Daniel J. O'Brien

Prehospital blind nasotracheal intubation by paramedics

Blind nasotracheal intubation attempts by paramedics in the field were prospectively reviewed. In particular, we analyzed the frequency, success rate, complication rate, frequency of performance by each paramedic, indications, and patient outcome. Blind nasotracheal intubation was attempted in 324 patients and successful in 231. The average success rate for medical patients was 72.2% (195 of 270 attempts) and for trauma patients was 66.7% (36 of 54 attempts). This difference was not significant (P greater than .05). Even with 59.8% of the 82 participating paramedics attempting blind nasotracheal intubation less than four times over the 19-month study period, the average success rate was 71.3%. There was a significant increase in success when blind nasotracheal intubation was attempted more than three times during the study period (P less than .005). Major complications occurred in 0.9% (three) of the patients. The overall complication rate was 13% (42). The incidence of complications tended to decline with increasing paramedic frequency but did not reach statistical significance (P greater than .05). Blind nasotracheal intubation is a safe initial field airway approach in spontaneously breathing patients in whom there are no contraindications. Even with a low frequency of performance, success and complication rates are acceptable.

Information-Sharing in Out-of-Hospital Disaster Response: The Future Role of Information Technology

Numerous examples exist of the benefits of the timely access to information in emergencies and disasters. Information technology (IT) is playing an increasingly important role in information-sharing during emergencies and disasters. The effective use of IT in out-of-hospital (OOH) disaster response is accompanied by numerous challenges at the human, applications, communication, and security levels. Most reports of IT applications to emergencies or disasters to date, concern applications that are hospital-based or occur during non-response phases of events (i.e., mitigation, planning and preparedness, or recovery phases). Few reports address the application of IT to OOH disaster response. Wireless peer networks that involve ad hoc wireless routing networks and peer-to-peer application architectures offer a promising solution to the many challenges of information-sharing in OOH disaster response. These networks offer several services that are likely to improve information-sharing in OOH emergency response, including needs and capacity assessment databases, victim tracking, event logging, information retrieval, and overall incident management system support.

Airway management of aeromedically transported trauma patients

The airway management of 176 consecutive traumatized patients aeromedically transported from the scene of injury was reviewed. In particular, the frequency of performance and time requirements for both blind nasotracheal intubation and cricothyrotomy were analyzed. Airway control was attempted in 70 (39.5%) patients and successful in 67 (95.7%). The average scene Glasgow Coma Scale (GCS) score of these 70 patients was 7.16 (SD = 3.94) and ranged from 3 to 15. For the remaining 106 patients the average GCS was 14.3 (SD = 1.36) and ranged from 6 to 15 (P less than .0005). The scene trauma score (TS) of the two groups was 10.2 (SD = 3.11) and 15.2 (SD = 1.38), respectively (P less than .0005). In the field, blind nasotracheal intubation by an emergency physician (n = 59) or paramedic (n = 3) was successful in 62 of 65 cases (95.1%). The complication rate for this procedure was 4.6%. Cricothyrotomy was performed in two patients. Only three orotracheal intubations were performed. The remaining three patients were nasotracheally intubated in the emergency department. Neuromuscular blockade was not used in either setting. Despite the difference in patient acuity, there was no statistically significant difference in scene or transport times between those patients emergently intubated and those who were not (P greater than .05).

Electronic weaponry — A question of safety

Electronic weapons represent a new class of weapon available to law enforcement and the lay public. Although these weapons have been available for several years, there is inadequate research to document their safety or efficacy. Two of the most common, the TASER and the stun gun, are reviewed. The electronic weapon was initially and still is approved by the US Consumer Product Safety Commission; its approval was based on theoretical calculations of the physical effects of damped sinusoidal pulses, not on the basis of animal or human studies. These devices are widely available and heavily promoted, despite limited research into their safety or efficiency and despite recent animal studies documenting their potential for lethality.

The evolution of air transport systems: A pictorial review

The air transport of patients began over seventy years ago in primitive biplanes. The ability to fly over the obstacles of the battlefield created enthusiasm in both the military and the medical communities. With the advent of vertical flight, the need for conventional runways was obviated allowing for casualties to be transported directly from the site of injury. After their introduction as air ambulances in 1945, helicopters soon supplanted ground ambulances with their speed and versatility. By the mid-1960s, civilian casualties were being transported by helicopter as regional trauma care developed in the United States. Today aeromedical programs continue to expand rapidly, even as closer scrutiny of their efficacy, cost, and safety are explored. A pictorial review highlighting the evolution of air transport systems is presented.

Long-distance fixed-wing transport of obstetrical patients.

Objectives: Aeromedical obstetrical transports are mostly performed utilizing helicopters. The program here reviewed performs mostly fixed-wing transports. The purpose of the current study is to review our fixed-wing transfers and identify the complications encountered. Methods: A retrospective review was conducted of the fixed-wing obstetrical air transports performed by the StatCare aeromedical transport service from July 1, 2000 through June 30, 2002. Information on each patient (age, gestational age, gravida status, diagnosis, preflight physical examination) was collected using a data sheet. Also noted were any described complications. Results: During the 24-month study period, 80 fixed-wing transports were performed. In-flight complications included nausea and vomiting (80%), increased contractions (8.8%), hypertension (1.3%), hypotension (1.3%), decreased maternal respiratory drive (1.3%), and infiltrated intravenous line (1.3%). Conclusions: The complications encountered during long-distance fixed-wing aeromedical transport of obstetrical patients include nausea and vomiting, increased contractions, hypertension, hypotension, decreased maternal respiratory drive, and an infiltrated intravenous line.

The impact of aeromedical helicopter programs on emergency medicine resident training: Resident attitudes, perceived risks, and benefits

Using emergency medicine residents as helicopter flight physicians is a recent evolution in residency training. In an effort to study the impact such a system has on residents in emergency medicine, residents participating in helicopter transport were surveyed at 10 programs in the United States. The potential survey field was 118 residents with (81%) responding. Generally helicopter transport was perceived to be educational (80%), enjoyable (88%), and safe (74%). A total of 75% felt that benefits of transport outweighed the risks, despite an increase in aeromedical helicopter fatalities in 1985. In six of ten programs residents wore shoulder restraints, in two they wore helmets, and in no program were fire-retardant clothing worn on a regular basis. Of the 72 residents involved in mandatory participation, 69% would continue flying in a voluntary system. Although it is clear that selected patients benefit from aeromedical transports, refined triage protocols as well as further studies to identify the costs and benefits of such transport programs to participating emergency medicine residents are needed. Flight safety equipment including helmets, shoulder-harness restraints, and fire-retardant suits are underutilized at all programs surveyed.

Percutaneous Transtracheal Ventilation: Resuscitation Bags Do Not Provide Adequate Ventilation

INTRODUCTION Percutaneous, transtracheal jet ventilation (PTJV) is an effective way to ventilate both adults and children. However, some authors suggest that a resuscitation bag can be utilized to ventilate through a cannula placed into the trachea. HYPOTHESIS Percutaneous transtracheal ventilation (PTV) through a 14-gauge catheter is ineffective when attempted using a resuscitation bag. METHODS Eight insufflation methods were studied. A 14-gauge intravenous catheter was attached to an adult resuscitation bag, a pediatric resuscitation bag, wall-source (wall) oxygen, portable-tank oxygen with a regulator, and a jet ventilator (JV) at two flow rates. The resuscitation bags were connected to the 14-gauge catheter using a 7 mm adult endotracheal tube adaptor connected to a 3 cc syringe barrel. The wall and tank oxygen were connected to the 14-gauge catheter using a three-way stopcock. The wall oxygen was tested with the regulator set at 15 liters per minute (LPM) and with the regulator wide open. The tank was tested with the regulator set at 15 and 25 LPM. The JV was connected directly to the 14-gauge catheter using JV tubing supplied by the manufacturer. Flow was measured using an Ohmeda 5420 Volume Monitor. A total of 30 measurements were taken, each during four seconds of insufflation, and the results averaged (milliliters (ml) per second (sec)) for each device. RESULTS Flow rates obtained using both resuscitation bags, tank oxygen, and regulated wall oxygen were extremely low (adult 215 +/- 20 ml/sec; pediatric 195 +/- 19 ml/sec; tank 358 +/- 13 ml/sec; wall at 15 l/min 346 +/- 20 ml/sec). Flow rates of 1,394 +/- 13 ml were obtained using wall oxygen with the regulator wide open. Using the JV with the regulator set at 50 pounds per square inch (psi), a flow rate of 1,759 +/- 40 was obtained. These were the only two methods that produced flow rates high enough to provide an adequate tidal volume to an adult. CONCLUSIONS Resuscitation bags should not be used to ventilate adult patients through a 14-gauge, transtracheal catheter. Jet ventilation is needed when percutaneous transtracheal ventilation is attempted. If jet ventilation is attempted using oxygen supply tubing, it must be connected to an unregulated oxygen source of at least 50 psi.