The Bleeding Edge: Finger Thoracostomy in the Field

Join us for another captivating episode of The FlightBridgeED MDCAST as Dr. Michael Lauria explores trauma medicine's most critical and evolving skill: the finger thoracostomy. Featuring special guest Dr. Bryce Taylor, a seasoned emergency physician, and flight medicine fellow currently doing a retrieval medicine fellowship at the University of Wisconsin Med Flight. This episode takes a deep dive into the nuances of trauma-induced tension pneumothorax and the art of rapid chest decompression in the field.

They cover everything from recognizing life-threatening tension physiology to deciding between a needle decompression and a finger thoracostomy and the evolving prehospital protocols that could save lives. Dr. Taylor shares insights on resuscitative ultrasound, operational challenges, and why empirical chest decompression may be the next standard of care for flight and EMS crews. Whether you’re a seasoned critical care provider or new to trauma medicine, this discussion will leave you better equipped to handle the unpredictable.

Available wherever you listen to podcasts or directly on our website, flightbridgeed.com. While there, explore our award-winning courses designed to elevate your critical care knowledge and professional practice.

TAKEAWAYS

• Understanding the difference between tension pneumothorax and regular pneumothorax is crucial in trauma care.
• Ultrasound can be a valuable tool for identifying pneumothorax in trauma patients.
• The choice between needle decompression and finger thoracostomy depends on the clinical scenario and the availability of a sterile environment.
• Proper identification of landmarks is essential for successful finger thoracostomy.
• Chest tube placement may be appropriate in a controlled environment with access to sterile equipment. Finger thoracostomy is a crucial intervention in the pre-hospital setting for trauma patients with chest injuries and hemodynamic compromise.
• Training and education for nurse medics in performing finger thoracostomy are essential for safe and effective implementation.
• The safety and efficacy of finger thoracostomy in the pre-hospital setting make it a valuable skill for managing trauma patients in critical care transport.
• The decision to perform a finger thoracostomy should be guided by the presence of hemodynamic compromise and the need for timely intervention in trauma patients with chest injuries.
• The use of finger thoracostomy as an empiric decompression in polytrauma patients with suspected tension pneumothorax is reasonable and can be performed in parallel with other resuscitative measures.

Creators & Guests

Host

Dr. Michael Lauria

FlightBridgeED Chief Medical Director | Content Creator/Host

What is The FlightBridgeED Podcast?

The FlightBridgeED Podcast provides convenient, easy-to-understand critical care medical education and current topics related to the air medical industry. Each topic builds on another and weaves together a solid foundation of emergency, critical care, and prehospital medicine.

Speaker 1 0:00
The content of this podcast is based on medical fact and evidence based practice from credible, authoritative sources, but is not a substitute for your institution's policies, procedures, common sense or good judgment. The views and opinions are those of Eric Bauer and flight bridge ed in their entirety. This is the flight bridge Ed podcast, critical care and emergency medicine education for nurses and paramedics.

Speaker 2 0:33
All right, hello everyone, and welcome back to the flight bridge Ed, MD, cast. My name is Mike Gloria. I'll be your host. I'm an emergency medicine EMS and critical care physician with a particular interest in critical care transport. And today we're going to begin our series called The Bleeding Edge on trauma, and every special guest today as we're going to be discussing fingers thoracostomy, which is an up and coming topic with more and more services using this particular skill. I'd like to introduce Dr Bryce Taylor. He is a physician who did emergency medicine residency and is currently doing a flight fellowship up at the University of Wisconsin, our amazing friends up at Med flight, one of the only physician based flight programs in the US, really the only one on par with some of our European and Australian colleagues. So tell us a little bit about yourself, where, where you where you grew up, where you did undergrad medical school, and how you got interested in a lot of the critical care transport

Speaker 3 1:37
stuff. Yeah. So I grew up in Northern Virginia, in the Washington DC suburbs on the Virginia side. I ended up going to Virginia Tech for undergrad, where I actually started in volunteer EMS advanced life support provider down there, pretty much all through my studies. After I graduated, I went and did a master's degree and then my medical degree at debusque down in Tennessee. Once I graduated, I went back to Virginia to Roanoke, where I did residency at Virginia Tech, Carilion School of Medicine at Roanoke Memorial Hospital. While there, I really liked all the trauma. Really loved all the critical care. We had a really robust three base nurse medic flight program under Dr Haley rose Inman, I was fortunate that she kind of took me under her wing and let me come along to do protocol development and medical direction, and then I also flew a ton, and that's kind of how I ended up getting into the mid flight fellowship.

Speaker 2 2:33
Well, fantastic. Welcome to the podcast, dude, as always, to try and get amazing guests on here that actually have experience doing critical care transport, so flying around and actually understanding what it's like to land on the side of the road at 2am having to treat a really, really sick trauma patient. So without further ado, let's start talking about finger thoracostomy. So as many of you in the audience now the reason that we do finger thoracostomy is for tension pneumothorax, and that's an important distinction. And I know we say it all the time, but sometimes I feel like those words don't always ring true. And I'm sure Bryce has had experiences as have I in the emergency department where someone maybe has some rib pain, and they desat to 88 for like a split second, and they come in with needles and catheters hanging out of their chest. So let's just really quick define the population. We're doing this on Bryce. So let's start out with what is the difference between tension and just a 10 pneumothorax and a regular, old fashioned pneumothorax?

Speaker 3 3:40
Yeah. So I think that I kind of, when I teach this, I kind of go into like four populations. I kind of go trauma medical, and then under both of those you have tension, and then non tension, you know, as far as this podcast goes tonight, you know, we're talking about trauma, so I'll kind of stick to that, but you can have a pneumothorax without having tension physiology. So actually, I would venture to say most pneumothoraces are not with tension. I know in the trauma bay, we would get pneumos all the time that we actually would just observe because, you know, they were less than 15% or some institutions use less than 33 millimeters, 35 millimeters on CT scan, they'll just do serial chest X rays and pulse oximetry, and they resolve themselves. Now, when you start to get signs of cardiovascular collapse, you know, you get the famous mediastinal shift, the tracheal deviation, the tachycardia, the hypoxia, the hypotension, you know, those things are really life threatening. And then that's when you want to rapidly decompress. Now, these people that have these massive traumas that end up going to respiratory failure, I know a lot of times we will go straight to the needle or straight to the knife just because of the respiratory failure from Poly trauma. Now they're still kind of, you know, they're still exploring as far as that goes. I don't have. Good, any good answer as far as whether or not you can just declare something's attention based on respiratory failure alone. But yeah, so basically, I just kind of define it as hemodynamic instability, or impending hemodynamic collapse. And

Speaker 2 5:10
that's a pretty good way to think about it, the hemodynamic profile being like the defining factor. I mean, there have been some discussions of, you know, defining, you know, sometimes I feel like, and, you know, correct me if you think I'm wrong. Sometimes people come to in the emergency department, in the trauma, they look really sick and like, Oh man, this guy's got contention, and they're fine. Lungs up, everything looks great. And because they're poly trauma, it can be really difficult sometimes to really weed that out. I would say there's a couple of exceptions, right? Like, just broken ribs, subcutaneous emphysema, up the wads, like, stuff like that. That's like, clearly there is air outside of the lung, in the pleural space going into the subcutaneous tissue. This is, this is a pneumothorax. Couple things. First of all, I'm interested to hear your opinion. So we talk about hemodynamic compromise. I definitely feel like I've had patients that are tensioning. They are maintaining a systolic blood pressure of like 98 102, kind of hanging in there, but their heart rate's in like the 130s or 140s technically, they're not hypotensive, but they're compensating. How do you draw the line in your mind between this is tension physiology, and I need to intervene, even though maybe the number's not like his systolic blood pressure is not 70, versus someone who's really sick and you think they're gonna be systolic blood pressure 70 really soon. Yeah.

Speaker 3 6:33
So I think having a good Gestalt as far as where things are gonna go is really important. You know, you don't necessarily have to be hypotensive to necessarily be in shock. Especially in young people, they can be compensating well for the moment, whereas, you know, give them a few minutes, they'll fall apart completely. And at that point, when you're doing the decompression, you're kind of chasing your tail almost. So I think taking the full clinical picture into into mind. There's also the shock index I will sometimes employ. I really like the shock index. People kind of use it more or less, depending on what is the pathology behind what they're evaluating. It started off with trauma as being kind of like a predictor to transfuse, but I think that it's a really good way to pick up a cold shock. Because, you know, having a higher shock index is not really normal for anybody. If they are having these pulmonary symptoms, they have a mechanism, and then their shock index is going up and not going down. I think that you have a good reason to look further into doing a decompression. Yeah,

Speaker 2 7:36
absolutely. And for our listeners who may be just hearing about shock index for the first time, would you mind just like, defining it for them and then, like, what? What shock index would have you pretty concerned. Basically,

Speaker 3 7:47
a shock index is a formula that you get based on the systolic blood pressure and the heart rate. There are calculators out there, but Dr Rosenman taught me something really easy, because I don't like to really necessarily sit there doing math on the side of a road. So if the heart rate is higher than the blood pressure, so like, if heart rate's 110 and the blood pressure is 90, you're gonna have a high shock index. Now, technically, where a high shock index is kind of depends on who you talk to the institution. I kind of go with the shock index of point 8.9, definitely one or more, I would say is beyond abnormal, but that's kind of it's an extra data set that I use, is I don't like hinge everything on it, so, like, I never use it alone to make a decision. But in addition to everything else, I'm finding it's a good way to really kind of get a bigger picture.

Speaker 2 8:36
Yeah, I agree with you 100% dude, and I like that trick, because that's basically what I use. I agree with you the literature, depending upon what you read, I think the majority of it, the cutoff is around like point nine, in terms of hemorrhagic shock, needing transfusions, more likely to die, etc. But I use one. I do exactly what you because it's easy, right? If you look at the systolic blood pressure, in the heart rate, if the heart rate is greater than the systolic blood pressure, right? There, you're above, like, point nine. You're above one, right? The ratio is above one, whereas normally, most of us should have a shock index of like, point five, right? We should have a systolic blood pressure heart rate in the 60s or 70s. Systolic blood pressure, 120s or so. So when that gets inverted, and your heart rate's 120 and your systolic blood pressure is 60, that's bad. So here's a question for you. My man on med flight, when you're flying and operationally responding to super sick trauma patient that you're that you are reasonably sick, let's say, you know, because there's there, it seems like there's always, like this bimodal distribution. You get there, you land, you get out of the aircraft, like they're about to die, right? Yeah, or they're, they're actually not doing so bad. You know, it's like one of our old ranchers in New Mexico is just sitting there asking for a cigarette, and he's, like, all broken, but he's doing okay. And rarely there's, like, that handful in the center that I'm like, he might have something going on. Looks like he's in a little bit of respiratory distress, but doing fine nasal cannula, maybe a little bit tachypneic in the high 20s. Are you ever using ultrasound on scene to actually see if there is pneumothorax present? Yeah,

Speaker 3 10:13
so actually, I do. So I love, like, resuscitative ultrasound. So I do not just for like my traumas, but, like, my medical is also, I'll do basically, it's almost like a modified rush. So I'll look at heart lungs and IVC, and it's actually really good for the pneumos and then the hemos, especially, I feel like it's even better for the hemos, because you can, like, just straight up, see the volume inside of the floral cavity. So with ultrasound, you know, going through residency, we all kind of go through the motions. When we get a trauma, we do the E fast. We do two lung points, like mid clavicular, and say it's a negative e fast. So one thing I make sure that I always do with my traumas when I'm looking at their lungs is I check three points. So I do mid axillary, I do mid clavicular, and then I try to get posterior and inferior, kind of like along where the diaphragm meets, because you kind of want to get all three dimensions within view, because having good lung slide in one part doesn't mean you have good lung slide all over. And we actually on mental I do find lung points all the time. That way. I would say that pretty much every non code decompression that we do, we will do an ultrasound beforehand, and then with peril and lifeguard. During my third year, we were rolling out a similar protocol to bring ultrasound into resuscitation as well. And and the three point was, you know, a big emphasis, as far as you know, their training went as well. One important detail I do always teach my residents and med students is that the ultrasound is really good for picking up a pneumo, but if it's a negative ultrasound, that doesn't mean that there's not a pneumo. Really. You need a CT scan to really say yes or no, but usually, if it's a big enough pneumo to be causing hemodynamic collapse, you've got to

Speaker 2 11:59
find it. Yeah, yeah. Yeah, agree there. And I think for me, at least, I I, I'll be honest, I don't do it all the time. I kind of you get in the back of the ambulance, you open up the door, you look at me like, oh my gosh, this guy looks like he's about to die. If they're doing CPR, it's pretty straightforward. He's gonna get empiric fingers, finger thoracotomies. If they look really sick, more likely to do it. But that middle population, I really feel like it helps, because if you identify the pneumothorax, and they're just a little tachypneic, but their hemodynamics are fine, you can sit on it, and you can wait, and you can say, hey, this is what's going on. I don't think we have to drain the air out of your chest right now. We'll fly out of the hospital, but that way, both you and your partner and the patient have a shared mental model that if things get worse, if their blood pressure drops, and, you know, there's pneumothorax, you know exactly what you got to do, which I think is helpful.

Speaker 3 12:45
And it's also a pretty good dynamic tool, because we can do them up in the air as well, pretty easily, so we can always reevaluate, yeah, and that's

Speaker 2 12:52
a great point, and especially in an environment where you can't really hear anything, and it can be difficult to, you know, evaluate your patient sometimes. Exam, re examining them. Serial examinations may be reasonable, but I agree most the time. I'm not really doing that in the air. So let's, let's say that they have attention. New mother, I should put you you are positive they have multiple broken ribs. Subcutaneous air for, you know, just for fun, you throw the ultrasound on there real quick and show everybody though there's no lung sliding. Why don't you? Let's just get out the old 14 Gage, right? Why? What's wrong with just needle decompression?

Speaker 3 13:27
I mean, it's always an option. We do carry in our bag. It wouldn't necessarily be a wrong answer. For sure, in the United States, I honestly have not ever seen a needle work coming in from pre hospital. Either the lung is up because the needle is in the lung parenchyma on the CT scan, or they didn't have a pneumo and the lung is in the soft tissue, or they have a pneumo and they have a needle in the soft tissue. You know, there's studies that are more and more frequently coming out that needles are either not long enough they are not mechanically capable of maintaining a valve or a conduit, and that they are placed wrong more than 80% of the time, to the point where it LS, ACL, ATLS and PCC have all moved to saying finger thoracostomy is the first line for a decompression. This has been over the past five or so years. I will say that the needle is probably more effective in the mid axillary than it is in the supraclavicular region, or, I'm sorry, infraclavicular, mid clavicular, you know, based on the amount of soft tissue that there is. So you're gonna have more soft tissue and muscle up in the anterior chest, then you are going to have along the lateral chest. The other instance where it might be worthwhile is like if you're trying to bridge someone. This is going to be especially relevant in combat tactical medicine settings, where you might not have a lot of time to knife, but you have some time to do a needle, and then they have body armor on. Um, so you can reach the mid axillary area. But I think other than that, I would just move straight to, straight to the knife.

Speaker 2 15:07
And this is a very reasonable move. I know we're we've been a little bit more conservative about it. Our at our shop, we've encouraged people to at least, if you can try with the with a needle. More and more I question, question that, and feel like, especially if you're hypotensive, if you're hemodynamically compromised from tension physiology, it's probably reasonable just move directly to the finger thoracostomy. I agree with you, and I think it's interesting, if you look at the evolution of it, right. There were those early studies in healthy soldiers and sailors that showed if you had like, the 3.25 inch needle that would be long enough to access the chest of more than 98% of people, 98% of people in that study, which was like young, healthy people, and more and more, as we see In the civilian environment, I'm sure everybody's patients, may be slightly fluffier than a healthy 22 year old Marine. So we see that it really doesn't get in the right spot if it doesn't get into the access to plural space, even if you put it in the right spot, which, as you mentioned, a lot of people don't, the majority of people don't, which is kind of scary, actually, but it also goes to speak for the stress that you're under trying to find the right anatomical landmarks on people is absolutely, absolutely challenging under these circumstances. Which brings us to my next point. So you're gonna do the finger thoracotomy. You got your scalpel out, your radar, rock and roll. You're about to clean off the skin. Where are you going and how are you finding the landmarks? It

Speaker 3 16:51
is kind of a skill you have to use. I know with lifeguard, they all found it on each other, pretty much on every flight, remember, they would all find it on someone else, to the point where they all found each other's pretty much in completion, because every every body habitus is going to be different. There's going to be structural changes, you know, that are very independent of each other and very individual. But you the way I was taught was that use the triangle as being the infra mare increase along the fifth rib. You use the lateral edge of the pectoral muscle, and then you use the latissimus dorsi line up the posterior mid axillary region. Inside there, you have the least likelihood of causing injury to another structure, and you have the most likelihood of getting into the chest.

Unknown Speaker 17:39
One of the other tricks that

Speaker 2 17:42
that I was taught as a practice, or necessarily any evidence to support this, but I've been trying to actually do a study where we look at this is on healthy cadavers. We've been actually able to see that if you take your hand, basically the palm of your hands, works on adults, adults to adults only, and basically jam it up into the axilla with the arm in about 90 degrees. It's going to put you about halfway down that triangle of safety. And I feel like that's that's enough to keep you away from the great vessels, but high enough to make sure you're in the right space. So again, I don't know what your experience has been, both in outside of the hospital. I would much rather people be a rib space or too high than low. I've definitely seen a lot of splenic and hepatic biopsies. I have not seen laterally. A lot of needles end up in, like an axillary artery or anything like that.

Speaker 3 18:34
That's kind of a trick that we taught lifeguard as well. Nice.

Speaker 2 18:38
So you know, if one of the questions that I think has come up on a regular basis is, if you're going to do this, right, why not just put in a tube? You're already halfway there, right?

Speaker 3 18:50
I think that's a very valid question. Some places do put in tubes. I think in the field, the likelihood of getting a sterile environment is very low. I think if you're doing an inner facility where you go to a room, and this will actually happen up here. Sometimes they'll call us, they'll set up for the chest tube and, like, have the chest tube tray out and all that, we'll lock in, sterilize and put the tube in. But that's in a room under a controlled environment. If you're doing a finger thoracostomy in the back of an ambulance, that's going to be the most controlled setting. You'll be doing it in the field, if not in a ditch or on the ground in the woods or, you know, wherever else you might find yourself. Putting in a tube is not wrong, but the likelihood of an infection from the tube, I would say, is higher. And I've not found any hard evidence for this. I'm just kind of going off of, kind of my empiric knowledge of indwelling hardware being placed in less than sterile conditions. And then I also, in my experience with trauma surgeons, they will pull out anything that you put in before you show up, so you can put the tube in. Now, if you have the bandwidth for suction, that is another thing to consider, because the tube really gives you better benefit when it. A suction rather than just being a conduit. If not, then it might as well just be a hole that you re decompress. When you show up, they'll put in a chest tube. They'll actually make a hole above the rib space that you did yours in, just based on infection rates. I

Speaker 2 20:12
think it'd be interesting to look at chest tubes versus finger throstomies in the field and rates of impaima. A couple things I think we under appreciate in the pre hospital setting. We'll just say, well, we got to save their life, you know, we got to do what we got to do, and we'll treat the infection later. I will say that pleural space infections, empyema is managing those in the inpatient setting, managing those patients in the ICU and the trauma ICU, in the medical ICU, pleural space does not have a lot of really good blood flow. It can be very complicated to treat. It's not very easy to treat, and it can lead to a lot of really bad complications that plus forms pockets and sticks to the lung and causes all sorts of issues. So it's, it's not an insignificant infection. It's not just like a soft tissue infection, guys that we can, like, throw a little bit of antibiotics at, and you're going to be fine. It's actually creates a really complicated infection. Number two, I agree with you. Bryce man, I think that the likelihood of a pathogen growing on a piece of plastic, a non living thing, in a space that's not well vascularized, is probably higher than just going in and out really quick. And third, honestly, I mean, if you look, even if you look at the literature right, the rate of complications from the tubes going in the wrong place, or hitting the lung, or going into or causing damage and being misplaced in the skin, the subcutaneous skin, after decompressing the chest, right? Is actually pretty reasonable, so I think it's probably okay. And some people disagree with me on this one. But if it's, you know, if I'm at an outside hospital doing retrieval from like, a place two hours away, in a very remote setting, you know, maybe if I can control it and have a control environment, but I agree with you, and probably in a trauma where I'm flying directly at Trauma Center, just do the fingers or cross me, one of the questions that comes up, man, is, you know, is it safe we have, you know, I get questions all the time from teams in the hospital, like the nurses and paramedics can actually access the chest with a scalpel. And you're like, Yeah, they're pretty good. They're pretty darn good at it. But is there any evidence to say that it's actually safe and reasonable for nurses and paramedics to do this procedure?

Speaker 3 22:30
So there are multiple studies, most of them at this point are from overseas. So as far as their generalizability to us, it will vary based on, like, differences in education. That's also going to be dependent on, you know, where you are, as far as, like, the state, and what that allows for. I will say that I think that this, in my opinion, I think this procedure is safer than an RSI. You know, you are doing one incision, and you're sticking your finger in with the blunt needle, or the the blunt Kelly's, and you're feeling what you're doing, whereas, like an RSI, you paralyze someone. You don't know if you're gonna get that airway, so you can be relatively sure of it, but who knows right now, there are studies that will show between 0% and 10% complication rates after finger thoracostomies. In the field, they actually did a study where they did a one day course where they did didactics, and then a practical, where they taught not just the procedure, but safety around the procedures, sterility, and then, like chest physiology, maintaining the open conduit to continue the release. And they found no significant complications. They had two I believe there were like lung lacks and then one incidence of cellulitis. Otherwise, they got all correct placement based on their review of the cases. And I believe there's like 59 cases. Now I will say that with the caveat that all those patients had very high ISS and that they were they were generally being coated at the time of placement, and more than half of them did not even make it to the hospital. So whether or not there were more complications, you know, we'll never know, but based on the ones that did make it, there was a very low complication risk. And then they're actually looking at this down in San Antonio with ground paramedics, where they have been doing basically cardiac arrest finger thoracostomies, and they found 10% or less are getting complications. I think as far as procedures go, it's definitely not going to be the most dangerous procedure that they can do, not going to be one of the most common procedures they do either, though. So I think there will be anxiety around that component. But as far as safety, I think, I think it's a very safe skill to be releasing,

Speaker 2 24:44
yeah, I think that's a I'll come back to the medical director side of that in a second. But before I ask you about that, we want to touch on one thing, which is, anytime we do a skill, especially in the trauma setting, people who are super sick with. That surgical pathology that may need definitive surgical intervention. We always worried about, like, time, right? Anything that takes more time and gets them to a place where I can give them more blood, I can give them, you know, they can, they can be stabilized and taken into surgery. Always concerned about that, is this procedure pretty lengthy? Like, how long do you think it takes the average, at least reasonably well trained nurse, paramedic, fight physician, to do this procedure. Yeah,

Speaker 3 25:25
I would venture to say that it would take less than 30 seconds each side. I know the way that we taught lifeguard was that they both come up on each side, one does one, and then they pass the scalpel and the other one does the other side, and then they go on to the rest of the resuscitation there also, that was also something that they looked at in San Antonio as well regarding the time on scene, as far as the additional morbidity, and they found no significant differences in scene time, transport time, or like, you know, time to the trauma bay. So I think as far as time intervention, as far as that paradigm goes, I think it's definitely something that's worth it, especially if you're going to relieve life threatening, you know, it's literally one of the H's and T's, if you can relieve that before you start traveling, you know, like, you can make the transport a lot less eventful.

Speaker 2 26:11
So getting back to the rollout. Now, I want to just kind of transition. We talked about the procedure, we talked about when to do it, so indications, we talked about that it's we talked about the challenges, at least with needle thoracentesis, and why it might be better and how you do it now, for our listeners who may be quality officers in their organizations or training officers or part of the educational cadre, or even preceptors in terms of training people to do it, how did you guys roll it out? And then what did you consider in terms of performance that says this credentialing, this person's good to go, they can effectively perform this skill, and then continuing education and continuing competency. So,

Speaker 3 26:54
you know, of course, it's going to be dependent on your state, kind of if you can even roll it out. So that's gonna be the first thing that you have to really look into. Virginia. Had brought it within the scope of paramedic nurses, like, a year or so before the protocol committee even started thinking about it. The rollout, or like, the development of the protocol actually started before I was even a resident there. Shannon pays one of the flight nurses that's been at lifeguard, I think, 12 or 15 years, and she is very involved with the protocol development, protocol rollout. She found out about the finger throttle costomy protocols at like Boston med flight and Memorial Hermann Life Flight. And she actually talked to one of the trauma surgeons at Memorial, and that's how she got the idea that, you know, this is something that we should be bringing into lifeguard you know, you know, high percentage of these scenes that are these massive poly traumas. Sure, that's a lot of these chest traumas are dying because of, you know, chest pathology. A good big percentage of them coming into the trauma, they are getting chest tailed with large outputs of air and blood. So, you know, how, how much more stable could we have got them on the way here before they're chasing their tail as far as resuscitation goes, she approached the protocol committee and the Medical Director, Dr rose Inman. Now, once you get that idea, you have to make sure that there's several parties involved that are going to be on board. So does the flight crew actually want to do that? Do they have the bandwidth to learn that new skill? Are they in a good staffing position where they're not being overworked to fill polls in the schedule, where they're not going to have, you know, time to learn this skill or to keep this skill up? There's also the medical director, you know, is medical director willing to release this skill for the paramedics and the nurses? You know? Some, some feel that their agencies are not ready for it, and that's completely within their purview. You are also bringing these people to not just the medical director, though, because you're bringing these patients to the trauma bay, which has both emergency medicine faculty and physicians that are not necessarily involved with the EMS side or even know anything about the EMS side. And then you have the trauma surgeons. We were very lucky at Carilion, because the there was a really good relationship between the trauma and lifeguard and, you know, the pre hospital setting. So really, once it became an idea, it was just a figure out if this is a feasible thing, figure out if this is a reasonable thing. And then, you know, figure out how to make it work. Once everybody was on board, they started to draft the protocol, which is basically like, if you read a procedure note for the placement of a chest tube, it's basically that, up until where the chest tube goes in, there's a very simple flow sheet, and the indication is traumatic cardiac arrest. That's not isolated head. So, you know, you might want to as far as, like, things went for us, we started with where it was the last ditch effort to get a heart rate back, and we kind of use this as a way to validate that it could work and it would work after that. It's just a matter of training. And

Speaker 2 29:50
did you guys eventually approve it for tension pneumothorax, outside of traumatic arrest? So

Speaker 3 30:00
that is, in the process, the cycle, I believe we wanted to have at least a year under our belt of getting these because we wanted to have, you know, at least double digits as far as the procedure goes for cardiac arrests. You know, there's kind of like a myth that, you know, we don't transport cardiac arrests. And it's like, no, actually, we do. But like, we try to get the heart beating before we transport, you know, like, you can still call us. So that was something that we were working on there as well. We're at about 11 now, I think, and we're 100% successful. We've gotten Ross on three of them. Nice with our success rate, they're gonna advance to there's a verbiage that's used in the main Life Flight protocols, that is, if the patient is in extremis, and that kind of lets the crews decide, you know, they can critically think, does this person need a finger thoracostomy for their attention? Pneumo. Nice. Now they're also rolling out ultrasound, so that's going to be something that can help as well. Nice,

Speaker 2 30:58
man. That's good. So we're kind of, the kind of bringing it in slowly started out with traumatic cardiac arrest, where it's absolutely indicated and the benefit certainly outweighs risk. And then kind of bring it into the non traumatic patient. When you were teaching it to people, did you guys use, you know, did you use porcine ribs? Did you use mannequin? Would you guys use?

Speaker 3 31:22
So we used trauma man, which is like a mannequin that is made specifically for tension pneumos And like, decompression chest tubes. But we also used the, like the porcine ribs, basically the trauma man let them feel the landmarks, pretty much is what it was best for. And then they could, you know, cut down, pop through the synthetic pleura, and then kind of feel the, you know, the mechanical lung, whereas the porcine is really good for actually, like feeling what the pleura feels like when you stick your finger through,

Speaker 2 31:53
yeah, yeah, that feeling, like popping through with the hemostat, yeah. And that's

Speaker 3 31:57
actually what I learned on and as a med student, was the poor sign model. There are certain companies, I think it's called, like Teleflex, that will do like cadaveric finger thoracostomy training. But I know that like resources for cadavers can be kind of usually limited to, like the med students and the residents, and sometimes the finger thoracostomies are all done by the time they get to the flight

Speaker 2 32:19
group. Nice. Yeah, and I think for at least in our situation, because we did something pretty similar, it doesn't, it's not like an everyday procedure. So we were able to essentially, QA, Qi, all of them, every single one. And was it your experience? Was your experience similar? Yeah, 100%

Speaker 3 32:38
of those go to QA. You know? They get reviewed by Dr Rosenman personally, and then they are all verified by the accepting physician when they roll into the trauma bay or post mortem. So they are the site. The site is actually verified as well. Yeah, yeah. That's

Speaker 2 32:55
definitely one of the benefits of that. When they come back to our trauma center, we can, either personally or on the CT scans or whatever, we can actually verify that it was in the right spot. The one question I didn't want to run by you, and it's kind of sort of a scenario question, which has kind of come up. And I love addressing these questions, because they're pretty real world, and I have so I have some thoughts on it, but I wanted to run it by you. Is the questions come up of you have a really sick poly trauma patient who has chest injuries and pelvis injuries and abominable injuries. And the question came up was posed to me, Well, you know, how do you know? If you know you're really trying to move quickly and resuscitate this person and fly them and maybe you don't necessarily have time to sit there and do the ultrasound. The ultrasound malfunctions, or something happens, and you're like, is this person hypotensive? Because they are in hemorrhagic shock or obstructive shock from attention, pneumothorax. Do you decompress? How do you approach that? Yeah,

Speaker 3 33:59
so I approach all trauma that is hypotensive as being hemorrhagic until proven otherwise, I definitely would start the volume product resuscitation. They'll probably, most definitely be coagulopathic as well. So getting the plasma started will help as well. My thing with resuscitation is that you can do more than one thing at once. So while you're starting the blood product resuscitation, you can also be cutting the chest, I think, in like these really sick poly trauma patients, doing an empiric decompression on both sides is completely reasonable. And if you don't do it there, the likelihood of it getting done in the trauma bay anyways, is going to be high. So, you know, with it's going to take a few seconds for the patient to start responding to the blood product volume. So, you know, you can't say yes, this is definitely hemorrhagic. No, this is not hemorrhagic. You know, yes, this is obstructive. No, this is not obstructive. Most of them are actually even going to be like a mix. I would, I would say, so. Yeah, no, I think, I think an empiric finger throat cost me without doing the ultrasound first is completely reasonable. A

Speaker 2 35:05
couple things. First of all, I think it's a largely academic question that won't get sussed out until it'll be a question that's answered in retrospect, right? We rule out all those other things when they've been scanned, when they're up in the ICU, and we're like, man, actually, they didn't have a focus of bleeding in the field, I think it's really hard. It's still really hard for me. I think any of us who have even gone through paramedic school, we got through medical school, you go through residency, you go through fellowship, still can be really hard. And I think I really want to emphasize the point that you made, that things can be done in parallel. So I wouldn't, I would absolutely start blood plasma The Whole Nine Yards through actively resuscitate this patient, assuming that they were bleeding someplace, and then move to the finger thoracostomy. As long as there's some reasonable evidence of chest trauma, then I would absolutely do it, because, let's say you decompress her chest and boom, now their blood pressure is like 110 over something. Goes from, you know, like 8070, over some days into 110, or it's like, miraculously, you can always dial the blood products back, and if they get a unit of extra blood, I don't there's risk associated with trans using anybody, but in this situation, I think the benefits would way outweigh the risk. More often than not, is you're expecting that giant rush of air, and you maybe get a rush of air, and you release some tension. But guess what? They're still hypotensive. They still need the blood, because they're still probably bleeding somewhere after they got hit by the city bus or the Mack truck or got run over by, you know, like a giant tractor or something like that. So I think Bryce is awesome, man. Thank you so much for bringing your experience, both in the operational flight side, and your experience as an assistant Medical Director, rolling a lot of this stuff out, or helping to roll it out with your awesome team there, we talked about, basically, again, just reviewing real quick the indications make sure that there's evidence of hemodynamic compromise. Just because someone's having trouble breathing and their sads may dip to 90 and they have some rib fractures, doesn't mean they have a tension pneumothorax. You should stick their finger in their chest. Why not the needle? Well, we know it's less effective at actually decompressing, and a lot of time we're not even in the right spot. And when someone's really that sick, I want to know I'm in the right spot. I want to know that I'm getting air out of the plural space. We also reviewed some of the literature that it seems to be safe and reasonable nursing paramedics, even though this appears to be an invasive skill, and I agree with you 100% our teams do much more dangerous things, like RSI and a whole bunch of you know, administer a whole bunch of drugs that have a lot of side effects. So I think this is of all those things that we do in critical care, transport relatively safe, and we know that, or we have some data that suggests that it doesn't waste a lot of time in the field. So it's probably reasonable. And then we talked about some of this stuff in terms of training and education, which is important. Bryce, thank you so much for joining me. We really appreciate it and hope to have you back on future episodes here. Well, for now, take care everybody and fly safe. We'll see you on the next episode of the MD cast.