Category: Emergency Medicine

DIY Traction Splint Trainer for Under $75

Traction splints have been around since the late 1800s and were first employed during WWI. Given the lack of alternatives and atrocious environment, they were credited with massively lowering the mortality rate of soldiers suffering femur fractures on the battlefield. The idea was simple – take the long, sharp shards of broken bone, which exist within millimeters of the largest artery in the body, and stabilize them to ease pain and help control or prevent massive bleeding.

http://www.haretractionsplint.com/history-of-traction-splinting/

A century later, little has changed. There are a few basic flavors, but all have the essentially the same design of a long rod that runs against the affected leg and something which with to pull tension upon and secure the foot or ankle. Despite a lack of continued innovation and even less in the way of empiric research, an almost identical device to that which made its debut with the British Army in 1915 is required aboard every ground ambulance in the country. And almost every one of them resides in a cabinet or under a bench, forgotten and ignored until the biennial state inspection rolls around.

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The “Thomas Splint,” c. 1915

All EMTs are taught the procedure for applying a traction splint, but too often it is done in the classroom then never again. In my own experience of almost a decade of EMS, I have had the opportunity to apply one only once. As an ER physician for the last three years at the largest, busiest trauma center in Virginia, I have yet to have a patient arrive with one in place. My theory is that providers often do not consider it when appropriate, and even when they do their familiarity and comfort with the procedure is lacking, so it is skipped. In fact, one study found them to be applied in only 38% of appropriate cases and of those, 2/3 were placed incorrectly.

In other words, if you happen to break your leg, there is only about a 13% chance someone will correctly stabilize that razor sharp bone jostling against your femoral artery while you bump along to the hospital.

Since accurately practicing the procedure without crippling and otherwise healthy recruit is difficult, I looked up available traction splint training models. They cost around $1800, and are full of unnecessary bells and whistles, well beyond the means of many small EMS agencies. So I took matters into my own hands and created a rugged, reliable, anatomically and physiologically accurate model for less than $75. I’m offering it here, open sourced, to anyone who may want to replicate it for his or her training department.

You will need:

  1. A plastic store mannequin 
  2. Rubber exercise bands 
  3. Duct tape
  4. 2’ of 1 ½” PVC pipe
  5. Long, zip ties, x4

Tools:

  1. Standard drill
  2. Manual or electric saw
  3. Measuring tape

How to:

  1. Rubber exercise bands were stretched along the length of a two foot long section of 1 ½” PVC pipe, using duct tape to secure either end. The pipe was then cut diagonally in the middle, simulating a fractured bone.
  2. A six-inch section of the mannequin’s thigh was removed.
  3. Matching holes were drilled in the proximal and distal sections of the “broken femur” and the mannequin leg.
  4. The simulated bone was inserted and secured at both ends with long zip ties passed through the holes.

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At rest, the proximal and distal segments of the mannequin leg fit together, accurately simulating the shortened extremity one would expect with such an injury. The exercise bands create a physiologic level of tension, and the leg can be pulled to length and stabilized using any commercially available traction splint. At length, the gap created allows the learner to visualize the physiology of the injury and intended function of the device.

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If you do make one, please post a comment and let us know how it turned out!

~Amir

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VCU Health Research Day  |  June 2, 2017

(The concept for this model was presented at the National Association of EMS Physicians annual conference in New Orleans, LA as an educational innovation on Jan. 24, 2017).

  1. American College of Surgeons (2009). Equipment for Ambulances. https://www.facs.org/~/media/files/qualityprograms/trauma/publications/ambulance.ashx
  2. American College of Surgeons (2012). Chapter 8 Musculoskeletal Trauma. Advanced Trauma Life Support Student Manual.  219-220
  3. Abarbanell, N. (2001) Prehospital Midthigh Trauma and Traction Splint Use: Recommendations for Treatment Protocols. American Journal of Emergency Medicine. 19 (2). 137-140.
  4. Skelton MB and NE McSwain (1997). A Study of Cognitive and Technical Skill Deterioration Among Trained Paramedics. Journal of the American College of Emergency Physicians. 6 (10). 436-438.
  5. Daughtery, M., Mehlman, C., Moody, S., LeMaster, T., & Falcone, R. (2013) Significant Rate of Misuse of the Hare Traction Splint for Children with Femoral Shaft Fractures. Journal of Emergency Nursing. 39. 97-103.

EpiPen cost soars 400%: Implications for EMS and the ED

I had a patient last week brought into the Pediatric ED for an allergic reaction. The child had known allergies, and by the EMR, had been prescribed an EpiPen by the Pediatrician – but mom said she didn’t have one at home to use. “We have insurance, but when I tried to fill the prescription, they wanted $620! I just can’t afford that,” she apologetically told me. I sat there in disbelief, assuming she had crappy insurance.

Flash forward three days later when the news hits the mainstream media:

“EpiPen price hike has parents of kids with allergies scrambling”

“Why did Mylan hike EpiPen prices 400%? Because they could”


Prehospital Implications

AEMTs and Paramedics, better check that drug box twice for your 1:1000 epi vials because you’ll be using them more often for anaphylaxis as parents and patients increasingly forgo the EpiPen. With a $400-$650 price tag (with insurance), and a 1 year expiration date, can you blame them? I certainly don’t.  So brush up on your local protocols, and stay vigilant. For a good review on anaphylaxis, check out this post.

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Emergency Department (ED) Implications

As with prehospital providers, we too need to be ready with the IM epinephrine.  It’s always been recommended after EpiPen administration for patients to come to the ED  to be observed for 4-6 hours in case they need a redose of epinephrine.  As patients increasingly skip that first dose, we should expect more potential for respiratory distress and need for difficult airway management.


EpiPen Alternative

Thanks to the Facebook Group EM Docs, I learned of AdrenaClick, a reasonable alternative we can prescribe for patients with severe allergies.  The mechanism of delivery is slightly different than the EpiPen (two caps to remove instead of one), but given that it’s 1/4 the cost – it’s what I’ll be prescribing moving forward.  AdrenaClick has a good training video on their website with detailed instructions for use.  With a coupon from GoodRx, AdrenaClick is available for as low as $141.67 at Wal-Mart.  It’s still more than the original $57 cost of an EpiPen when acquired by Mylan, but better than current EpiPen prices.

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If you want to learn more about the skyrocketing prices of the EpiPen and the not-so-coincidental tie to congressional mandates requiring EpiPens (like AEDs) in schools, check out this article on Bloomberg.

<Disclaimer> And, of course, I do not endorse the efficacy of, nor am I paid by AdrenaClick. They just happen to be the only other comparable epi auto-injector on the market right now.  <Disclaimer />

~Steph

 

PulsePoint: An ER Doc’s experience answering the page

In April, 2016, Richmond became the first city in Virginia to partner with the CPR crowdsourcing app PulsePoint, bringing their technology to our city. Across the US the incidence of sudden cardiac arrest is over 300,000/year, and survival rates are generally less than 10%. Early CPR and defibrillation can triple that number. Other municipalities have had success with the technology, with early data showing it to be an effective way to get a bystander’s hands on the chest prior to the arrival of EMS units.

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While neither Steph nor I have been alerted by the app yet, one of our interns has had it go off not once but twice in just three months. I spent a while picking his brain about it last night so we could share his experience.


Amir: Ok Mike, you were telling me a couple of weeks ago that your PulsePoint actually went off. Could you just explain to anyone who maybe hasn’t heard of PulsePoint exactly what it is and why you have it?

Mike: Sure, PulsePoint is an app that’s tied with the local EMS dispatch. Whenever there’s someone nearby who needs CPR, people with the app get a notification and can respond to help.  Essentially trying to do for CPR what tinder has done for online dating.

Amir: Perfect. Except preferable not to wait for the other person to swipe right as they have only moments to live. Got it.  So it’s on your phone, just monitoring the EMS dispatch, waiting for some unsuspecting person to drop – and that’s where your story starts. Lay it on me and the rest of the English speaking world.

Mike: When the alert went off I was enjoying my day off watching Game of Thrones. I had received one alert previously that I didn’t respond to (that one was while I was in the hospital), so I recognized the alert. It was a nearby address, and “CPR Needed,” no other information. I threw a shirt on (always don appropriate PPE first) and ran out the door. When I got there, I identified myself as a doctor (liability much?) and was let in. The victim in question didn’t actually require CPR; I did a jaw thrust to keep the airway open, and literally 45 seconds later an EMS crew made their way in. And from there, EMS basically was running the show.

Amir: Ok so most importantly, have you seen this season’s finale?  It was amazing.

Mike: I can’t believe they killed off [insert character you’ve only just finally felt an emotional connection to]. So unexpected.

Amir: Speaking of killing off, back to this maybe-dying person.  How did you even know where to go?

Mike: Pulse Point has a pretty clean interface. When the alert came up it has a Google Maps type street grid.

Amir: How far away was the spot?

Mike: Just a block or so, looking into it the app will typically alert a provider within 1/4 of a mile, depending on the agency.

Amir: So pants on, shirt on, out the door – leisurely stroll down the block? Or were you hoofing it?

Mike: I think I had a decent clip going. Not a full on sprint.

Amir: You live about 1/4 mile from us. If that app ever puts a pin on our house I expect you to transform into Usain Bolt.

But ok so you’re keeping it cool, it’s their emergency not yours after all, and you show up. What kind of place? Apartment? House?

Mike: House; one I had biked past many times around the neighborhood.

Amir: What’s the etiquette here? Politely knock on the door or charge in like Superman? I imagine the latter comes with the risk of being, you know, shot to death. But for all you know it’s an innocent baby dying in there, and you’re literally the only person who can save her, right?

Mike: Yeah, the thought crossed my mind. There’s definitely a can of worms to be opened here: how do Good Samaritan laws apply to physicians, was the correct address sent through the app, the list probably goes on.  But I knocked and was let in, so cross at least one of those concerns off the list.

Amir: Did they ask who you were or how you knew what was going on or what you were doing there?  I mean no uniform, badge – you’re Joe Schmo for all they know.

Mike: It was pretty hectic and everybody just seemed to accept that I was there to help. No other questions asked.

Amir: What did you find in there?

Mike: Respiratory distress, cause unknown. As somebody who doesn’t have a background in EMS, approaching this in the field is definitely a different thought process than undifferentiated respiratory distress rolling into the ED. Differential diagnosis isn’t too important when your treatment options are limited to what you bring with you, which in this case was nothing.

Amir: Great point. Something more docs should keep in mind when EMS rolls in with a hot mess.  So not breathing, could be overdose but could also be massive head bleed, who knows? You don’t even have gloves. So you jaw thrust, trying to avoid any and all fluid leakage, and just hope the cavalry arrives soon. You weren’t up for mouth to mouth?

Mike: In retrospect, I did have my Red Cross pocket mask in the depths of my closet. Now it’s been moved to the shelf in my kitchen.

Amir: That’s a great tip. If you’re going to use this app and respond to god-knows what, be as prepared as possible. Maybe a little kit for the car and home with some basic stuff – gloves and a barrier mask.

Mike: But that does lead into another thing I’ve been considering about PulsePoint. The cavalry in this case was less than a minute away. From their website, PulsePoint costs over $10,000 to implement, and another $10k to $28k a year to maintain. So the agencies most likely to be able to afford an extra service like PulsePoint are also the agencies that are well funded, and most likely to have an EMS crew right around the corner.

Amir: Ah so you think maybe we need to see some pre/post implementation outcome data.  I’d say if that guy had been in cardiac arrest though, those 45 seconds could make a significant difference.

Mike: Oh sure, it’s definitely a good idea. Especially considering that you don’t need to be a doctor to get the app. Anybody who’s BLS certified or better can join up. And unless there are some hidden costs involved, it’s still less expensive than a lot of the other “bells and whistles” that EMS agencies can add to their toolkit.

Amir: {{*cough* ACLS drugs *cough*}}  Any other tips for potential heroes out there?

Mike: Just the usual things that I’m sure are second nature to EMS providers. Expect the unexpected, prepare for as much as you can, and the number one rule, first do no harm to yourself. “Survey the scene, don’t expose yourself to harm” doesn’t get drilled into us a ton as docs, but there’s a reason it’s the first step in BLS training.

Amir: Perfect. So to sum up:

  1. Get Dressed.
  2. Don’t show up empty handed.
  3. Watch your back. And your front.
  4. Have a good lawyer, just incase.

Mike: Couldn’t put it better myself.

Amir: I love it. Thanks for sharing the story. I can’t believe it’s gone off not once but TWICE for you.  I’ll let you have the last word to your now adoring public.

Mike: Flarhgunnstow.


I had to look up that last word. Apparently it’s this:

If you know CPR and are willing to help someone whose life depends on it, go to PulsePoint.org and see if your city has partnered.  If you don’t know CPR yet, the American Heart Association website can help you find a CPR course.

~Amir


billet_michael
Michael Billet, MD is now a PGY-2 in Emergency Medicine at VCU Medical Center in Richmond, VA. He attended the University of Virginia for both his undergraduate and medical school training. He likes long walks on the beach, Settlers of Catan, and is definitely the guy you want on your trivia team.

 

A Simple Way to Include Radiology Imaging in Your Presentation

If you work in the medical field, you’ve likely had to present a patient case report. You do a chart review, gather the physical exam and lab data, but often importing the CT scans, ultrasounds, MRIs and other video imaging for display in your PowerPoint can be a time-consuming and frustrating task.

I recently discovered an easy way to include multimedia medical images into PowerPoint in a fairly easy way. This process works on a Mac. For PCs, I’ve been told Pacstacker  is the best available option for importing radiology imaging into PowerPoint.


You’ll need access to 3 things to get started. Make sure you have each of these available on the same Mac:

  1. The radiology image you want to capture, with the ability to scroll through
  2. QuickTime for Mac
  3. PowerPoint for Mac or PC

QuickTime includes a feature similar to the “Print Screen” feature.  Instead of capturing just one image that instant, it captures your desktop activity in a selected area over time.  The result is a video file you can import into PowerPoint or other presentation software.

Step 1: Open up your Radiology imaging viewer and select the scan you wish to include.

Step 2: Open QuickTime.  From the File menu, select “New Screen Recording.”

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Step 3: When the “Screen Recording” box pops up, click the red circular button to begin.

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Step 4: A tan box will appear, asking you either click once to record the full screen, or drag and select with your mouse the portion of your screen you want included in your screen capture. For capturing radiology images, you’ll want to make sure you include only the image and exclude any personal identifiers to be HIPAA compliant.

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Step 5: While recording, scroll through your imaging study making sure to include everything you want to display.  I recommend scrolling through by clicking the arrows on the keyboard rather than using the mouse, as the cursor may accidentally enter the image field and therefore appear in your presentation.

Step 6: Click  the “Stop” button to stop recording your screen capture.  The button is somewhat hidden in the bar at the top of the screen.  It’s the circular icon with the square in the middle that you see in the image below (right side of the screen, leftmost).

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Step 7: After you click “Stop,” you’ll be prompted to save your video to your computer. Remember the location; you’ll need to find it later when you import your video into PowerPoint.

Step 8: Open your PowerPoint presentation.  To import your imaging study, Go to Insert>Movie>Movie from File.  Then find your file and click OK.

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Step 9: Your imaging study is now imported into PowerPoint as a video.  You can scroll backward and forward as needed during your presentation.  To preview your video, start your presentation and click the triangular “Play” button on the bottom left.  Note: if you click anywhere else on the slide, it will advance to your next slide, not start your video.

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PowerPoint has improved over the years, and videos are now automatically embedded with your presentation when you save your .PPTx file.  You may need to save your presentation file to DropBox, Google Drive or another cloud storage app as the file size is usually too large to send via email.


So that’s it – a previously arduous task made surprisingly simple. I hope this saves you some stress and time.

~Steph

5 Things I Learned in Business School I Wish I’d Learned in Medical School

These days, many people enter medicine as a second career.  I am no different.  I was an undergraduate business major and worked in the corporate world of internet marketing for 6 years prior to medical school.  Perhaps a science major would have been more practical when I was spending 7 hours struggling to understand some fundamentals of molecular biology; however, my business background did occasionally give me a leg up. Going back to school at 30-something, surrounded by recent college grads, I realized a few lessons I picked up along the way weren’t necessarily obvious to others.

1. Everyone has a job, and they all matter

Despite modern movements away from it, medicine is an extremely hierarchical world.  Medical students pine for that long white coat.  Doctors bark orders at nurses without introducing themselves or asking nicely.  Phlebotomists, lab techs, housekeepers and others largely go unnoticed.

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Copyright: Michelle Au | theunderweardrawer.blogspot.ca

One beautiful reality of capitalism is that jobs don’t exist unless they are vital… IMPORTANT.  In medicine, we need janitors, doctors, accountants, secretaries.  Everyone with a title has responsibilities and is therefore necessary for the organization to function.  Companies with excess overhead from superfluous staff don’t stay in business very long (VA Hospitals aside). So when the surgical consultant steals a computer terminal from the ED Tech so she can finish her note, this disrupts work flow, and sends a message that somehow the doctor’s work is more important than the ED Tech’s.  It’s just not true.  Be mindful that everyone on the team has a job to do and people will want to be on your team.

2. “For-profit = evil” is not always the case

Yes, pharmaceutical companies are responsible for their reputations as greedy, evil, for-profit companies.  Just ask Martin Shkreli.  And while it would be great to provide free medications to any and all who truly have need, research and development (R&D) of new medications is risky and costs money.  A lot of money.

 

On average, a new drug takes anywhere from 11-14 years to make it to market, and that’s IF the drug makes it that far.  Of any new drug developed in a lab, there is an 8% chance that drug will actually make it to market, meaning it’s prescribed by doctors for actual patients.§ The money spent on R&D for 92% of unsuccessful drugs is a true cost, and those bills still need to be paid.  Smart R&D focuses on modular development, so that one lesson learned developing a drug that failed can be applied to new research that will hopefully help a different drug get to market.

Yes there is excess and greed.  Yes Big Pharma develops drugs based on profitability, not strictly based on need.  People with “orphaned diseases” have to create non-profits and raise funds for R&D since the pharmaceutical companies won’t do it.  It’s not ideal.  Attracting the brightest minds to develop major pharmaceutical innovation requires paying people well, and I’ve yet to hear anyone tout how well-paid they are at their non-profit organization.  In the end, it’s not as simple as saying “just lower the prices or make it free.”

3. Product perception is reality

Marketing is everything.  You can have the best product in the world, but if no one knows it exists, or if consumers don’t understand what it can do for them, they won’t buy it.  Similarly, you can get all the science right in medicine, but if results, diagnoses and plans aren’t communicated, getting it right doesn’t matter.

If anything this is even more applicable in medicine than business.  While people have some innate understanding of what makes a good vacuum cleaner, they probably need more help understanding their liver failure and what treatment they need. I never assume patients understand their disease.  Taking 5 minutes to explain the relation between the liver and ascites goes a long, long way.

4. Dress & Look the Part

Being a medical professional requires knowledge, honesty and altruism.  Most people get that part right.  But professionalism in medicine also means being on time, dressing professionally, and remembering that people are always watching.  So for the EMT: put down the cigarette, tuck in your shirt and wear your gloves when needed.  For the medical student: be the first one arriving to rounds, wash your white coat (not just once a semester either), lose the stubble and open toed shoes and ditch the piercings for the day.  Doctors: wash your hands, put down your iPhone and give patients your undivided attention. All the knowledge in the world can be quickly overshadowed by a distracting or detracting exterior.

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“The Doctor” by Luke Fildes

5. Listen to Customer Feedback

This is not “The customer is always right.” Medicine is different.  Just because a patient thinks he needs antibiotics for his cold doesn’t mean he should get them.  But your customers do know their bodies best and how they are feeling at the time.  If you are handing a patient discharge paperwork and they “still don’t feel right,” stop and listen.  In this case, the customer feedback is critical, and the price to pay may be high – both for the patient and for your wallet.  Any seasoned Paramedic will tell you, “When the patient says they are going to die, I believe them.”  We’ve all been there.  And if you haven’t yet, it’s just a matter of time.


So that’s it, 5 small things.  What lessons have you borrowed from an earlier career and applied to medicine?

~Steph

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§ http://www.fdareview.org/03_drug_development.php