Transcript Michael Abernethy, MD, FAAEM

Best of Med Flight
Landing Zone Preparation &
Communications
Why is this so important?
Undesignated / Spontaneous LZs
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High risk –espc at night
Obstacles on approach Wires Cell Towers
Ground hazards – signs, poles debris
LZ security – people vehicles
How well was it scouted out –we are
100% dependent on your eyes
Alternate LZs.
You don’t have to land
the helicopter exactly at
the accident scene
That’s why God put
wheels on the ambulance
Designated LZs
Communication
• MF dispatch 608-263-3258
• Your county 911 dispatch
• Cell contact on scene
Initial Info
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Location – street and cross street
Relationship to city, well known landmark
Contact agency
Cell contact on scene
Contact frequency – Typically Marc 2
Incident type and basic patient info
Do you need more than 1 helicopter?
Radio contact
• MARC 2
• 5-10 minutes out
• Use vehicle radios – handheld have
limited range
• Our #1 interest – LZ information
• VERY brief patient update
What to do if no
radio contact ?
Common LZ Problems
• Personnel “marking” the LZ
• Personnel approaching aircraft before
blades stop turning
• LZ security once helicopter lands
• LZ has to be secured 5 minutes prior to
landing until 2 minutes after takeoff
• No vehicle, regardless of height within 50
ft of aircraft. Especially ambulances
Brownout / Whiteout
Large Patients
Im not afraid of heights
Im afraid of widths
Meanwhile in Germany…
A Slippery Slope..
• Car 1 looses control on ice at highway
speeds
• Collides with car 2. Both go over 30
degree embankment
• Car 1 slides sideways, impacts tree into
drivers door
• Car 2 T-bones Car 1 into passenger side
• 2 occupants of car 2 self extricate –minor
injuries
• EMS arrives – Extensive damage toCar 1.
Driver is obviously pinned. Talking but
confused
• Walmart parking lot 200 yrds from scene
• Med Flight called – Landed within 15
minutes
• Significant intrusion on both passenger
and driver doors
• Pt alert, confused, slightly agitated. Pinned
by legs
• Complaining of chest/abd pain
• Collar placed. IV established, O2
• Initial VS 150/80 100 18
Wisconsin EMS Rule 11a
If it is Saturday night and you
respond to an accident scene after
10pm and do not find a drunkKeep looking because you are
missing a patient
CAR 2
CAR 1
Initial Approach
• Car 2 winched up towards highway
exposing passenger side of Car 1
• Plan is to remove passenger door and top
Additional support personnel
beamed down from the Enterprise
The concept
of “Holding
the C-Spine
”
Passenger side is no go
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Now at 50 minutes post incident
Outside temp 35 F
Patient becoming more agitated-yelling
BP dropping 100/70
Lets hold things for a minute..
Medical Interventions
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Given Ketamine 50 mg IVP
IO placed in L humeral head
Concern re internal bleeding –TXA
Started PRBCs
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Pt BP improves slightly
Dissociated state –protecting airway
T= 50 mins Tree cut away
Top removed
Pt starts to vomit and vomit and vomit
EMS rules regarding vomit
• The volume of vomit always exceeds the
size of the container be a factor of 2
• Standard suction is useless for Saturday
night puke ( consists of McNuggets &
partially chewed burritos pressurized by a
pitcher of Milwaukee's Best) –you need a
shop vac
• Always point the pt at the person you like
least
Tailoring the Extrication
(speed/spinal precautions) to
the patients condition &
environmental issues
Situation a little more urgent
• Pt quickly put in a KED
• Lifted out – put on long board
• Transferred to ambulance
Why don’t you just put him in
the helicopter and go?
In the Ambulance
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Initial GCS 13 –now 7
Pt intubated using Glidescope
Given 2 units of PRBCs
10 minute flight
To the trauma bay….
In The Emergency Dept
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BP 90-100 systolic
Labs –hgb 8.5 Etoh 0.19
FAST exam with ultrasound positive
CT scan of head/neck – negative
CT Scan of abd/pelvis – extensive splenic
laceration
What is a FAST exam?
Focused Assessment by
Sonography for Trauma
Taken to the OR
• Uneventful splenectomy
• Transfused total of 4 units PRBCs
• Discharged to home POD 5
Case #3
16 y/o healthy female
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Alone in the lap pool at waterpark
Found unresponsive in 4 ft of water
Immediately picked up on security video
Submerged 3-4 mins MAX
Park EMTs pull her from water, no pulse
911 called
Start CPR, AED applied, shock advised
Immobilized, C-collar
We have a pulse
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Local paramedic service arrives
VS 110/60 HR 120 irreg
Bagged on 100% O2 sats 85%
No evidence of trauma
Frothy sputum, bilat rales
GCS 6-7 Pupils 4-5mm reactive
IVs x 2
Prior to MF
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Pt intubated, high airway pressures
Freq suctioning,
12 lead –freq multifocal PVCs, no STEMI
MF lands at hospital helipad as ambulance
arrives
Handoff
• Vital signs and Neuro status unchanged
• Pt sedated, paralyzed put on ventilator
• What is the history again??
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Uneventful flight Home
Handoff to ED
Evaluated in ED – head CT NL
CXR – pulmonary edema
Most labs and studies c/w drowning
Admitted to PICU
Its just another tragic drowning..
Whats the history again?
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16 y/o healthy 5’ 7”
No etoh, drugs, trauma
Lap pool is 4’ deep
Call to the water park – Can you pull the
security videos?
• What about the initial AED?
Torsades de Pointes
• Polymorphic Ventricular Tachycardia
• Caused by:
• Congenital mutation of cardiac electrical
system
• Electrolyte abnormalities
• Drugs
Radically changes treatment
• Not just a drowning
• It’s a drowning caused by syncope caused
by cardiac arrhythmia
• Drowning similar to geriatric falls- What
caused it? Primary vs secondary
Secondary Drowning
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Trauma / CHI
Seizure
Drugs/ETOH
Cardiac Syncope
Hot Tub issues
ICU Course
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Aggressive pulmonary support
No electrolyte abnormalities
Neuro status improved quickly
Extubated on day #4
No neuro deficits
Cardiology consult
Electrophysiology Studies - EPS
Found to be at high risk for
malignant arrhythmias
Next Step
AICD – Automatic Internal
Cardiac Defibrillator
Discharged to home
• No Meds
• Normal activities
• No restrictions
In closing, Just two words
Altruism
Awesome
This is the official “You Are Awesome” notification
from the UW Emergency Care Conference staff
indicating how awesome you actually are
Fini . .
@FLTDOC1
[email protected]