Akute Notfälle bei Trägern von Schrittmachern bzw. AICD

Ich bin ja oft wirklich überrascht, welche Ängste bei unseren Kollegen entstehen, wenn ein Patient mit einem Schrittmacher oder einem Defi eintrifft. Gerne möchte man sofort das Aggregat vom Spezialisten überprüfen lassen …

Vermutlich liegt meine Unverständnis darin, dass ich mich selbst Jahre mit dieser Thematik beschäftigt habe und die Fortbildung in diesen Bereichen eher mau ist. Außerdem sind derartige Ereignisse für uns persönlich auch ziemlich selten. Und damit ist man einfach nicht geübt im Umgang mit diesen Themen.
Deshalb fand ich es sehr spannend, dass in einer aktuellen Ausgabe der Zeitschrift Notfall – und Rettungsmedizin ein CME Artikel zu dieser Thematik enthalten ist. Ausgehend von ganz banalen Dingen wie Definitionen, Typen von Schrittmachern etc. gehen die Autoren auch fallbezogen auf ganz besondere Situationen ein und erklären diese aus meiner Sicht wirklich sehr sehr gut.

Also, wenn Sie etwas Zeit haben für konzentriertes Leben. Es lohnt sich absolut!

Und dann gibt es natürlich auch noch die üblichen Verdächtigen, wenn man sich eingehender informieren möchte: Schon in nähere Details gehende Bücher zu dieser Problematik, Übersichtsartikel und sicherlich wird man auf Youtube oder in der Bloggemeinde fündig.

Red Dust, dingoes, trauma and Sepsis

Guest post by Dr Chris Edwards of EMJourney recounts his time as a remote retrieval registrar based in Alice Springs – @EMtraveller

I’ve had the privilege to work as a Retrieval Registrar for the Alice Springs Hospital Retrieval Service in Central Australia for the last 6 months. How to describe it – words that spring to mind include:

  • Challenging (unlike many other retrieval jobs, you often are intimately involved in the logistics planning)
  • Satisfying (providing ICU level care to the most remote parts of Australia)
  • Scary (providing ICU level care to the most remote parts of Australia!)
  • Clinical character forming (Brown underpants occasionally needed)
  • Interesting (When a potassium > 7 and severe rheumatic heart disease no longer turns your head)
  • Scenic (people pay money to see Uluru from the air, I get paid)

The Central Australian Retrieval service retrieves patients mainly by fixed wing aircraft over a catchment area of 1.6 million square km. We also perform inter-hospital transfers to Adelaide and Darwin (that’s 3.5 hours, one way, either way!) Let me try to put the sheer size of our catchment area and distance from our tertiary referral centres into perspective…

Here is Australia, our tertiary referral centres and our catchment area roughly outlined…

01 tertiary referral centres

02 Australia and the USA

03 Australia and Europe map

I think you get the idea – this is a huge catchment area! With one other small hospital in Tennant Creek, the rest of our primary retrievals are to remote health clinics, staffed by RANs (Remote Area Nurses).

In our primary retrieval we don’t have sub-specialty retrieval teams so we do it all, although we do occasionally take a paediatrician with us. Common conditions, mostly from our indigenous population but occasionally a grey nomad or overly adventurous backpacker, include:

  • Trauma (usually penetrating or MVA)
  • Sepsis (and sometimes overwhelming septic shock)
  • Snake bites/stick bites
  • Renal disease – Missed dialysis with APO and/or hyperkalaemia
  • Threatened/established/imminent/delivered labours at term/pre-term (I mentioned the brown underpants right?)
  • Paediatrics – URTIs, LRTIs, infected scabies, post-streptococcal glomerulonephritis

Mostly our patient population is young, less than 50 years old – I haven’t retrieved a single NOF fracture since I got here!

Then there’s the inter-hospital retrievals; Mostly to Adelaide, we take intubated patients on inotropes, trauma patients with chest drains and vacmat with spinal precautions, recently lysed STEMIs, including failed thrombolysis with ongoing arrhythmia for rescue PCI (52 shocks is my current record); I’ve even taken two patients so far with intra-cranial bleeds and extra-ventricular drains (first time I had even seen one).

Equipment and Staff

The plane we use is the Pilatus PC-12, a single-engine turboprop made by the Swiss. It has a cruising speed of approximately 500km/hr and a maximum service ceiling of 30,000ft with cabin pressurization of

Pilatus PC-12 with patient being transferred onto stretcher loader

Pilatus PC-12 with patient being transferred onto stretcher loader

Interior of the PC-12

Interior of the PC-12

On the plane, we carry the doctor’s bag, which contains central lines, arterial lines, fast trach intubating LMAs, rapid infusion catheters, EZ-IO, scalpels, bougies and other useful gear. We also have onboard a standalone intubation kit, cannulation kit, equipment for infusions, syringe drivers, pump sets, a full cold and warm drug box, an Oxylog 3000, a Zoll X-series monitor/defibrillator/pacer and of course the most important – coffee/tea bag. Additional equipment we can carry includes a maternity pack, trauma pack, neonatal pack, a vacmat, a humidicrib, paediatric ventilator, surfactant, a Sonosite M-Turbo and 2-4 units of packed RBCs.

Our Flight Nurses are the backbone of the clinical service. Trained in both critical care and midwifery they have a broad skill set and a lot of experience. They have invaluable clinical and logistical knowledge and when it comes to obstetric cases, my general approach is to ‘Remain Above The Navel’ and do what I’m told!

Pilot and Flight Nurse taking a turn in the front seat

Pilot and Flight Nurse taking a turn in the front seat

The Retrieval Doctors have a varied background – some are Rural and Remote Medicine trained, some are budding intensivists, but the majority are Emergency trainees. What we all need to have in common is the ability to be flexible and manage a difficult airway or an unstable patient on your own, supported by the FACEM in ED and Retrieval specialists.

Sun protection is a must

Sun protection is a must

Typical Day

No such thing as a typical day in this job. You might be heading to Adelaide with an ICU patient – if you do, that’s your whole day, because it’s a 3 hour one way trip. If you aren’t tasked to an inter-hospital transfer, at some point you will likely get an SMS from RFDS operations with a job. You check the email system and read the clinical information – then you call the clinic and speak to the RAN – get the latest details, suggest management or procedures and try to get a feel of how sick the patient is and what equipment you might need to bring. Then it’s a trip into the hospital if you aren’t already there, grabbing your gear and driving or taking a taxi out to the RFDS hanger.

Once there you load up the plane and head off. Most of our retrieval locations are within 1 hour’s flight from Alice Springs, with a few outliers like Elliot and Kiwirrkurra taking 2 hours. Flight time will usually include discussing the plan with your flight nurse and finding out any logistical challenges from your pilot (eg. Day strip only, weights permissible, pilot hours remaining).

Occasionally you may instead be tasked to go to a cattle station, roadhouse or the side of the road but in most cases you will be going to a clinic in a remote community. When you arrive, someone will meet you in a car to take you and your gear to the clinic. The clinics vary in size and equipment but most will have at least a small ‘Emergency’ room.

Typical remote clinic emergency room

Typical remote clinic emergency room

It’s hard to really describe accurately the first time you arrive at a remote community clinic. I remember being surprised by all the dogs (and the occasional donkey and camel) and the hurried advice from the flight nurse not to try and pet them. I remember the flies being everywhere (we carry mortein in the plane) and I remember the crowd that greeted us, largely children ages 5-12, mostly with crusty noses and curious smiles and scattered amongst them would be one or two proud elders. I even remember one time where I heard a commotion outside the clinic and popped my head outside to see several children beating a snake with a water bottle, right near where we would be loading the stretcher…

So, at the clinic, you assess your patient(s), perform therapy as necessary and package for transfer. It’s important in this job to not spend unnecessary time on the ground – because you, the plane and the crew are an important resource for a large area of Australia. Once you are ready, you load your patient into the ‘Troopy’.

The Toyota Land Cruiser 70 Troop Carrier, affectionally known as a ‘Troopy’ is the ubiquitous remote area 4wd transport all over the globe. In Central Australia they have been modified to carry one or two stretchers. Having ridden in the back of many of them now, I can definitely say that they are a bumpy ride, but they’re very reliable and spare parts are easy to get.

‘Troopy’ ambulance

‘Troopy’ ambulance

After arriving at the plane, you load the patient, with or without an escort and head back to Alice Springs – unless another job comes through whilst you are in the air and nearby!

Airstrip intubation due to deterioration – note the fuel barrel table

Airstrip intubation due to deterioration – note the fuel barrel table

Some of the cutest smiles in Australia

Some of the cutest smiles in Australia

What is it like to live in Alice Springs

Alice Springs is great. Many of the junior hospital staff are on temporary placements as well – young trainees keen to explore the area. From social nights at the local pubs (Monte’s being the most popular), to bike rides, local hikes and camping trips. The mountain biking and trail running is truly world class with several professional class races held here and the rock climbing hides some real gems and capacity for endless new development.

Within 4 hours driving there are a host of great hiking and camping spots, many with large permanent water holes (some locals have canoes!)– Ormiston Gorge, Palm Valley, Kings Canyon and of course you can’t miss out on a trip to Uluru and you can take a plane there or drive.

View of Alice Springs from Anzac Hill

View of Alice Springs from Anzac Hill

Swag camping at Palm Valley

Swag camping at Palm Valley

Palm Valley – where you can come see palm trees in Central Australia

Palm Valley – where you can come see palm trees in Central Australia

Rainbow valley and clay pan

Rainbow valley and clay pan

Uluru in a rare rainstorm

Uluru in a rare rainstorm

Local events are varied and the peak season for events and tourists is in Winter. There’s the Finke Desert Race (which I was involved with as a medical officer at Finke), the Beanie Festival, Wide Open Spaces, the typically Territorian Henley on Todd, the Alice Springs Show, Territory Day (the one day of the year you get to buy and use fireworks) and the Camel Races.

Finke Desert Race

Finke Desert Race

Sounds exciting? Well I had a blast. It was a challenging job and I think it begins shaping you as a future consultant. The friends I made and the adventures I had were all great experiences. I urge anyone who might be interested to consider a 6 month rotation up here as a Retrieval Registrar – you’ll get a lot out of it!

remote retrieval

The post Red Dust, dingoes, trauma and Sepsis appeared first on LITFL: Life in the Fast Lane Medical Blog.

Dr Jim DuCanto on his SMACC US experience

The following is an excerpt from feedback that Jim provided me after SMACC Chicago. He kindly gave permission to share his thoughts with you all.

Well…..

It was a transformative experience. I was walking around that conference with my head spinning, so great was the energy of these people and their passion. It was like an out-of-body experience—I have not ever felt anything like that. To have colleagues in EMS and Emergency Medicine happy to meet me and talk about airway management like that was a bit overwhelming— But it all works out when you learn that what makes it all better is when you finally wake up and take a positive, leadership role in your interactions with colleagues and staff. Simply don’t allow room for negativity. We can do this at work, and we can also do this in life.

Giving the Ted-style lecture was intimidating at first, but I simply had to be honest with myself—I was asked to provide the talk because of the knowledge, innovation, passion and willingness to teach that I have shown through PHARM and EMCRIT. I belonged there, and I was going to do the best job possible.

I centered myself with my breathing, and took stock of where I was: The Arie Crown Theater, a major venue for theatrical performances in Chicago. I had been there once as a youth to see a play—I never thought I would be there on stage. I breathed into my heart and my center, and envisioned that my father, a prominent Chicago lawyer, now passed on 2 and a half years, was sitting in the audience. At worst, I could give the lecture to his visiting spirit.

Rich introduced me in a respectful, affectionate manner, in effect, declaring to me and the crowd how much respect and warmness he had for me—it was a perfect introduction. I sought to start the lecture on a lighthearted note, using the opening notes of “Stairway to Heaven” to give the history of “stuff” kind of a Renaissance Faire feel. Then I scrolled the iPhone over to the guitar solo that song is known for to describe the modern day…. Anyway, that was fun.

I gave the lecture as if I was speaking to my best and most interested students, and also my best friends. I know I blew people’s minds with some of the videos. Maybe what they walked away with was that there is no reason to get excited, even though the patient is dying. I am sure that video will give many the confidence to face the hopeless with a lot more dignity, and a bit more courage. What I did not say at the end of my lecture (which I did state at the end of Rich’s course), was that sometimes you are going to be called on to help people die. When that time comes, you will know it—my instructions are for everyone to pull together and work as a team and kill the patient together (I know that’s a bit crass, but that gets the point across—you attend the patient to the end (not committing a heinous act).

Giving that workshop was fun! I’ve given boat loads of workshops, and this one was good because of the students! Our planning and implementation were great, but if the students don’t connect, put out the effort, ask questions and take chances, the seminar would otherwise be flat and boring. I knew Tim Leuwenberg would be absolutely lit on fire by running the SALAD sim—he was a natural, and it gives him (as well as all of us) the ability to re-define the simulations moving forward in a manner that challenges and stimulates us intellectually as well as professionally.

When I returned back to my lab to put everything away and wash the SALAD mannequin, I had this odd feeling that I didn’t really belong in private practice—I belonged where the young and vibrant students and attendings are. It took a few days for this feeling of remorse, as it were, to wear down, but it gave me the opportunity to look at myself at where I am, and potentially where I may go. The truth is..I am in the perfect place right here, right now. I have employment, the administration of the hospital has given a colossal simulation space in the office building (was formerly their sleep lab, now decommissioned) and they are looking to me to help run simulation for their physician staff. I am also Quality Officer of the hospital at present (until the end of the year).

The colleagues I met in person had a huge impact on me. Reuben Strayer, has bonded with me on a mutual interest in ketamine-driven sedation for airway management. Andy Sloas and I are the newest BFF’s on intubation through SGA’s. Sam Ghali share interests on all sorts of stuff. Chris Carroll is building tongue mannequins, somewhat with my input. I’m helping the college student, Mitch Page, build mannequins. The saga of the SALAD simulation continues with Mike Abernathy and Mike Steurwald at UW Madison.

Overall, I hope to continue to collaborate and participate with you and Yen and the whole of the FOAM movement. I have a few concepts that need vetting, like:

1. If an CICV situation exists, would mechanical chest compressions potentially open the airway to allow endoscopy from above if VL and video stylet endoscopy is used (like a rigid bronch through epiglottitis)? Allow you to follow the bubbles?

2. Can a technique involving using a rigid suction catheter to deliver a bougie be useful, as bougies are too difficult to rely upon with hyper curved VL’s? Use the suction catheter to deliver the bougie. And the suction catheter can decontaminate or deliver oxygen.

and more..

Thanks Mihn! The saga continues!


Filed under: airway, SMACCUS Tagged: airway, james-ducanto, SMACCUS