26 August 2008

Standing Trendelenburg on it's Head

He didn't work on Shock, and neither does his position, Dammit.

Friedrich Trendelenburg (May 24, 1844 – December 15, 1924) was a German surgeon and son of the philosopher Friedrich Adolf Trendelenburg. A number of medical treatments and terminologies have been named for him. He is perhaps best remembered for the Trendelenburg position in which the patient is placed on a bed which is put into incline such that the patient's head is lower than his feet. Trendelenburg first used this technique in 1881 for an abdominal surgery. (Wiki)
During World War 1, Walter Cannon, an American physiologist, and the same guy that coined "fight-or-flight", as well as developing the theories of homeostasis, popularized the use of Trendelenburg position as a treatment for Shock. 10 years later, he changed his mind.

Ladies and Gentlemen, in case you were absent, sleeping, or ignorant during that block of instruction, the First World War, the Great War, the War to End All Wars took place primarily in Europe from 1914 to 1918. The Treaty of Versailles was signed 28 June 1919.

WW1 ended Ninety years ago. So, at the latest, 80 years ago Dr. Walter Cannon decided he had erred, and rescinded his recommendation for the use of Trendelenburg position in the treatment of Shock. There are 12 listed surviving Veterans of that Conflict. Unlucky Thirteen if you count the Position that inspired this post.

Trendelenburg is still a fixture in initial management of Shock. Despite the fact that it doesn't work, and is potentially more harmful. The theory WAS that by elevating the lower portion of the body, either through Trendelenburg Position or passive elevation of the lower extremities, one could effect a form of autotransfusion, in which blood would be shunted "to the core". In the few studies that support this belief, performed on healthy subjects, these positions increased left ventricular filling, stroke volume and cardiac output, but the effects were transient and returned to baseline within 10 minutes. Conversely, numerous studies show that lung volumes are compromised by the weight of the viscera upon the diaphragm, and increased stress is placed upon the right ventricle. There is also evidence of increased risk of retinal detachment, brachial nerve paralysis, and of course, cerebral edema.

What's even more worrisome than the continued insistence of Trendelenburg, is the lack of elucidation. Individuals are taught to use Trendelenburg for Shock, but never which Type of Shock this nonsense supposedly works on.

Is it intended for Obstructive Shock? No, only relieving the obstruction will help. But you go right ahead, make that PE, tamponade, or pneumothorax dependent. It seems like a good idea to me.

Is it intended for Distributive Shock? As in neurogenic, septic, or anaphylactic shock. Nope, turning a patient upside down doesn't make "the Tank" any smaller. However, every patient with wheezing, urticaria, and profound angioedema LOVES being stood on their head.

Is it intended for Endocrine Shock? Does gravity have any effect on hormones?

Is it intended for Cardiogenic Shock? Like patients who can't breathe, myocardial infarction patients, and CHF-ers LOVE lying down. Even better if you can INCREASE the strain on their heart. Choke yourself.

Trendelenburg Position was intended for use during Hypovolemic Shock. Back in 1917-ish. Then Dr. Cannon changed his mind. Yet just about every where you go, "lay 'em down, raise their feet" is a given when it comes to initial management of a Shock patient. FR, First Aid, BSA, Brady, DOT, AAOS, NR, U.S. Army...

During the second stage of Shock, the Compensatory Stage, the body employs multiple physiological mechanisms in an attempt to reverse the condition. These include neural, hormonal, and bio-chemical mechanisms. I'm not going to get into Acid-Base balances, or renin-angiotensin, etc.

What I will discuss is the action of the carotid baroreceptors. The baroreceptors in the carotid arteries detect hypotension, and signal the release of adrenaline (epinephrine) and noradrenaline (norepinephrine). These are catecholamines with dual roles as hormones and neurotransmitters. Noradrenaline predominately causes vasoconstriction (α1) with a mild increase in heart rate, whereas adrenaline predominately causes an increase in heart rate (β1) with a small effect on the vascular tone; the combined effect results in an increase in blood pressure.

The body is an amazing machine. It manages to compensate, quite well. However, by throwing the legs up, or standing someone on their head, you manage to deceive the carotid baroreceptors into thinking the body has adequate blood volume, and pressure. In turn, they do not trigger the release of catecholamines. The body doesn't get the message to compensate. As soon as that Transient effect of standing them on their head subsides, you succeeded in helping the body skip right through Stage 2 of Shock, and right into Stage 3, the Progressive stage, or more ominously: Decompensation.

There are, however a few appropriate uses for Trendelenburg.
  • Abdominal surgery (HOLY SHIT, that's what it was intended for!)
  • Central Venous Line Placement in the jugular or subclavian veins. I'll extend that to EJ's for you Paramedics, but the arms of a stethoscope kinda work better.
  • Reducing abdominal hernias. For the same reason it's used in abdominal surgery.
  • Waterboarding. Yeah. Because of it's negative effects on breathing and airway. Fuckin' Terrorists.
  • Various obstetric and gynecological procedures, or practices.

As Usual, Dr. Bledsoe knows what's up.

  • Martin JT. The Trendelenburg position: a review of current slants about head down tilt. AANAJ 1995;63:29-36.
  • Ostrow CL. Use of the Trendelenburg position by critical care nurses: Trendelenburg survey. Am J Crit Care 1997;6:172-6.
  • Taylor J, Weil MH. Failure of the Trendelenburg position to im-prove circulation during clinical shock. Surg Gynecol Obstet 1967;124:1005-10.
  • Sing RF, O’Hara D, Sawyer MA, Marino PL. Trendelenburg position and oxygen transport in hypovolemic adults. Ann Emerg Med 1994;23:564-7.
  • Terai C, Anada H, Matsushima S, Shimizu S, Okada Y. Effects of mild Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. Am J Emerg Med 1995;13:255-8.
  • Bivins HG, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med 1985;14:641-3.
  • Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979;7:218-24.
  • Reich DL, Konstadt SN, Hubbard M, Thys DM. Do Trendelenburg and passive leg raising improve cardiac performance? Anesth Analg 1988;67:S184.
  • Terai C, Anada H, Matsushima S, Kawakami M, Okada Y. Effects of Trendelenburg versus passive leg raising: autotransfusion in humans. Intensive Care Med 1996;22:613-4.

25 August 2008

Needless ShoutOut, Rogue

Well, apparently it's going to be necessary to post a bit more often. Rogue Medic not only referenced my most recent entry, but he also placed my name in the subject line. AD read his post, and gave him some "linky-love" which has subsequently caused more than a few extra people to stumble upon my mutterings.

Now, more than 2 people read my writing. Accordingly, I must write more.

And so it begins...

23 August 2008

Tourniquets, Trendelenburg, Tampons, Toilet Paper

...or Four Things that Get me fired up. This will likely be a three or four part post...

Certain subjects inevitably come up whilst discussing Trauma management. This is especially true when discussing such things with individuals in the Military. Two of the subjects I'm referring to are controlling bleeding from an extremity, and preventing/controlling shock.

It's common knowledge that exsanguination from extremity wounds in the Number One cause of preventable death on the Battlefield. The Military is finally getting away from it's complete and total fear of effective tourniquets. From the time we take our very first Boy Scouts and Brownies First Aid class, we're taught to apply a dressing, apply direct pressure, utilize pressure dressings, use pressure points, elevate, and as a very, very, OMIGOD Don't Even THINK about it, last resort, tourniquets are mentioned. Can tourniquets cause tissue damage? Yes. I'm not here to deny that. Is there the potential for neuropathies, necroses, and no-mo-hands-and-footsies? Absolutely. Shutting off distal blood supply is no joke. It's a very serious procedure, applied in some of the most dire of circumstances. Some First Aid guides don't even mention Tourniquets. FR, EMT, and even Paramedic courses skim over them. In Paramedic school they'll discuss "back in my day, we used to push enough epinephrine to give a rock a pulse," giving every code bicarb, or in the more recent past, stacked shocks. Science has shown that those practices aren't necessarily effective, and don't save lives. Yet more time is spent mentioning THEM, than the appropriate and effective application of a tourniquet.

Tourniquets Save Lives. You can read whatever studies you want about the harm done by a tourniquet. Paresthesia, amputation, worst case scenarios. People with those outcomes are Alive. It's common knowledge that a properly applied tourniquet can be left in place for greater than 4 hours before irreversible damage occurs. Ask a surgeon. They perform procedures all the time with tourniquets in place.

Properly applied.
They save lives. Damage is minimal when properly applied. So why are we so afraid of them? Why don't we embrace the fact that they save lives, and spend time actually LEARNING how to apply them properly? I challenge you to go to your crew room, your next refresher, ask someone at the ER, or your new preceptee what they would use to appropriately apply a tourniquet, and how they would go about doing it.

You'll meet quite a bit of resistance. There will be people that insist that they'll never have to apply a tourniquet, and no one ever should. I mean, 4 liters of NaCl is a good replacement for 4 units of blood, right? Tourniquets are evil, right? They are harmful and too much can go wrong.

Now try to have a conversation with the same people about emergency airways, and worst-case scenarios. Discuss intubation, S.L.A.M., crichothyroidotomy, translaryngeal jets, retrograde intubation, bougies, etc. After all, those can be intense, but we're taught skills to manage the airway.

Painful Truth for all you heroes out there. Patients can often be killed iatrogenically by airway management, mismanagement and overmanagement. The same is not said about bleeding control. You don't kill patients by "overmanaging" their bleeding. This is not to say airways don't save lives. But I think I learned somewhere in Physiology that blood might be important too.

We are taught When, Where, Why, What, Who, and How to Intubate. We know the consequences of a poor intubation, and are taught to recognize when things don't go according to plan.

We are taught that tourniquets are a last ditch effort, and we should exhaust all other methods before resorting to a tourniquet. Well my friend, while you're holding pressure for several minutes to see if it will work, your patient has lost half their blood volume. We should be teaching people how to recognize when a tourniquet is necessary. You can assess bleeding fairly quickly, and figure out what tricks are going to work. If you can't, your training, and/or your experience, has let you down. Time is of the essence. When, Where, Why, What, Who, and How.

The answers are not Never, Nowhere, None, Nothing, No one, and Not. Quit teaching it that way. Common Sense has been discarded for Common Practice for far too long.

Outdated tip of the hat to TOTWTYTR

22 August 2008

Two pair of boots.

Although at present I am a desk-riding, coffee swilling, paper-pushing, lamentable Pogue, I haven't always been. I have had the fortune of experiencing two very different worlds. I am a Medic, and I am also a Paramedic. When I say "Medic", I mean: ["Doc", Corpsman, Combat Medic, Healthcare Specialist, Medical NCO], that is to say, Military trained, combat tested. When I say "Paramedic" I mean the obvious. I am both. This is not to say this is rare, but it is certainly not the norm. The majority of my EMS counterparts have not seen the types of things I've seen as a Medic. On the other hand, not many of my Medic colleagues have the training, or the experience, or the background of dealing with the things we see and treat as an Advanced Life Support Provider on the streets.

The two worlds are very different, and not necessarily complementary. As a matter-of-fact, none of my jobs, though related, are necessarily complementary, but that's not the point right now...

My counterparts in both careers frequently discuss the advantages of being dually trained. For Me, it works. I enjoy both, I try to excel at both, I get a little taste of everything. However, I don't necessarily believe that being dually trained will make you better at either job.

Combat Medicine is, imagine this, predominately Trauma. Penetrating. Burn. Blast. Primary, Secondary, Tertiary impacts. Barotrauma. Life. Limb. Eyesight. Every incident is approached with Triage, and mass-casualty potential. GSW to the thigh? Hold pressure, self-aid/buddy-aid, return fire, I'll get there when I can. Scene safety is a little different in these parts. Quit whining, put rounds downrange. Suppressive fire for your buddies, gimpy. If you let them down, I have more patients.

Medical problems exist, but they are not the bulk of the load. Heat Exhaustion, Behavioral Emergencies, the occasional First Sergeant with Chest Pain. These are exceptions to the rule.

Street Medicine, as you all know, is Medical ailments, with the occasional trauma mixed in. ABD Pain, Asthma, COPD, CHF, CP, Diabetes, DOE, DK, FDGB, GIB, HA, LOL, N/V/D, SOB, Syncope, TMB, SI, NAD, WTF. Trauma is generally a small slice of the pie. And what trauma we do get for the most part is MVCs, assaults, Falls, various blunt trauma, and the occasional penetrating trauma.

Trench Medicine resides somewhere between where [PHTLS, ITLS, BTLS] left off, and ATLS begins. The Medic is trusted to do whatever it takes, in the absence of orders. Your assignment is to save lives. If you don't have a PA, or a MD, or a Senior Medic, you're It.

Street Medicine = ACLS + PALS + DOT + PEPP + AMLS + Protocols + OEMS x 'Handcuffs'. Patient needs a surgical crich? No way. Bougie? Not in your Protocols. This post is not about protocols though. They have their place, and they have their reasons. Besides, Rogue Medic does a better job talking about them.

To me, the differences between these two Worlds is abundantly obvious, crystal clear. Yet it seems to some folks, the difference between Urban and Rural medicine is more apparent than the difference between Military Medicine and Street Medicine.

Civilians, for the most part, don't suffer from shrapnel wounds. Their MVC wasn't caused by an explosive-formed projectile from an improvised explosive device.

Soldiers, for the most part, shouldn't have underlying cardiac conditions. They are not diabetic. They've never even heard of Fibromyalgia. They are otherwise healthy-ish, and between 17 and 40 (for the most part...)

Civilian ailments require thought. Differential diagnoses. (Sorry...clinical impression...) Their illnesses and plights run the gamut. Soldier's life threats are typically pretty obvious.

Trauma vs. Medical. Action-Thought vs. Thought-Action.


09 August 2008

Sweaty, Inconsiderate, Offensive, Effeminate

...or "Things that Bother Me at the Gym".

Of late I've gotten off my lazy ass, and begun somewhat of a fitness regimen. Now, I use "lazy ass" somewhat relatively. I wouldn't categorize myself (past or present) as your stereotypical EMS Provider. I'm sure my readership (all 2 of you) will agree, that [Providers/Professionals/Employees/Workers] of Emergency Services [Public Safety] , in general aren't always in tip-top, peak, physical condition.

Conversely, I am not a Gym Rat. I don't work at the gym, I don't spend half my life at the gym, I don't receive my cable bill at the gym. Everything in moderation. Some of those freaks need a social life, or a hobby that doesn't involve rosin, full-length mirrors, and Bosu balance balls. But I digress. The following is a list of things that irk me at places of fitness, in no particular order.

Mandex. Pretty much self-explanatory. Chances are, if it was ridiculed 5, 10, 15, even 20 years ago, it's probably still a No-Go. Don't get it twisted, just because UnderArmour and similar product lines are all the rage, doesn't mean your lower half needs to be wrapped in painted on synthetics. Unless you're in contention for the Tour de France, involved in some sort of aquatics, or are an up-and-coming Luchador, leave the Lycra to the Ice Capades. Even if you participate in an activity where form-fitting clothing is appropriate (i.e. Triathlon, Greco-Roman Wrestling), it still does not belong in a gym. Sorry Mr. Unitard, but if you can buy your gym clothes at the same store that sells a man-sized Mr. Incredible costume, there's been some sort of disconnect. Hell, even Richard Simmons had enough common sense to wear man-panties to cover up the unsightly protuberance of his grapes.

For a moment, let's remain on the subject of the jewels. It's warm in the gym, you're going to get hot, and perspire. Your Boys are probably going to descend a bit lower than normal in an effort to keep your swimmers at the appropriate temperature. Please keep that in mind when making your apparel selection ante-workout, or when pondering whether "today is a good day to go Commando". I believe I speak for everyone when I state we'd rather not see your knackers pasted to your left leg in the middle of a workout. Find out where Spandex Guy bought his mantyhose and wear some support under your daisy dukes. Thank you muchly.

In MY society, where we shower regularly, cologne and perfume are purchased with two people in mind. The person who is wearing it, and the person They are trying to impress. Maybe some folks are trying to impress people at the gym, or trying to pick someone up, but the over-powering cologne is nauseating. In any setting it's inappropriate, but a gym should smell like sweat, disinfectant, rubber, and metal. Hey, Davidoff, it's a place of fitness, not the goddamn center aisle at JC Penney. Your eau de toilette is awful, tactless, and inconsiderate. And as far as the hottie on the elliptical is concerned, you'd be better off with chloroform. P.S., Let me know how that hair gel works out IF you manage to break a sweat.

Proceeding in the vein of attempting to impress folks, STOP Posing. STOP Strutting. You might look good. You might not. Yay! There're lots of mirrors. I understand that two large groups of people that frequent gyms are the insecure and the overconfident. EVERYONE wants to see their improvements, and their hardwork paying off. I don't hold that against you. Regardless, striking Mr. Olympia poses in the mirrors, or pacing laps across the gym while strutting like a peacock is obnoxious. Chances are, if people ARE looking at you, they will snicker, and make snide remarks. If that's what you're going for, drive on.

If YOU are the person who's attention has been captured, don't gawk. It's infinitely more sketchy to stare at someone at a Gym than it is at the mall. Seriously, people are half dressed, sweaty, and more vulnerable. You're are the very reason Curves, and other Female-Only gyms have opened.

Everything you need to know, you learned in Kindergarten. If you use something, put it back where you found it. It's not that difficult to place things in their proper place. Why is it that as soon as people enter a Gym they become Anal-expulsive? It seems like every weight rack has an odd number of each measurement, and there are weights randomly strewn about, in places they don't belong. I shouldn't have to go to the Spinning room to find a plate, nor should you have the curl bar in the pilates area. And quit leaving equipment on the floor.

Adam Sandler throw-back, you know, before he started doing romantic comedy. "Having Sex, or lifting weights?" Quit making so much damn noise during your workout. Grunting out the LAST rep in order to avoid moving your bowels is forgivable. After all, I wouldn't want you to soil those sweet control tops. But groaning and grunting on every repetition is not ok. It sounds like a tennis match in a roman bath house.

That's all for now.