An article you need to read

Firehouse Magazine contributor Daniel Byrne has a great article in the April issue that just came into HM HQ.

In it he tackles the issue of college educated recruits and how the mission of the Fire Service has changed to the point that advanced learning can actually be a plus instead of a hindrance.

I’ve heard many a time that “college boys” had no place in the firehouse and that they could never learn “with all that stupid crap in their heads.”
I never told them I was a college boy. When it sneaks out that Happy has a bachelor’s in EMS, they cock their heads and say things about how funny it would be if I was telling the truth.

But there it is on the wall here at home, framed next to the wife’s degree, Medical School tassel proudly hanging form the corner. Wow did those Pre-Med folks hate having us next to them at graduation. We weren’t real Medical Students while attending and then weren’t real firefighters when we got out.

Byrne’s article is available on the website for registered members, which I am not, and I hesitate to reproduce it here for obvious reasons but I would like to add in one quote that made me smile.

“If you think your college-educated rookie, who has a proven ability to learn and comprehend difficult concepts, cannot grasp the basics of our job, then the problem may in fact be yours.”

Find a copy or subscribe, this article alone is worth it.

‘New’ airway technique

Just in case I invented this technique, I’m calling it the Happy Inverted Trendelenburg Leveling Airway Stabilization Technique or HIT LAST. Hence the late Dr Trendelenburg inverted here.

We are always taught to deal with supine patients, but how many of them present differently? Most often when we find them we manipulate them into our treatment position. But that isn’t always best.

We responded to a female who had not been seen for days and was found prone on the bedroom floor, emesis of varying type and time drying on the floor near her face, which was slightly turned to one side, likely saving her life.

She is unconscious, responding to loud verbal and pain only with mumbles clogged with emesis. The textbook says to roll her over and manage her airway. I figured since her body has been dealing with this for sometime, I’ll trust it has an idea how to solve it. As she’s breathing I can hear the stridor and the aspirated emesis is still pouring out slowly. Some may argue it was spilling from the esophogus, but I have to assume at this point it is coming out of the airway.
Her O2 sat is in the 80’s and her pressure is in the 60s, but I’m still hesitant to roll her over and create a natural blockage for all that junk to roll right back down into her lungs.

Then I got an idea.

All we had were a bunch of police officers at the scene who broke down the door for the well being check, so I put them to work. We ruled out trauma, so the unfamiliar movements we were about to perform could be handled by unfamiliar hands.

I fired up my suction with my airway kit open and ready. I instructed the legs to be lifted slightly first, just about a foot off the ground. When they were set, I had the next two officers, positioned at her waist, lift her mid section about 8 inches off the ground. When the wave came, I was ready. We gathered close to 200 cc of emesis from that movement and the stridor cleared. Since gravity was doing all the work, I was able to get fluid a supine patient would have choked on. She coughed a few times, understandable, then her sats started to climb after replacing the O2 we had on during set up.

Now supine and onto a board for removal and her lung sounds were far better. Not perfect, but better than the globs of fluid I heard earlier. Not even rhales, ronchi or bubbles, but sludge like. Like when your foot sinks deep into a mud puddle. Now I hear ronchi.

Code 3 to the ER she’s satting 99% on high flow, color is improving and she’s opening her eyes from time to time while taking 10 good solid breaths per minute.

At the ER, after RSI meds were administered,(gag intact pre-hospital) the Doc’s have that fancy slide scope, the one with the camera on the blade. They see all sorts of chunky goodness my mighty suction couldn’t clear that she was breathing around. Stuff so old it didn’t wiggle when she breathed. Her pressure was over 100 and a nice narrow complex rhythm was beating along as they intubated and “stabilized” her.

When I described my actions to the Docs, they smiled and said, “Yeah, that works alright.”

It’s not an A list intervention, but in this case I think allowing the junk a natural escape assisted with suction was the way to go. Many may argue that immediate full supine access and intubation would have been the way to go, but she still had a gag reflex in place and I have no access to alternate intubation methods. Yet.

So the HIT LAST is born. Keep it in mind the next time you hear that voice in your head say, “Oh crap, this airway sucks.”