Civilian Emergency Medical Services Research Articles

Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis.

Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

Redesign of Military Patient Handoff Training for Emergency Medical Services

We conducted a qualitative research inquiry to facilitate the redesign of a military patient handoff training program for a new population of civilian Emergency Medical Services (EMS) learners. Emergency Medical Service providers provided insights about the organizational and interpersonal factors that contribute to patient handoffs, which were used to tailor the existing military patient handoff training for a civilian population. Results revealed four key phases in the patient handoff journey and three topics regarding improvements to the EMS handoff process: importance of interpersonal communication, dedicated time for handoffs, and standardized communication.

Managing a Mega Mass Casualty Event by a Civilian Emergency Medical Services Agency: Lessons From the First Day of the 2023 Hamas-Israel War.

On 7 October 2023, Israel faced an unexpected attack by Hamas, causing over 1,200 deaths and injuring more than 9,000 individuals. This report delves into the rapid medical response spearheaded by Israel's civilian Emergency Medical Service, Magen David Adom (MDA), during this crisis. Utilizing data from MDA's electronic database, 4,097 dispatch records from the day were analyzed. Of these, 39.3% were directly related to the attack. EMS teams faced multiple challenges, including handling an overwhelming number of casualties and navigating active combat zones, which impeded safe access to victims, posed significant risks to teams' safety, and constrained patient evacuation strategies. This incident underscores the importance of reinforcing healthcare resilience, particularly emphasizing the need for centralizing various aspects of response efforts. These include streamlined communication, national coordination of pre-hospital resources, and systemic management of patient evacuations. Moreover, providing substantial support for EMS personnel, who operated in highly challenging conditions, is imperative.

Analysis ofMilitary-Civilian Patient Handoff at Vista Forge Multi-Agency Nuclear Disaster Exercise 2022.

The leadership of Vista Forge 2022 requested evaluation of the handoff process between military assets and civilian emergency medical services (EMS) providers by the Beth Israel Deaconess Fellowship in Disaster Medicine (BIDMF). Vista Forge was a multi-agency military-civilian full-scale disaster exercise coordinated by the U.S. Military. The exercise, held in Atlanta, Georgia, simulated response to a nuclear bomb in an urban setting by military and civilian disaster teams. BIDMF had several two-person teams who monitored handoff procedures between military assets after decontamination and civilian emergency medical services providers during the exercise evaluation. A verbal handoff between military and civilian entities was usually not done. Triage tags placed on mannequins before decontamination remained attached to the bodies and were sent with them to civilian hospitals. Triage tags were generic military forms without specific radiation or chemical exposure information. Not all decontamination groups had the same medical capabilities, and in a disaster it is unclear how these teams would manage medical emergencies. Future studies should develop a standardized handoff procedure to be used in mass casualty situations, and trial it in future multi-agency disaster exercises. Radiation specific triage tags should be considered.

Mobile Integrated Health Care Roles of US EMS Clinicians: A Descriptive Cross-Sectional Study

Objective Mobile integrated health care (MIH) leverages emergency medical services (EMS) clinicians to perform local health care functions. Little is known about the individual EMS clinicians working in this role. We sought to describe the prevalence, demographics, and training of EMS clinicians providing MIH in the United States (US). Methods This is a cross-sectional study of US-based, nationally certified civilian EMS clinicians who completed the National Registry of Emergency Medical Technicians (NREMT) recertification application during the 2021–2022 cycle and completed the voluntary workforce survey. Workforce survey respondents self-identified their job roles within EMS, including MIH. If an MIH role was selected, additional questions clarified the primary role in EMS, type of MIH provided, and hours of MIH training received. We merged the workforce survey responses with the individual’s NREMT recertification demographic profile. The prevalence of EMS clinicians with MIH roles and data on demographics, clinical care provided, and MIH training were calculated using descriptive statistics, including proportions with associated binomial 95% confidence intervals (CI). Results Of 38,960 survey responses, 33,335 met inclusion criteria and 490 (1.5%; 95%CI 1.3–1.6%) EMS clinicians indicated MIH roles. Of these, 62.0% (95%CI 57.7–66.3%) provided MIH as their primary EMS role. EMS clinicians with MIH roles were present in all 50 states and certification levels included emergency medical technician (EMT) (42.8%; 95%CI 38.5–47.2%), advanced emergency medical technician (AEMT) (3.5%; 95%CI 1.9–5.1%), and paramedic (53.7%; 95%CI 49.3–58.1%). Over one-third (38.6%; 95%CI 34.3–42.9%) of EMS clinicians with MIH roles received bachelor’s degrees or above, and 48.4% (95%CI 43.9%-52.8%) had been in their MIH roles for less than 3 years. Nearly half (45.6%; 95%CI 39.8–51.6%) of all EMS clinicians with primary MIH roles received less than 50 hours (h) of MIH training; only one-third (30.0%; 95%CI 24.7–35.6%) received more than 100 h of training. Conclusion Few nationally certified US EMS clinicians perform MIH roles. Only half of MIH roles were performed by paramedics; EMT and AEMT clinicians performed a substantial proportion of MIH roles. The observed variability in certification and training suggest heterogeneity in preparation and performance of MIH roles among US EMS clinicians.

Characteristics of Patients Treated by Helicopter Emergency Medical Services in Ireland from 2012 to 2022: A Retrospective Analysis of Ten Years of Data

Introduction:A dedicated primary scene landing Helicopter Emergency Medical Services (HEMS) has been in operation in Ireland since 2012. Commencing with a unique collaboration between the Irish Aer Corps and civilian Emergency Medical Services (EMS) it has expanded to include a second charity funded model in the south west of the country. Both services operate under a single governance and dispatch system and provide an Advanced Paramedic level of care to the patients they serve. There is limited published literature on prehospital care in Ireland and to date no detailed descriptive study of patients treated by HEMS in Ireland. This research describes the characteristics of the patients treated by HEMS in Ireland.Method:This retrospective study will investigate the data of an excess of 8000 patients responded to by HEMS (2012-2022) in the republic of Ireland. Descriptive statistics will be used to interpret patient demographics, geographical spread, receiving facilities, mechanism/etiology of disease or injury, vital trends, transportation decisions and clinical interventions and short-term clinical outcomes.Results:Early stage data extraction shows seasonal variation in HEMS use with increased use in the summer months. Almost twice as many male patients vs. females were treated by HEMS while the most common age profile was 55-65 yrs. Trauma presentations have increased over the past 10 years and now account for over 60% of the overall caseload. The most common medical etiology was cardiac arrest or post resuscitation care followed by STEMI Care, the most common trauma cases were from road traffic collisions followed by falls and farm accidents.Conclusion:This study will be the first to describe the overall characteristics of HEMS patients in Ireland over a decade of service provision. As the Irish health system continues to evolve, so must its aeromedical services.

Comparison of the Scope of Practice of the Army Combat Medic Specialist and Civilian National EMS Certification Levels

Introduction The transition of Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) from military to civilian emergency medical services (EMS) is challenging, and the pathway is not clearly defined. Our objective was to evaluate the current military requirements for 68W and how they compare to the 2019 EMS National Scope of Practice Model (SoPM) for the civilian emergency medical technician (EMT) and advanced emergency medical technician (AEMT). Methods This was a cross-sectional evaluation of the 68W skill floor as defined by the Soldier’s Manual and Trainer’s Guide Healthcare Specialist and Medical Education and Demonstration of Individual Competence in comparison to the 2019 SoPM, which categorizes EMS tasks into seven skill categories. Military training documents were reviewed and extracted for specific information on military scope of practice and task-specific training requirements. Descriptive statistics were calculated. Results Army 68Ws were noted to perform all (59/59) tasks that coincide with the EMT SoPM. Further, Army 68W practiced above scope in the following skill categories: airway/ventilation (3 tasks); medication administration route (7 tasks); medical director approved medication (6 tasks); intravenous initiation maintenance fluids (4 tasks); and miscellaneous (1 task). Army 68W perform 96% (74/77) of tasks aligned with the AEMT SoPM, excluding tracheobronchial suctioning of an intubated patient, end-tidal CO2 monitoring or waveform capnography, and inhaled nitrous oxide monitoring. Additionally, the 68W scope included six tasks that were above the SoPM for AEMT; airway/ventilation (2 tasks); medication administration route (2 tasks); and medical director approved medication (2 tasks). Conclusions The scope of practice of U.S. Army 68W Combat Medics aligns well with the civilian 2019 Scope of Practice Model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W Combat Medic to civilian AEMT would require minimal additional training. This represents a promising potential workforce to assist with EMS workforce challenges. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

Do we need pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in the civilian helicopter emergency medical services (HEMS)?

Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) can be a life-saving procedure for patients with non-compressible torso hemorrhage. We aimed to evaluate the potential eligibility for REBOA in trauma patients of a civilian helicopter emergency medical service (HEMS) using a stepwise approach. A retrospective analysis using the electronic database (HEMSDER) of "DRF Luftrettung" HEMS covering the period from January 2015 to June 2021 was performed. Trauma patients aged ≥ 16years and with a National Advisory Committee for Aeronautics (NACA) score of ≥ 4 were assessed for potential REBOA eligibility using two different decision trees based on assumed severe bleeding due to injuries of the abdomen, pelvis, and/or lower extremities and different vital signs on the scene and at hospital handover. Non-parametric statistical methods were used for comparison. A total of 22.426 patients met the inclusion criteria for data analysis. Of these, 0.15-2.24% were possible candidates for pre-hospital REBOA. No significant differences between groups on scene and at hospital handover regarding demographics, assumed injuries, and pre-hospital interventions were found. In the on-scene group, 21.1% of the patients remained unstable even at hospital handover despite pre-hospital care. In the handover group, 42.8% of the patients seemed initially stable but then deteriorated during the pre-hospital course. The number of potential pre-hospital REBOA in severely injured patients with a NACA score of ≥ 4 is < 3% or can be even < 1% if more strict criteria are used. There are some patients who may benefit from pre-hospital REBOA as a life-saving procedure. Further research on earlier diagnosis of life-threatening bleeding and proper indications of REBOA in trauma patients is needed.

Rescue Activity of a Civilian Helicopter Emergency Medical Service in the Western Cape, South Africa: A 5-Year Retrospective Review.

Helicopter search and rescue (SAR) in Africa is conducted primarily by military organizations. Since 2002, the Western Cape of South Africa has had a dedicated contracted civilian helicopter emergency medical service (HEMS) conducting air ambulance, terrestrial, and aquatic rescue. To our knowledge, this is the first description of the operations of an African helicopter rescue service. A 5-y retrospective review of the terrestrial and aquatic helicopter rescue activity of a civilian-operated HEMS in the Western Cape, South Africa, from January 1, 2012 through December 31, 2016, was conducted. Data were extracted from the organization's operational database, aviation documents, rescue reports, and patient care records. Patient demographics and activity at the time of rescue, temporal and geographical distribution, crewing compositions, patient injury, triage, clinical interventions, and rescue techniques were analyzed. A total of 581 SAR missions were conducted, of which 451 were terrestrial and 130 were aquatic rescues. The highest volume of rescues was conducted within the urban Cape Peninsula. Hoisting using a rescue harness was the most common rescue technique used. A total of 644 patients were rescued, with no or minor injuries representing 79% of the sample. Trauma (33%, 196/644) was the most common medical reason for rescue, with lower limb trauma predominant (15%, 90/644). The most common clinical interventions performed were intravenous access (n=108, 24%), spinal immobilization (n=92, 21%), splinting (n=76, 17%), and analgesia administration (n=58, 13%). The rescue techniques utilized are similar to those described in high-income settings. Uninjured patients comprised the majority of the patients rescued.

Resuscitative endovascular balloon occlusion of the aorta in severely injured patients in the emergency trauma room: a case series

Eine Hämorrhagie ist in 30–40 % der Patienten, die im Rahmen eines Traumas versterben, todesursächlich und die häufigste vermeidbare Todesursache. Für nichtkomprimierbare Blutungen im Bereich des Abdomens oder des Beckens wird in den letzten Jahren zunehmend (wieder) die Anwendung der „resuscitative endovascular balloon occlusion of the aorta“ (REBOA) zur temporären Blutungskontrolle diskutiert. Seit August 2020 steht im Schockraum des Universitären Notfallzentrums des Universitätsspital Bern die REBOA als Therapieoption im Rahmen der Schwerverletztenversorgung zur Verfügung. Wir berichten in dieser Fallserie unsere Erfahrungen aus allen 7 Anwendungen im Laufe des ersten Jahres.

Occupational injury among paramedics: a systematic review

IntroductionParamedics are frequently exposed to acute and/or chronic environmental, operational and patient-related factors that increase their risk of physical and psychological injury. However, there has been wide variation in reported...

Annual Cost of Civilian EMS: An Analysis of Navy Expenditures in Southern California

Objective: Southern California Naval hospitals incur substantial costs through the use of civilian emergency medical services (EMS) as they lack an internal transportation team. This study aimed to quantify the volume and the associated charges for these transports in the Southern California area as these are currently unknown. Methods: This is a retrospective analysis of de-identified billing claims accessed through the Military Health System Management Analysis and Reporting Tool (M2) system. Data collected included the number and type of transports from Naval Hospitals in the Southern California area as well as the resulting charges. Data from Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) were collected over the 2018 and 2019 fiscal years. Results: There were 19,886 and 19,014 total ambulance transports in 2018 and 2019, respectively. Of these, about a quarter (8674/38900, 22.3%) were 9-1-1 calls from the patient’s home resulting in an admission at a military treatment facility or network hospital. The majority were interfacility transports (20138/38900, 51.8%). These included transports from hospital discharge to home (3900/38900, 10.0%), transfers between hospitals (1648/38900, 4.2%), transfers from an office to a hospital (1818/38900, 4.7%), and transport for medical care (11682/38900, 30.0%). A large portion of these transports were for unclear transport needs (10088/38900, 25.9%). TRICARE paid $3,872,057 in 2018 and $4,004,996 in 2019 for a total of $7,877,053 spent on ambulance transport over the 2 years analyzed. Outside health insurance paid $10,217,016 over the same timeframe for these same claims. Conclusion: The interfacility transport costs incurred between NMCSD and NHCP are substantial, possibly leaving room for cost savings to be determined by further studies.

Search and Rescue Helicopters for Emergency Medical Service Assistance: A Retrospective Study

ObjectiveThe time until treatment is a crucial factor for the outcome after medical emergencies. One way of reducing transportation time is the use of helicopter-based emergency medical services, but poor weather conditions, commitment to another mission, or technical problems may limit the availability. In these cases, military search and rescue (SAR) helicopters can be used. The aim of this study was to investigate the role of SAR helicopters in the civilian emergency medical system. MethodsWe conducted a retrospective study of SAR mission reports and SAR medical records collected from the archives of the Royal Danish Air Force for the years 2016 and 2017. ResultsA total of 1,262 mission reports were included with a total of 628 medical records available in the study period. There were 490 of 1,246 (39.3%) missions involving patients. Interhospital transfers accounted for 306 of 604 (50.7%) of cases, whereas island evacuation constituted 110 of 604 (18.2%) cases. The most prevalent suspected diagnosis was acute coronary syndrome (14.4%). The 30-day survival rate was 87.6%. ConclusionThe military SAR helicopters were most commonly activated for civilian emergency medical service mission assistance due to poor weather conditions. The most frequent medical condition was acute coronary syndrome.

Immediate Paramedic Tactical Response Unit in a Civilian Emergency Medical Service: The First Year Experience.

An immediate paramedic tactical response unit was implemented into a civilian emergency medical services (EMS) system. This was compared with the preexisting traditional tactical EMS support (TEMS). The primary aim of the study was to evaluate the effect on tasking frequencies. The secondary aims of the study were to assess mission timings and the effect on patient encounters. Paramedics with tactical emergency medical training provided immediate response on a 24/7 basis. They responded to support police in high-risk TEMS scenarios and incidents in a Tactical Emergency Casualty Care (TECC) role. Tasking frequencies, timings, and clinical input were compared between the first year of immediate response and 3 preceding years of TEMS. The number of TEMS dispatches increased from an average of 5 to 54 annually. The median time from dispatch to scene arrival decreased from a median of 54 minutes (interquartile range [IQR] 39-65) to 17 minutes (IQR 11-26) (p < .0001). The overall mission duration decreased from a median of 3 hr 13 min (IQR 2 h 29 min to 4 h 40 min) to 1 h 12 min (IQR 34 min-1 h 18 min) (p < .0001). The number of treated patients increased from one minor injury annually to 13 severe and six minor injuries annually. Implementing immediate tactical paramedic response significantly decreases response time and mission duration and increases the number of activations and resultant number of treated patients.

Prehospital administration of blood products: experiences from a Finnish physician-staffed helicopter emergency medical service

BackgroundMassive infusions of crystalloids into bleeding hypotensive patients can worsen the outcome. Military experience suggests avoiding crystalloids using early damage control resuscitation with blood components in out of hospital setting. Civilian emergency medical services have since followed this idea. We describe our red blood cell protocol in helicopter emergency medical services (HEMS) and initial experience with prehospital blood products from the first 3 years after implementation.MethodsWe performed an observational study of patients attended by the HEMS unit between 2015 and 2018 to whom packed red blood cells, freeze-dried plasma, or both were transfused. The Student’s two-sided T-test was used to compare vitals in prehospital phase with those at the hospital’s emergency department. A p-value < 0.05 was considered significant.ResultsAltogether, 62 patients received prehospital transfusions. Of those, 48 (77%) were trauma patients and most (n = 39, 81%) suffered blunt trauma. The transfusion began at a median of 33 (IQR 21–47) minutes before hospital arrival. Median systolic blood pressure showed an increase from 90 mmHg (IQR 75–111 mmHg) to 107 mmHg (IQR 80–124 mmHg; P < 0.026) during the prehospital phase. Four units of red blood cells were handled incorrectly when unused red blood cells were returned and required disposal during a three-year period. There were no reported adverse effects from prehospital transfusions.ConclusionWe treated two patients per month with prehospital blood products. A prehospital physician-staffed HEMS unit carrying blood products is a feasible and safe method to start transfusion roughly 30 min before arrival to the hospital.Trial registrationThe study was retrospectively registered by the Tampere University Hospital’s Medical Director (R19603) 5.11.2019.

Transition From Military Prehospital Medicine to Civilian EMS.

Currently, there is a disconnection between veteran military medics and the civilian Emergency Medical Services (EMS) workforce. This project aimed to characterize the rate of civilian certification among military medics, both active duty and retired, and identify perceived barriers to continuing a career in EMS after military separation. The National Association of Emergency Medical Technicians (EMTs) administered a 21-question online survey to participants. Individuals were recruited through the National Association of EMTs membership communications, Military Relations Committee members, and social media. All responses were anonymous and no identifiable information was collected. Survey questions were compiled and reported as a percentage of respondents. Free-text responses were categorized based on broad themes identified by the authors and are reported as a percentage of respondents. Results included 456 veteran and active duty respondents, of whom 304 (70.7%) had prehospital experience while in the military and 250 (58.1%) had emergency department experience. Over 60% of respondents participated in combat-related duty with 37% having at least 18months of overseas deployment. Civilian EMT certification was held by 164 (36.7%) survey participants and 170 held paramedic certification (38.1%), while 65 (14.6%) held no EMS certification. There were 119 (28.1%) respondents who stated that they did not plan to work in civilian EMS. Top selected reasons for not pursuing civilian EMS careers included: pursuing a medical career that was not prehospital (28.5%), pay disparity (18.1%), and no interest in civilian prehospital medicine (16.4%). Write in responses indicated general frustration with maintaining certification and a desire for advanced certification (AEMT, paramedic) to be supplied by the military prior to transitioning to a civilian workforce as many respondents felt their military-endowed skills and experiences were better aligned with these advanced EMS licenses. The majority of survey respondents held an EMS certification of some kind and suggests that recent efforts to supply military medics with civilian certifications have been largely successful. However, there is still a large portion that remains noncertified or expresses disinterest with entering the civilian workforce. Generally, many of those certified feel their military scope of practice exceeded civilian EMT certification and requested AEMT or paramedic licensure opportunities while still active duty military.

Operational K9s in the COVID-19 World.

Severe acute respiratory syndrome coronavirus 2 (SARSCov- 2) is hypothesized to have originated from a spillover event from an animal reservoir. This has raised many questions, with an important one being whether the widely disseminated coronavirus disease 2019 (COVID-19) is transmissible to other animal species. SARS-CoV-2 is primarily transmitted person to person. K9-to-human transmission, although theoretically possible via fomites, is considered minimal, if at all, and there have been no reported cases of K9-to-human transmission. Human-to-K9 transmission, although rare, seems more likely; however, in only one case has a K9 been suspected to have displayed symptoms of COVID-19. Preparation, decontamination, hand hygiene, and distancing remain the key factors in reducing transmission of the virus. The information presented is applicable to personnel operating within the military conventional and Special Operation Forces as well as civilian Tactical Emergency Medical Services communities who may have the responsibility of supporting an operational K9.

The use of prehospital blood products in the resuscitation of trauma patients: a review of prehospital transfusion practices and a description of our regional whole blood program in San Antonio, TX

BackgroundPrehospital management of the traumatically injured patient has evolved significantly since the organization of emergency medical services across the United States in the 1970s. Initially focusing on the utilization of crystalloid solutions to restore shed blood volume, robust military and civilian trauma experiences led to a modern day shift towards balanced blood component and ultimately whole blood use for immediate volume replacement. In addition, prehospital transfusion or remote damage control resuscitation (RDRC) has been widely adopted. This has led to point of injury resuscitation using blood products both in the United States and abroad.ObjectivesThis article will review the evolution of civilian and military prehospital resuscitation as well as the current practice of prehospital whole blood transfusion in the civilian trauma population in the United States. Additionally, we will provide an overview of our regional trauma system's use of whole blood with focus on the programme infrastructure, donor programme, product rotation schedule and logistical challenges. Finally, we provide three case report examples of the effective use of whole blood in our civilian emergency medical services (EMS) programs.

Concepts of Prehospital Advanced Airway Management in the Operational K9: A Focus on Cricothyrotomy.

Similar to people, airway obstruction is a potentially preventable cause of combat and line of duty death for civilian law enforcement Operational K9s (OpK9) and military working dogs (MWD). Basic (i.e., body positioning, manual maneuvers, bag-valve-mask ventilation) and advanced (i.e., endotracheal intubation, surgical airways) airway techniques are designed to establish a patent airway, oxygenate and ventilate, and protect from aspiration. A surgical airway (cricothyrotomy [CTT] or tracheostomy [TT]) is warranted for difficult airway scenarios in which less invasive means fail to open an airway (aka "Cannot intubate, cannot oxygenate"). In people, the surgical CTT is the preferred surgical airway procedure; most human prehospital providers are not even trained on the TT. Currently, only the TT is described in the veterinary literature as an emergent surgical airway for MWDs. This article describes the novel approach of instituting the surgical CTT for managing the canine difficult airway. The information provided is applicable to personnel operating within the US Special Operations Command as well as civilian tactical emergency medical services that may have the responsibility of providing medical care to an OpK9 or MWD.

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innovation, emergency medicine, tourniquet: innovation, emergency medicine, tourniquetFigureFigureFigureThe tourniquet has certainly had its share of critics. We'll never know how much of the negative press was from improper education, poor logistics, or prolonged application times, but the criticism has persisted since the Civil War even though no evidence substantiates any particular opinion. The criticism was mostly anecdotal, and negative results were likely due to flawed medical infrastructure, not the device. Emergency tourniquets have now achieved a certain degree of respectability. Bolstered by the United States' military medical experience in Iraq and Afghanistan, emergency tourniquets have been found to be truly life-saving without being limb-compromising, as long as they are in place for no more than two hours. Success overseas prompted medical experts to advocate for using emergency tourniquets in civilian emergency medical services. A growing contingent within the medical infrastructure is calling for commercial tourniquets and appropriate training even for the general public, especially in light of our recent tragic mass-shooting events. Commercial tourniquets have already been introduced at public venues adjacent to or within automated external defibrillator stations. This makes perfect sense because the first responders in any mass-casualty incident are usually civilians. What if commercial tourniquets are not available? We can use an improvisational one. This is a last-resort device because complications could develop depending on its design, construction, or material, but it can save lives if the extremity is actively hemorrhaging and no one else is around, as was reported in several disaster situations. We came up with a laundry list of items that could be found anywhere to serve as improvisational tourniquets, and developed a simulation model to test our theory. A 1-2 kg pork loin stood in for an adult's upper extremity or a child's lower extremity. It was encased in netting and polyethylene food wrap, and placed in a serving tray. Surgical tubing (1-2 mm diameter) attached to an IV bag of normal saline was inserted into a tunnel in the pork loin, and a 3-4 cm incision (the wound) was made in the pork down to the tubing. Adding the Windlass Then we began collecting and using various common items as a tourniquet (e.g., scarves, ties, belts, scrubs, etc.). We tested each item's efficacy by measuring how much fluid was in the tray once we opened the IV and applied the tourniquet (time limit: 1.5 minutes). Each of us is of a different weight, size, and strength, which gave us confidence in our initial results. We measured the fluid accumulation for each of our attempts, and used that as our individual control and documented the results. We then repeated the tests but added an improvisational windlass (e.g., dry-erase markers, trauma shears, pens, mosquito hemostats, Schnidt forceps, etc.). We discovered that the windlass was a critical part of the tourniquet. The amount of IV fluid each of us lost was much less than the amount lost during our control experiments using the windlass. Using a dress-tie tourniquet only, the fluid loss by each researcher was 144 cc, 102 cc, and 102 cc for the three researchers. We added a routine hemostat as the windlass, and the fluid loss dropped to 36 cc, 60 cc, and 29 cc. It took effort, however, to twist these objects to achieve cessation of the hemorrhage. Next we tried using a telephone receiver. It was the best improvised windlass we tested, a benefit because telephones are found virtually everywhere. Repeating the same experiment but adding the phone receiver windlass, the fluid loss was 26 cc, 22 cc, and 12 cc. Not only was the phone receiver easy to apply, it was the easiest to twist and stopped the flow of fluid virtually immediately.FigureWe learned from our experiments that a pork loin can serve as a relatively inexpensive model for improvisational tourniquet training. We also found that a windlass is an important aspect in stopping a severe extremity hemorrhage. Applying pressure while twisting the windlass is critical because it's virtually impossible to tuck it into the tourniquet proper like you can with the commercial variety. Many items can serve as a windlass, but the phone receiver appears to be the most efficacious one to stop a major bleed quickly and is more ubiquitous than other items. We have tweaked our “Impede-the-Bleed” educational program for our students based on this preliminary study, teaching them how to make an improvisational tourniquet using a phone receiver when nothing else is readily available. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].