For the past few decades, the importance of spinal immobilisation has been emphasised in standard texts, trauma education such as the international Advanced Trauma Life Support (ATLS) & Pre-Hospital Trauma Life Support (PHTLS) courses and in many emergency medical service (EMS) operating procedures. Such approaches often mandate the universal application of spinal immobilisation to trauma patients [1,2,3].
This approach is based on the logic that spinal injuries are not uncommon in trauma patients and that EMS must adhere to the notion of primum non nocere (‘first do no harm’), by ensuring that potential spinal injuries are not exacerbated during patient extrication and transfer.
As a result, traditional dogma has emphasised the application of a semi-rigid cervical collar (C-collar) for all trauma patients and has until relatively recently included the mantra of transfer of patients on a rigid ‘spinal’ board.
“I’ve been teaching the ‘ATLS handshake’ on ATLS-EMST courses for the past few years…but have become increasingly concerned with the blind application of semi-rigid collars to patients, without considering nuance of the circumstances.
“This is especially relevant in rural areas, where facilities for imaging are often limited – the requires subsequent transfer if clinical suspicion exists and the possibility of patients suffering harm from being immobilised in C collars for prolonged periods”
The rationale for spinal immobilisation is based upon the principles that :
trauma patients are at risk of spinal injuries
trauma patients may have an unstable injury of the spine
further movement of the spine could cause further damage than that originally sustained
spinal injures can cause significant morbidity and mortality
the application of a semi-rigid C-collar and spinal immobilisation device prevents potentially harmful movement of the spine
measures to provide immobilisation of the spine are in themselves harmless and can be applied to a large number of patients as a routine ‘precaution’
Spinal injuries are associated with trauma, of that there is no doubt. Global incidences of spinal cord injury are reported to vary from 8-246 cases per million, likely reflecting reporting and coding variability as well as socioeconomic and geographic differences . Similarly the sequelae of spinal cord injury are not contested – the potential adverse morbidity and mortality from cervical injuries can be catastrophic, as evidenced by those unfortunate enough to have suffered traumatic injury to the cervical spine (C-spine) with neurological sequelae. High cervical injuries can be fatal or cause quadriplegia, lower spinal injuries can cause permanent disability, reduced ability to work and decreased quality of life, with deficit relating to level of spinal cord injury. However, the times they are a’changing.
The Dogma of Cervical Collar Application
The notion of minimising further movement of the cervical spine in a trauma patient appears intuitively logical, especially mindful of the potential catastrophic damage of a cervical injury. Thus traditional teaching and practice has been for early cervical spine immobilisation. This may take the form of manual immobilisation, application of a semi-rigid C-collar or the use of head blocks and tape.
Whilst manual immobilisation may be appropriate for initial responders prior to the application of a collar, it does require both hands of the rescuer. Thus use of C-collars has been practiced widely by many prehospital services to both free up personnel from the provision of manual immobilisation and in accordance with the notion of minimising further injury to the C-spine.
But why worry about the use of C-collars? Are they not a simple intervention where the potential benefits mandate routine application? Sadly the answer is no. A more nuanced and targeted approach is necessary. This is in recognition of not only little evidence of benefit, but also the potential for harm [5,6]. Poorly fitted collars are not uncommon and may cause harm.
Other harms may include:
obscuring injuries by presence of a collar 
increasing scene time [6,7]
raising intracranial pressure by impediment of venous return [8,9,10]
limiting mouth opening and hampering airway management [11,12,13,14,15]
causing lateral flexion or unrestricted movement if incorrectly applied 
forcing those with pre-existing deformity or fragility of the C-spine into harmful positions via injudicious application 
pressure necrosis from the collar itself if left in situ for > 2 hours [18,19]
Trauma patients are a heterogeneous population. It is perhaps easiest to consider mechanism of trauma as being classified into either penetrating or blunt to guide further discussion. These classifications are not exclusive; some patients may have a combination of blunt and penetrating injuries.
The literature shows that routine application of C-collar to patients with isolated penetrating trauma is at best of no benefit and indeed may cause harm . Oteir et al have recently conducted a systematic review confirming that C-collar application in penetrating trauma is associated with increased scene times and concealment of neck injury, with C-collar application associated with increased risk of mortality . The overall recommendation is that patients with a single isolated penetrating injury do not need a C-collar, unless there is additional evidence of significant blunt force trauma or flexion/extension injury to the C-spine.
What then of the remaining patients? Those with blunt force trauma and a significant mechanism of injury, or those at particular risk (such as the elderly)? Or the unconscious patient? Although controversial this offers an opportunity to re-examine established dogma with a view to developing a more nuanced practice.
(i) the awake patient with blunt trama:
One can posit that application of a C-collar will minimise movement and reduce the risk of downstream injury. However the application of a semi-rigid C-collar is not proven to minimise spinal movement. A 2015 International Liaison Committee on Resuscitation (ILCOR) draft consensus statement analysed the question as to whether spinal motion restriction affected key ‘critical outcome’ measures (including changes in neurological injury, complications, overall mortality, pain, patient comfort, movement of the spine and overall outcome . The reviewers note the paucity of evidence for restriction of spinal motion, with C-collars – commenting that studies are limited as based on either healthy volunteers and cadavers. The consensus statement argues against routine spinal motion restriction for both adults and children with blunt trauma and suspected C-spine injury. Tellingly this draft states “because of proven adverse effects in studies with injured patients, and evidence concerning a decrease in head movement only comes from studies with cadavers or healthy volunteers, benefits do not outweigh harms, and routine application of cervical collars is not recommended”
Hauswald and colleagues argued back in 1998 that the initial traumatic impact will cause injury to the spinal cord with subsequent movement unlikely to cause further damage . Subsequent to this, a 2001 Cochrane review failed to demonstrate a benefit to routine application of cervical collars ; yet a decade later this has remained a ‘standard of care’ espoused by many emergency services.
Perhaps most problematic is the otherwise well patient who complains of midline cervical spine tenderness in the absence of a neurological deficit. Such patients have traditionally been placed in full spinal precautions and transferred for imaging – indeed, examples abound of patients involved in motor vehicle collisions who have self-extricated and been placed in an undamaged vehicle pending assessment, who have then developed cervical pain and required extrication with full spinal precautions – even to the point of being cut from a vehicle that was not involved in the accident.
In the UK, unthinking application of a spinal immobilisation protocol has lead to farce after patients self-extricate from crashed vehicle…relocated to police car…then complained of neck pain!
This begs the question as to the natural history of patients who may have suffered a C-spine injury but are neurologically intact and otherwise well. How should EMS move forward in the face of uncertainty of the benefits of routine C-collar application and the understandable concern of an unstable C-spine injury causing devastating neurological sequelae?
For conscious trauma patients, the development of reliable cervical spine screening tools such as the Canadian C-spine rules and the NEXUS criteria allows the possibility of rapid exclusion of clinically significant C-spine injury according to defined criteria . However this requires consistent application of these rules, which may be problematic where significant heterogeneity exists in EMS responders (for example, different skills mix between volunteer ambulance officers, paramedics, intensive care and extended care paramedics). Nevertheless, whilst the superiority of NEXUS vs Canadian C-spine rules has been contested , they can be taught relatively easily. However as Benger & Blackham comment “the specificity of both rules is such that they still mandate immobilisation in a large number of injured patients” .
A more pragmatic approach may be to consider that those patients who are able to self-extricate and mobilise are often able to stabilise and protect their own C-spine . Thus a mature prehospital service may decide not to routinely apply C-collars to patients with penetrating trauma alone, to those who fulfil validated screening tool criteria and conscious, stable and cooperative patients without distracting injury who are able to protect their own C-spine. Some patients may wish to lay supine or find comfort in the support of a collar and this should be accommodated where possible. However for the vast majority of patients, a C-collar merely indicates that a potential cervical injury has occurred (one could equally well use a red dot or triage tag). Hence Benger & Blackham’s suggestion of transporting such patients in the “position of comfort” and ensuring that any concern regarding potential spinal injury is communicated to the receiving team .
(ii) the patient with reduced level of consciousness and blunt trauma
As discussed above, conscious patients, even those with a suspected cervical spine injury, are able to protect their own C-spines . However those patients with a reduced level of consciousness cannot. Nor may they be able to protect their own airway. A balance needs to be determined between airway management and spinal immoblisation. On occasions there may be competing priorities between the need to minimise spinal movement AND maintain airway patency . Use of a left lateral or HAINES (High Arm In Endangered Spine) position may be required to provide a stable airway whilst minimising the risk of secondary spinal injury, with no reported difference between techniques .
However both of these positions did produce potentially clinically significant movement of the spine; moreover it must be remembered that blunt trauma patients may also have other significant injuries, not least pelvic disruption. A strong argument can therefore be made for early airway intervention in such patients, then immobilisation in a manner to minimise further handling and protect not just spine but also pelvis and long bones, minimising further injury and the risk of decubitus ulceration. This will be discussed in greater detail under consideration of total spinal immobilisation below.
For the unconscious patient, some form of C-spine immobilisation may be considered – but not at the expense of impeding airway management. Other considerations such as the effect of C-collar on intracranial pressure (ICP) and scene time must also be considered. In a provocative paper, Sundstrom et al. propose abandoning the use of C-collars in this cohort, transporting those with unsecured airways as expeditiously as possible, without a C-collar and in the left lateral position to definitive care .
Of course, a mature EMS should be able to deliver definitive care in the field. Provision of advanced care such as pre-hospital RSI, inotropic support and blood may afford not just a patent and protected airway, but also the neuroprotective benefits of normoxia, normocarbia and normotension. In contrast to Sundstrom’s proposal of transporting unintubated patients with decreased cosnciousness in left lateral, such patients may be better served by early intubation then be transported supine with measures instituted to minimise spinal movement.
Spinal Immobilisation & The Curse of the ‘Spinal’ Board
Reference to the ‘spinal’ board has been a mainstay of ATLS teaching until very recently. Indeed it is only with the advent of the 9th edition of the ATLS manual that emphasis on the rigid backboard has been swayed from discussion of a ‘spinal protection’ device to an ‘extrication device’ , although many course directors (self included) have purposefully de-emphasised the use of rigid boards for immobilisation for many years prior to approved changes in the ATLS manual. Standard principles of ‘splinting to skin’ and the potential for long transport times (particularly in the rural Australian context) risk the very real danger of pressure necrosis from patients stripped naked and placed on an uncomfortable hard board for transfer to definitive care. Even short periods of immobilisation are associated with consequent pain, a problem worse for patients with altered consciousness or who are intubated and unable to move [28,29]. There is also some evidence that immobilisation on a hard board can cause a reduction in respiratory function [30,31]. For awake patients, there is the potential for motion sickness and vomiting whilst secured supine .
Like the C-collar, rigid boards may still be used in the prehospital setting as an extrication device to facilitate extrication, but have no role to play in spinal immobilisation per se. How then to provide spinal immobilisation in the pre-hospital environment? Supine patients may be best transferred from ground to stretcher using a scoop mattress to minimise movement (bear in mind that patients with clinically significant spinal injuries are at risk of other injuries such as unstable pelvic fractures, thus the dogma of log-rolling on/off a hard board risks worsening both spinal injury, pelvic injury, and skin integrity) .
Newer devices (such as the vacuum mattress or ‘vac mat’) offer both spinal immobilisation from head-to-toe, as well as minimising risk of pressure necrosis . They form a ‘cocoon’ for both conservation of heat and minimising spillage of bodily fluids. Transfer from scoop to a vac mat should preferably occur with a pelvic binder already in situ if there is clinical suspicion of pelvic disruption. If there is concern regarding clinically significant movement of the C-spine despite vac mat, then additional measures such as head blocks may be used (avoiding C-collars due to potential for raised ICP) .
Thus both the traditional dogma of immobilisation on a rigid ‘spinal’ board and universal application of a C-collar to all patients with suspected spinal injuries are being questioned by many [35,36]. Instead careful patient selection and use of appropriate immobilisation is advocated.
A Pragmatic Approach for Spinal Immobilisation of Pre-Hospital Trauma Patients?
Trauma medicine and pre-hospital care is characterised by the need to make decisions based on a paucity of evidence, making decisions based on the best available evidence and adjusting over time.
One criticism of many of the published reviews of the use of C-collars is that many, whilst explaining the problems of routine C-collar use and documented harms, fail to recommend a practical approach to spinal immobilisation for the future – instead opting for motherhood statements regarding the need for further trials [2,3,4,5,6,7].
Whilst data from large scale randomised controlled trials is preferred, there needs to be careful consideration to the appropriateness of universal C-collar application to trauma patients by EMS providers, mindful of the fact that C-collars are not without risk. Individual EMS may wish to develop their own protocols, under a clinical governance program, to tailor spinal immobilisation strategies according to skillmix of providers, of available devices, of casemix and accounting for transport times . Indeed some EMS have abandoned the use of semi-rigid collars, guided by both literature showing absence of benefit and potential harms, as well as expert opinion.
The Queensland Ambulance Service has recently made a move to replace hard collars with soft, which may be appropriate for both awake and unconscious patients facing prolonged transport times . In contrast, as proposed by Sundstrom recently, Norway EMS providers are moving to abandon routine use of C-collars and transport unconscious, unintubated patients in the left lateral position .
Development of protocols, guided by expert consensus, allows the opportunity for large multi-centre randomised controlled trials to guide future refinements. In the meanwhile a practical approach to spinal immobilisation may be considered as below – using C collars and rigid boards purely to facilitate extrication
Thus best evidence is that C-collars at best serve as a marker that a patient has a potential cervical spine injury. The routine application of a C-collar is inappropriate in isolated penetrating trauma and in patients who are alert, cooperative and can self-maintain neck immobilisation in the absence of a distracting injury. use of NEXUS and Canadian C spine criteria may be helpful in initial assessment by trained providers.
Collars can cause potential harm, so for those patients for whom a cervical spine injury is suspected it may be appropriate to consider manual immobilisation (subject to ergonomics and availability of expertise) or alternative measures including use of a C-collar purely during the extrication phase.
Subsequent management may include the use of soft cervical collars for both awake patients (if desired by patient) and unconscious patients (although the latter may benefit from the use of head blocks to prevent the head from ‘lolling’). In a subset of those unconscious patients for whom airway protection has not been achieved or unavailable, consideration should be made towards transport in the left lateral position, minimising spinal movement.
Rigid boards should only be used as an extrication device, with preference given to minimal handling (avoid log-rolling) using scoop stretcher to lift onto a stretcher to allow complete spinal immobilisation via use of a vacuum mat, supported by pelvic immobilisation if indicated.
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Every now and then, discussion amongst clinicians turns to the hypothetical of “what if you were stranded on a desert island?” and then leads into fierce debate on emergency drugs, preferred contents of a doctors bag or various airway devices.
Of course all of this is hypothetical – not many of us are going to be stranded, Lost-style, on a desert island and forced to manage an airway. In an ideal world we’d all work in a well-stocked theatre or ED with a variety of equipment to manage the difficult airway…
But many of us do work in areas where choice of equipment is needfully limited – such as in the prehospital and retrieval environment, or in rural & remote areas. Limitations may be imposed by cost, by size and shape, by weight or by need to fulfil various functions.
To my mind equipment for airway management in such areas should be not just readily available, but allow a suite of options, be affordable and offer advantages in both routine and emergency situations. Standard difficult airway plans usually revolve around Plans A, B, C & D
Plan A – Primary intubation strategy (eg: direct or videolaryngoscopy)
Plan B – Alternative intubation strategy (eg: videolaryngoscopy or intubation through LMA as conduit)
Plan C – Maintenance of ventilation (eg: bag-mask ventilation, supraglottic LMA ventilation or to allow awakening (the resumption of spontaneous ventilation requires no residual paralysis)
Plan D- Rescue techniques for the “can’t intubate, can’t ventilate” scenario ie: emergency surgical airway
[of course, plans may be adapted to suit patient eg: initial plan for an awake fibreoptic, with back up plan in case of deterioration involving double-set up of ‘one look’ laryngoscopy, then rapid progression to a primary surgical airway in a case of massive supraglottic oedema, etc]
Much has been written elsewhere about DL vs VL and Emergency Surgical Airways. I won’t rehash them here, but instead point interested people towards EMcrit here and here respectively…. but what of the humble LMA in our airway plannng?
For many years, the Classic LMA (cLMA) has been the stalwart of rescue ventilation. It is a familiar tool to many – indeed can be placed by trained volunteers such as ambulance officers in rural and remote areas. But the design has been improved; many second-generation LMAs offer the following :
gastric drainage channel
ability to allow higher ventilation pressures
Many ambulance services have considered switching from the Classic LMA to the LMA Supreme (sLMA), as it has both bite-block, gastric drainage and allows higher pressures than the cLMA. However, like the cLMA, the sLMA is a lousy conduit for fibreoptic intubation.
Other devices exist, for example the Ambu AuraGain – an LMA which has bite block, gastric drainage and is specifically designed to function as a conduit for fibreoptic intubation via LMA. The iGel (pictured above) is in a similar mould, although like the Ambu does not allow BLIND passage of an ETT for intubation.
“the ability to place an ETT through an LMA, whether blind or with a fibreoptic scope, is a powerful combination for a back-up airway device”
Of course for placement of an ETT blindly through the LMA, there is the FastTrach intubating LMA. This has been around for a while, and allows blind intubation through the hyperangulated channel. Success rates for blind intubation through the device are good, reportedly at 81-100% – success can be improved to 95-100% with a flexible fibreoptic scope using the FastTrach as a conduit to facilitate intubation.
Flexible fibreoptic intubation is not a skill available in many austere environments, nor necessarily a skill of many emergency physicians…but a malleable fibreoptic stylet is both relatively easy to learn and can be a cheap addition to a difficult airway kit. But the hyperangulated channel of the Fastrach won’t accommodate a malleable stylet!
Other problems of the Fastrach are that it has no gastric drainage port, which seems to be a major downfall in a product designed as a rescue device in an emergency.
It is also notoriously difficult to remove the LMA over the ETT once in situ – best advice is to leave the LMA-ETT complex in situ once successfully placed, and perform a careful removal in a place of safety such as the operating theatre with multiple backups. There have been cases of the airway being lost during removal of the LMA over ETT, most notably as part of the cascade of catastrophes in the infamous Gordon Ewing’s or ‘exploding scrotum’ case…
Moreover the Fastrach is a bulky device and primarily used as a backup LMA specifically for placement of an ETT. It does not come in paediatric sizes. It would NOT be your primary LMA for rescue ventilation or use in a prehospital pack, although some use it as a backup backup LMA…
The Desert Island Airway
The IDEAL device for use as part of an airway kit in an austere environment (the ‘desert island airway’) should serve as a backup for laryngoscopy, allow gastric drainage, have an integral bite block, be relatively compact and able to serve as both primary and backup LMA, and finally to allow both BLIND and FIBREOPTIC intubation.
The AirQ is such a device. I think it’s the bees knees for my difficult airway kit – and I am not alone (EMcrit covered this device ages ago – it has seen some improvements since)
I had the unexpected good fortune to run into Dr Daniel Cook last week at Adelaide airport; Daniel was over in Adelaide for the ANZCA Anaesthetic Conference and headed stateside..whilst I was on y way to Melbourne to instruct on the rather excellent “critically ill airway” (CIA) course with a star-studded Australian faculty.
There are several AirQ devices in the family – I am a growing fan of the Air-Qsp blocker model. There’s no pilot balloon, the LMA cuff self-pressurises. Most importantly it comes in a variety of sizes and is both cheap and small enough to serve as primary rescue LMA AND as an intubating LMA.
If I had to chose one LMA only, then this device ticks boxes for both prehospital service or use on the airway trolley in an austere environment (ED resus, ICU, ward, rural etc). It has advantages of being
of a compact size for storgae in pack or trolley
range of sizes
allows simple ventilation as an LMA
allows placement of an orogastric tube to drain stomach
has an integral bite block
allows intubation either blind, or via fibreoptic device (both via expensive flexible scope or cheaper malleable stylet)
It’s also a lot less fiddly to remove an LMA over the ETT when placed via the AirQ than the Fastrach and has some nice touches – the anaesthetic circuit connector is detachable but is held in place via a plastic retainer (it’s very easy to drop these connectors when under stress or hands slick with saliva, blood or lube)…the packaging also contains a bronchoscope adaptor, allowing ongoing ventilation if decide to place an ETT by flexible fibreoptic scope – a little detail, but an absolute boon as prevents “needless faffing around looking for a bronch adaptor” in a time of crisis!
Staged Airway Management for Transition from Prehospital to ED Care
But I think the REAL game-changer is that use of such a device allows a staged approach to airway management. In the past, I’ve seen ambulance services place a classic LMA for eg: OOHCA – typically this is where intubation is either not an option (volunteers or paramedics) or has failed despite being within their skill set (difficult intubation).
Leaving aside the fact that such the classic LMA device do not accommodate high ventilation pressures, their downfall is that that cannot function as a conduit for an ETT nor do they have a bite block or gastric drainage.
So the OOHCA survivor may arrive in ED Resus, with a soiled airway, biting down on the cLMA and now generating negative pressure pulmonary oedema….and the resus may grind to a halt as the ED team take out the LMA and perform laryngoscopy to place an ETT. We would see the same with the Supreme LMA (although both gastric drainage and bite block are significant advantages)…but due to the narrow diameter of the channel, the sLMA still needs to be removed if an ETT is to be placed. The iGel and Ambu AuraGain do allow passage of an ETT…but only with a flexible fibreoptic scope – rarely available immediately in ED. So blind intubation is probably best in the ED via an LMA placed earlier in the prehospital arena…
The Fastrach allows blind intubation, but is expensive and bulky, so unlikely to be used as the primary back up airway in a prehospital service. Gastric drainage is not possible unless one deflates the cuff to allow tube passage…it’s a good device…but too expensive and bulky to be used as primary LMA, in my opinion.
To my mind the Air-Q LMA actually allows a staged approach to airway and progression from prehospital to hospital or as ascend the airway skill gradient. Specifically, it is
small enough and cheap enough to be available across a prehospital service or rural hospital network
allow gastric drainage and high ventilation pressures, with an integral bite block
can be placed by relatively inexperienced staff
then allows an ETT can be placed blindly by success rate improved with either a malleable fibreoptic stylet or a flexible fibreoptic scope in the ED whilst resus continues…
I’ve never worked in an ED where flexible fibreoptic is immediately available (perhaps it should!)…but the reality is that flexible fibreoptic is a skill that needs regular skills maintenance – whereas the use of a malleable fibreoptic stylet (such as the Levitan FPS) is pretty straightforward and can be easily used through the AirQ…
So – if I could only have one LMA, I’d go for the Air-Q. Admittedly the blind intubation rate isn’t as good as Fastrach (although this can be improved by extension of the neck and application external laryngeal manipulation) – but it is small, affordable, comes in a range of sizes and allows a staged progression in airway management without interruption – indeed it appears designed for this.
On this basis, it is my recommendation for a single LMA with variety of uses in prehospital and rural environments where flexible fibreoptic scopes are not available.
The table below summarises pros and cons of various LMAs discussed above.
I should add that the AirQ comes in paediatric sizes – unlike the Fastrach…
Watch a quick video of the Air-Q from the inventor Dan Cook here
Jim DuCanto demonstrates intubation using a malleable stylet through the AirQ here:
Those who attended #Retrieval2015 in Scotland last week may have been fortunate enough to see the “All About That Base” parody video from SAAS-MedSTAR.
Readers of the blog will know that I spent the second half of 2015 with MedSTAR, South Australia’s retrieval service and part of SA Ambulance Service (SAAS).
As a rural doctor I am usually a user of this service. It’s taken a few years after being invited to coordinate time off to arrange time out of practice on KI and visit MedSTAR, but it eventually worked out.
I have become interested in the use of FOAMed to help deliver “quality care, out there” and my gut feeling has been that there are many lessons from prehospital care that are relevant to rural practice – the rural environment is limited in both resources and personnel…and there is no immediate backup in a crisis. With the advent of FOAMed there really is no excuse for the isolated rural clinician to be the ‘weak link’ in critical care, at least in terms of knowledge. However, whilst critical illness does not respect geography, rural clinicians are limited by the occasional nature of such work, limited equipment, lack of standardisation and audit as well as deskilling.
So it was useful for me to use time at MedSTAR in order to see the heterogeneity in practice “out there” in rural SA, as well as to learn from paramedic colleagues as the experts in prehospital care. It was also an opportunity to see how well the skill set of the enthusiastic rural doctor can translate into the prehospital environment…
It wouldn’t be appropriate for me to dissect my experience of MedSTAR in full here. It was a useful experience, although it was not what I had expected based on previous experience since the inception of MedSTAR in 2007.
Relevant lessons for rural practice included :
the value of regular case audit to drive improvement
the need for standardisation of equipment and use of SOPs for key procedures
potential for immersive scenario training to improve team work
need for benchmarking with others, whether intra- or interstate
I hope that we can implement some of these lessons into rural hospitals run by Country Health SA. Bottomline, I hope to use the lessons learned to help encourage rural clinicians to embrace the difficulties faced by dealing with critical care infrequently, and seek to drive quality improvements. Whilst the retrieval service offers an excellent standard of care, I believe that opportunities exist for rural clinicians to value-add in the time awaiting the cavalry, rather than just call for help…
All About that Base
MedSTAR covers both adult and paediatric populations in SA and interstate. Transport platforms include land ambulance, rotary wing, RFDS and Lear jet (the latter for interstate missions). Work involved primary missions (mostly from the roadside), modified primaries (usually from a small rural facility) and secondary transfers from larger rural and metro hospitals. The base is located at the Adelaide Airport with training hangar, sleeping quarters, admin offices and general areas. A purpose built new base will soon be co-located adjacent to both RFDS and helicopter hangars on the airfield, which is exciting.
With two adult and one paediatric team on 24/7, there was plenty of time to train and also plenty of downtime between missions. As part of the ‘farewell’ for the 2015 cohort we prepared this video (with the self-taught iMovie guru, Dr Kat Shelley editing the raw footage).
Sadly the full unexpurgated version of the video (including hilarious bloopers) hasn’t been approved for general distribution. The above is the sanitised version….enjoy!
Thanks to all at MedSTAR (particularly the SOT/Rescue Paramedics) who added to my learning and made this a valuable experience.
The concept of a “GP anaesthetist” or “GP obstetrician” can be a vexed one.
Colleagues with the appropriate specialist ticket (FANZCA & FRANZCOG respectively in Australia) may question why the heck a general practitioner is meddling in their arena of expertise. We may hear similar from FACEMs in regard to emergency care.
I have no doubt in my mind that appropriate specialty training is the Gold standard and to be aspired to. But there is a reality in rural Australia – the immense size of the continent and the relatively low population density mean that there is neither the workload to sustain a specialist presence in smaller rural towns…nor the income potential.
So – rather than the ‘precision scalpel’ of a specialist in anaes, obs or EM, rural Australia is reliant upon the ‘swiss army knife’ of the rural generalist. I am indebted to colleagues in rural medicine who are devoted to shifting the bell-curve of expertise of rural generalists to the right – in particular FOAMed inspirations Casey Parker of BroomeDocs and Minh le Cong of Prehospital & Retrieval Medicine blogs.
My own KIDoc and RuralDoctors.Net sites are devoted to the concept of delivering “quality care, out there”, drawing on the collective experience and tacit knowledge of both specialists and generalists worldwide.
So to the topic of rural anaesthesia and the rural “GP anaesthetist”. I gave a talk at the ANCZA scientific conference in SA last November – the theme was ‘anaesthesia allsorts’ and encompassed speakers from military, austere, retrieval and rural backgrounds, self included.
My title slide on “GP Anaesthesia 2020 an byeond” caused a small furore (the infamous ‘use two hands, squeeze bag gently’ picture); the talk can be downloaded here
The fact remains that, despite the increase in FANZCAs looking for work, there is little chance of them moving to isolated rural Australia – nor would there be the workload to keep them in employ. For the meanwhile, training exists to ensure rural GPAs are able to safely deliver elective and emergency anaesthesia in their communities, recognising limitations of both skill and equipment…
The training is run under the auspices of the Joint Consultative Committee on Anaesthesia (JCCA), a tripartite body with representatives of ACRRM, ANZCA and RACGP. The curriculum is designed to ensure that the GP-Anaes can safely deliver anaesthesia to selected elective cases, as well as deal with the common emergencies.
I’ve been keen to ensure that my needs have been met beyond the JCCA curriculum as delivered – with the wealth of FOAMed information out there, there’s no excuse not to ensure that GP-Anaes have the following additional considerations covered :
– a bombproof difficult airway plan, appropriate to available equipment (AFOI kit not usually available in rural)
– robust plans for ‘unusual’ situations where no immediate backup exists (the bariatric patient needing DSI; the ‘fish-in-airway’ scenario; the fencewire vs larynx etc)
– familiarity with ketamine for both analgesia, dissociation and induction
– robust failed spinal and failed epidural plans
– use of ApOx, DSI, second generation iLMAs, scalpel-finger-bougie techniques etc
– a good repertoire of nerve blocks for use in OT and in ED
Most importantly, I think ongoing audit via peer review and regular case discussion is essential, facilitated by experts (whether metro FANZCAs or rural docs). I spent the second half of 2015 with MedSTAR, South Australia’s retrieval service – this was a good opportunity for me to experience the heterogeneity in skills “out there” in rural SA, as well as to reinforce my belief that lessons from prehospital care are highly relevant to rural practice, not least:
regular case audit
standardisation of equipment and SOPs
It makes me wonder what should be the expected skillset of GP-obstetricians on graduation before heading bush? Ability to perform a partial hysterectomy in case of catastrophic PPH? Not just Ventouse and low-/mid-outlet forceps, but also Kjiellands rotational forceps? Advanced obstetric USS skills?
Meanwhile, I think the future of GP anaesthesia is safe, in rural areas at least.
If you’ve been following blogs such as THE PHARM recently, you’ll probably have seen reference to a chap called Minh le Cong and a drug called ketamine. Now it’s no secret that many in the prehospital and emergency fields are fond of ketamine – it’s a useful dissociative agent with analgesic properties and can be given IM, IV or IN and used for analgesia, sedation and induction.
Like any drug it requires familiarity with use and titration to effect (although I prefer pre-drawn drugs for RSI, with doses based on IBW and haemodynamics). I reckon that if I polled a roomful of doctors and asked them to give a dose of ketamine, many would be hesitant having not used it before. Safe practice mandates familiarity with the drug and appropriate training and monitoring…
Sedation of the Acutely Agitated Patient – a High Risk Procedure
But there is an area of practice that has bugged me for some time, namely the management of an acutely agitated patient. This is a difficult situation – the patient is agitated and may be a risk to self and others. The staffing in a rural hospital is minimal – there is no ‘Code Black’ with security officers – the team may involve an RN and EN initially, with the on-call doctor off site and taking some time to arrive.
Whilst a calm environment and de-escalation is ideal, sometimes situational urgency mandates use of agents to calm the patient. It’s all well and good if the patient is cooperative and insightful enough to take a dose of oral medication (typically olanzapine antipsychotic +/- oral diazepam)…but if not, they may require a rapid ‘takedown’ with IM or IV medication.
And this is a problem, as the agents commonly recommended by many Health Department protocols STILL include short-acting agents associated with profound respiratory depression. Alternating cycles of extreme agitation, and administration of short- and long-acting agents can lead to increasing amounts being used and a slide into respiratory collapse.
Looking few various protocols from various sources can be confusing; there’s a wide variety in suggested agents – a quick search in an (unnamed) rural ED showed a variety of available protocols. This is potentially dangerous – in a crisis, the ‘occasional sedatonist’ is likely to seek some form of protocol..and yet may lack familiarity with the agents in use.
The Occasional Sedationist may be reassured by a protocol and lulled into a false sense of confidence in administering drugs without adequate backup
Many protocols seem to encourage polypharmacy, including the use of IV midazolam. Other agents in some of these protocols include ;
IM – olanzapine, haloperidol, clonazepam, midazolam, lorazepam zuclopenthixol
IV – midazolam, diazepam, lorazepam
Even though there have been recent Coroner’s reports on deaths of such patients, a recent report failed to address the issue of safe sedation and instead focus on the need for more rapid transfer. Whilst I am in favour of rapid transport of patients requiring retrieval (not least because of the demands on staff in a resource-limited environment), it’s not the lack of a helicopter that kills these patients – it’s the cycle of agitation-sedation and cardiorespiratory collapse, occasionally exacerbated by restraint that is dangerous. Couple this with a general failure to approach the clinical situation with the same diligence as we would for providing procedural sedation in ED or OT, with it not unheard of for these patients to be nursed in a dark room, supervised by a mental health worker outside the door, with occasional recording of routine obs – scant appreciation of the fact that we are giving administering anaesthetic agents!
Moreover, many of the protocols available in EDs make vague reference to ‘safe environment’ without specifying the need for airway equipment, the use of ETCO2 to monitor nor airway or anaesthetic risk assessment.
Droperidol & ketamine – safer than short-acting benzos!
So the Twittersphere was abuzz today with the announcement of the DORM-2 study from Melbourne – a prospective observational study looking at the safety of droperidol for management of these patients. Older readers may remember concerns from 15 years or so ago regarding droperidol and prolongation of the QTc causing torsade de pointes. The study demonstrated no prolongation of the QTc in the cohort studied, nor any incidences of torsades de pointes (a criticism is that this is relatively rare and would require a larger study). More importantly, the study demonstrated the effectiveness of droperidol in achieving a state of rousable sedation – the goal in this situation.
I think this is important. I use droperidol occasionally in theatre for both sedative and anti-emetic properties; it’s available in most hospital or can be ordered in. And I think it’s a useful addition to the armamentarium. So much so that I’ve dropped haloperidol from my approach and will run with initial olanzapine where possible; if this fails, IM droperidol titrated to target sedation score.
Of course ketamine DOES also have a role; and I am a particular fan of it’s use for transport of such patients without the need for risking RSI in an unfasted patient with unproved airway (obesity, OSA and COPD are not uncommon in these patients, as are complications of intubation such as aspiration and the need for an ICU bed at the other end). There are protocols available for running ketamine infusions once initial sedation is achieved. I won’t reproduce them (for examples see here and here), but suggest that early consultation and advice from the retrieval service is mandatory…
Safe Sedation Guidelines 2015
Moreover, it helps bolster a rationale approach to sedation of the acutely agitated psychiatric patient – there’s been a bit written on this recently, with release of a Consensus Statement – The Acutely Agitated Patient in a Remote Location as well as a collaborative effort between some emergency and rural clinicians in Australia to guide practice in rural ED or on the wards.
We’ve termed it ‘Surviving Sedation Guidelines’ in recognition of the very real risks that use of these agents can pose.
See also posts on Surviving Sedation Guidelines 2015 from the PHARM here, from BroomeDocs here and from KIDocs here
KEY PRINCIPLES OF SURVIVING SEDATION GUIDELINES
Early Goal Directed Sedation (EGDS) – titrated sedation to an objective level using a validated sedation scoring system
Consideration of emergency sedation as a form of procedural sedation/anaesthesia.
Minimum standards of patient assessment, resuscitation equipment and clinical monitoring
De-emphasis on sedative drug choices with more emphasis on continuous clinical assessment and titration to effect
There is a lot more to psych sedation than just bunging in a dose of benzo and walking away…I’d encourage people to read the extensive notes on Minhs blog post regarding this, and consider the use of droperidol, as well as stalwarts olanzapine and diazepam in a stepwise approach titrated to a desired sedation level.
Other than oral diazepam, there is no mention of using short acting benzos such as midazolam…and I think this is a GOOD thing! See what you think….