even knows he needs help. (Statistically, the busiest time for farm trauma is Tuesday mornings at about 10:30 for some reason.)

Neenan talked about the personality of the farmer in general. They tend to be extremely hard working and tough. They don't want to admit when they're hurt, and they don't want to stop working. It takes a lot for a farmer to admit he needs help, so frequently the 911 call doesn't even go out until things are really, really bad.

Neenan presented 4 clinical scenarios which were taken from actual case studies. He presented the scene through photographs and diagrams and had the group work out how they would take command of the scene and what steps they would take for extrication and transport. Along the way we learned many of the pitfalls of farm rescues, access being a big one. Most of the accidents happen far back on the Back 40 where you can't get an ambulance in and you have to hike the person out. He encouraged everyone to put Medlink on standby for any callout for farm trauma, just in case. They can always be told to stand down if you don't need them but it takes awhile to spin up the bird so you might as well get them in the air ready to go. Average time from 911 call to EMS on scene on a farm trauma is 45 minutes, and even if the trauma was reported immediately, that leaves only 15 minutes of the Golden Hour for transport. Use the helicopter.

The cases he presented were: A man who tried to clear a jammed grain auger on a combine and had his hand caught in it, and was not discovered for hours, by which time he was covered in snow; two teenagers riding a tractor, struck by a pickup on the highway; an inexperienced driver on an old tractor, trying to pull stumps with it (which they are not rated to do anyway), who flipped the tractor over onto himself; and one more. I think it was a grain bin entrapment but I cannot remember for sure.

By the way, grain bin rescues are unique in that usually only one or two EMTs will actually have eyes on the patient until after the rescue. He pointed out that this can be very tough for the rest of the EMTs on scene, who are maybe walking around outside the grain bin for up to 3-4 hours waiting for something to do. He pointed out the psychological effect of this on a person who wants – needs -- to rescue, and said that it can cause poor judgment and that Incident Command needs to be watching for this.

By the end of this lecture I wanted to sign up for the EMT-B class.

Session III: A Sneak Peep Down the Pipes (Airway Management)

Terry Dorshorst, RN, RRT

Kolby Kolbet, RN, BSN, EMT-P

Gundersen Lutheran Specialty Care – Transport and MedLink Air

Terry and Kolby brought in two anatomic specimens which they set up on a table at the front of the hall with a camera and projector so we could all easily observe on the screen. The specimens were porcine lungs, heart, trachea, esophagus and larynx. One specimen also had the aorta attached. They demonstrated various forms of intubation and the tools used. At long last I understand what LMA is because I saw it demonstrated on a pig! They did endotracheal intubations and then did some tracheostomies to show how that works. They showed how a collapsed lung inflates. They demonstrated hyperinflation and its dramatic effect on the lungs. They demonstrated a tension pneumothorax by stabbing holes in the lungs, putting a plastic baggie over the heart-lung specimen and then using the Ambu bag to try to inflate the lung, then demonstrated insertion of a chest tube through the baggie and how the lung quickly reinflated.

There was still some time left, so they demonstrated what an abdominal aortic aneurysm is by injecting water between the layers of the aorta. They also dissected one of the hearts to show the thickness of the left ventricle wall compared to the right. (A pig's atria are very small compared to a human's, in case you ever wondered.)

After the presentation, we were all invited to come up and play with the pig parts if we wanted to. This was right before lunch. :o)

Session IV: Should Tipping Be Allowed in EMS?

Tom Carpenter, NEMT-P, CCEMT-P

EMS Educator

Gundersen Lutheran EMS

Tom Carpenter, or “Carp,” presented this fairly light after-lunch session on tipping. His premise is that yes, tipping should be allowed in EMS – in fact it's mandatory. Only his twist on it is that he feels he owes his patients a tip. He has worked out a scale: They get a dollar for making him smile, five dollars for making him laugh, ten dollars if they teach him something new. He spent about an hour telling the stories of things he has learned on EMS calls and concluded by saying if he actually had to pay out the tips he owes in cash, he would be broke, so he puts them back into being a better paramedic for the next callout.

Session V: Underlying Psychiatric Disorders in Emergency Care

James Padesky, MS, RN

Nurse Therapist

Gundersen Lutheran Psychiatry

This was an excellent presentation on how to handle psychiatric emergencies as EMS personnel. Padesky was well prepared but also tailored the lecture to his audience so beautifully that he appeared to just be having a chat with us all. He asked for example situations that the EMS people present had faced in the past year or so. I believe over the hour 4 different people brought up their scenarios and how they had handled them. He led a discussion of each case and the strategy employed to help the patient. My husband told me that his EMS training skips straight from the part were the EMT tries to figure out what is wrong with the patient to the point where the patient is in the ambulance and is completely unhelpful in instructions on how to get the patient to get in that ambulance. That was what this session was all about: Gaining trust, establishing rapport and defusing a dangerous situation to the point where the patient is willing to be helped. Strategies that people had employed successfully mostly centered around the establishment of a real rapport with the patient based on cues on the scene and in the patient's behavior or speech. One EMT faced a locked door when her patient refused to allow her in, thinking the EMT had killed the patient's father. The EMT spent about 20 minutes on the other side of the door, talking with the patient “as if she were my grandma.” Eventually the patient unlocked the door. In another case, EMTs were able to establish rapport with a gentleman by picking up somehow on the fact that he had once been a fireman, engaging him in conversation about that, and then appealing to him to allow them to do the job he had once done so well himself.

Padesky also briefly touched on the difference between a psychiatric emergency that an EMT should be able to handle, and a situation where law enforcement needs to take over. An example would be any time there is meth involved. He said that's primarily a criminal situation, not a psychiatric one. Another would be where the patient has put a child or other helpless person at risk, essentially a hostage situation. That's the time to step back and let law enforcement work.

Session VI: I-35W Bridge Collapse

Kurtis Bramer, EMT-P, AS, CEM-MN

Supervisor, Emergency Manager

Hennepin Emergency Medical Services

Minneapolis, Minnesota

This was a wonderful session that talked through the EMS response to the I-35 bridge collapse. We heard the early 911 calls and analyzed the response from that moment on till the last body was gently and respectfully carried to shore. Bramer's team was in charge of all the EMS response and credits its success to careful planning long beforehand, so that people did not have to consult a playbook or wait for direction, but smoothly stepped into what they had been trained to do. His response plan's strength is its flexibility. It is a very lightweight plan where people's duties are assigned based on how quickly they arrive on scene. For example, the first EMS person on scene always takes the position of EMS Branch Director/Transportation. The second EMS person, who is usually the first person's partner, takes on the job of Triage Supervisor. The second ambulance in goes straight to the EMS Branch Director and is assigned a job from there. Everybody is trained for all jobs, so anyone can step in and do the job. There are specific directions on how to identify oneself on the radio, instructions to do face-to-face communication any time it is practical and stay off the radios as much as possible, and to avoid the use of cell phones entirely unless there is no choice.

The I-35W bridge collapse represented many huge challenges, geography being a big one. There are no boat landings near there. The river is encased in concrete banks with no place to get down there and pull people out of the river, no way to get a boat up there unless you go way downriver. Plus it's right below the lock and dam so you cannot approach it from upriver. The bridge itself dumped all kinds of rebar and concrete into the river. The bridge deck was about 70 feet above the water line, so cars had already fallen a great distance by the time they came to rest, and so had the people inside. One area, where the bridge had fallen straight down from a pilon, had formed what they called “The Pile,” a several layers thick heap of concrete, rebar and cars. People were trapped in there.

There were jurisdiction issues to hash out at first, too: The state highway patrol said they were in command, since it was an interstate. Minneapolis city police thought they should be in command, as it took place in their city. Hennepin County Fire thought they were the obvious choice. And EMS just wanted to get a good handle on who might be hurt, and where.

There was a huge response from fire departments and EMS personnel from all over the place, which is admirable, but there were very few access roads to the area that were not already blocked, and all the additional traffic actually hindered the rescue efforts. That tide was actually turned by a few people on foot who started directing traffic and kept vital access roads open for EMS. Private citizens in pickup trucks also ended up running patients out to where the ambulances could park, which was vital.

Bramer commented on the bigheartedness he saw that day, how many people he saw who were wounded but would not leave the collapsed roadway, persisting in rescuing people from cars. He talked about a man with a flail chest who simply would not stop working until finally he was so short of breath that they were able to get him into an ambulance. Trucks from various area restaurants and food service suppliers showed up to help feed the rescue people. We saw slides of people in shorts and flip-flops, climbing around in the rubble trying to rescue others. It was a little frightening to see, but you have to admire their concern for their fellows.

Bramer discussed the effect of shock on EMS personnel and how it clouds judgment. One of the early 911 calls was from a very experienced EMS officer. His voice sounds so calm on the tape. Yet his shock is evident in his choice of words; he understated the magnitude of the collapse and politely requested “three or four units, if you have them available.” It was not ignorance on his part, it was shock that made him make this erroneous call.

This presentation was fascinating in that he told about both successes and failures. Over all the effort can only be seen as a giant success. When one considers the possibilities, the fact that only 13 died is a success. He also pointed out errors that were made in the field that he hopes to learn from. In context, these mistakes were not major, but they were things that could have been done better, certainly. One was that the “walking wounded” were not attended to. An EMS team that was on the scene early in the situation was met by a large crowd of shocked, frightened but still mobile survivors and directed them to take rest in a grassy, shaded park area, but then they did not leave anyone with them to take care of them, and by the time someone went back to check on them, they had all left. Some of them surely needed help but did not get it.

Another mistake was when the mobile command post was first set up right in the middle of the Tenth Street Bridge. It offered an excellent view of the scene, but was a poor choice of site because nobody knew yet what had caused the I-35 bridge to collapse. What if it was terrorism? A favorite tactic of terrorists is to stage a second blast for an hour or two after the first, right where emergency personnel are likely to set up. He encouraged EMS commanders to practice running an operation without line of sight of the scene. He asked, “Do you really need to SEE the accident to run it?” The answer is no, yet as helping personality types, we tend to want to have eyes on scene. It takes practice to run it without seeing it, and he encouraged that.

And another mistake was in supervision. He showed a bunch of slides of rescue personnel taking risks with their own safety in an effort to rescue someone. He said that this is a supervision problem. He said that when helping personalities are all wrapped up in their effort to save someone, they tend to do things they would normally realize are too risky. For example, there were guys in full bunker gear working at the water's edge. Bunker gear does not float. If it gets wet, you sink. That was not really the fault of the firemen, it was the fault of their supervisor who should have been checking on them and reminding them gently to be safe themselves.

He touched briefly on the response from Hennepin County Hospital. There was not a lot of hard information coming out of the scene at first (another mistake he admits), and someone had to make the decision to put the hospital on an alert status. As he put it, that's a “six hundred thousand dollar decision.” Whoever it was did make the decision to go on alert and it turned out to be correct, of course. I was interested to hear that one part of the alert is to clear the ER and trauma bays. They make a sweep through and immediately admit everyone who is waiting who is actually sick, saving further assessments till later, and everybody else, they send home. That must be a hard call to make. For starters, that's money going out the door. Plus they might be sending home someone who really needs help. But that's the call they have to make. Within about 20 minutes they had cleared the ER, had most of the trauma bays open and staffed, and had cleared out and staffed several ORs.The staffing part is probably what made the effort pay off so well; trauma patients were in the door and on the table in a matter of minutes.

My husband attended a presentation on the same topics a year ago by the same gentleman, and he commented how much the presentation had improved over the months. He recalls that Bramer had a lot of anger to express the first time around, and wonders if maybe it was just too soon after such a traumatic event for Bramer to have processed things sufficiently. This is now an excellent presentation, informative and inspiring.