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Wed Sep 17 01:26:43 BST 2008

Some EMS services are more out of control than others. The last one I  
saw come in the patient did nor even gave a pneumo. Fortunately the  
needle failed to reach the pleural space.

Typed by my index finger and sent from my iPhone!!

Andrew J. Bowman
Acute Care Nurse Practitioner
Trauma Nurse Specialist
Emergency Department Registered Nurse
Paramedic
Witham Health Services
Lebanon, Indiana
765-485-8510 (Work)
765-426-4189 (Cell)

On Sep 16, 2008, at 7:58 PM, Larry Torrey <LTorrey at maine.rr.com> wrote:

> Do you see a lot of these procedures?  I work in a teaching hospital  
> in a major US city, and see one, maybe two per year come in the door  
> from EMS.
>
> LT
>
> MARK FORREST wrote:
>> Pre-hospital needle thoracocentesis is probably the most over-used
>> unnecessary skill in the EMS tool box. All to often we see an RTC
>> casualty with a minimal degree of respiratory compromise 'needled
>> just in case'!! Many of them have iatrogenic problems related to this
>> action
>> However, I do agree with Tim, that in some rare cases that I have
>> seen, pre-hospital throacocentesis (with a 14G cannulae) can be life
>> saving. When it has been necessary, I actually remember that the
>> 'hiss' has been genuinely loud, unlike the many innappropriate ones
>> that I have seen with little if any postive sign or improvment.
>> As for diagnosis, the last pre-hospital one that I decompressed was
>> the driver of a car in a high speed RTC who I was asked to see as he
>> was very distressed with his breathing. From the backdoors of the
>> ambulance I could see the hyperinflation, grossly unequal movement of
>> his chest and his oxygen saturation of 75% on high flow oxygen! The
>> paramedics actually heard the decompression 'hiss' outside the
>> ambulance. He rapidly stabilised and was transported the short
>> distance to hospital for an x-ray and a drain.
>> If you want to see 'real'clinical signs of tension then try the ICU.
>> When these patients tension on IPPV they have some of the most barn
>> door signs that you will ever see....including mid-line shift, which
>> I have never seen pre-hospital.
>> Dr Mark Forrest Consultant in Anaesthetics & Critical Care Medical
>> Director of Cheshire Fire & Rescue Service Medical Director of ATACC
>> ----- Original Message ---- From: Robert Waddell II
>> <bobwaddell at bresnan.net> To: "Trauma & Critical Care mailing list"
>> <trauma-list at trauma.org> Sent: Tuesday, 16 September, 2008 8:11:16 PM
>> Subject: Re: Needle Decompression
>> Thanks Tim, I'll try to get the paper.  Your comments have a greater
>> volume than some may see in that the classic signs, especially those
>> listed in most of the text, include deviated trachea.  I believe it
>> was Lee in the 80's who showed through a large post evaluation  
>> analysis that tracheal deviation occurred in non-viable (dead)  
>> patients and was an extremely late sign and demonstrated that looking
>> for the deviation wasted time and aided in the practitioner loosing
>> focus of the treatable injuries.  Maybe it is time for main stream
>> EMS to re-think the "why we do what we do" and get back to a stronger
>> focus on the patient we're caring for and their positive outcomes.
>> Thanks again.
>> Take care,
>> Bob bobwaddell at bresnan.net 307 920 2020
>> On Sep 16, 2008, at 12:53 PM, Coats Tim - Professor of Emergency  
>> Medicine wrote:
>>> Several posts on this thread have mentioned the 'classic' signs of
>>> tension pneumothorax. However there is a very good paper from the
>>> Emergency Medicine Journal in 2005 that should make you rethink
>>> and question. See:
>>> Leigh-Smith S, Harris T. Tension pneumothorax—time for a rethink 
>>> ? EMJ 2005;22:8–16.
>>> What SImon and Tim showed was that 'classic' signs of tension  
>>> pneumothorax are based on operative experience in an anaesthetised
>>> patient, where compensatory mechanisms have been reduced. In the
>>> non- anaesthetised patient there may be a number of compensatory  
>>> mechanisms which means that the 'classic' signs may well not be  
>>> present. My experience is that in a non-anaesthetised patient the
>>> 'classic' signs of tension pneumothorax only occur periarrest.
>>> On the issue of 'does field needle thorocostomy work?' my
>>> experience is yes, but only very occasionally. It is certainly not
>>> as important an intervention as some prehospital trauma courses
>>> make out.
>>> Tim Coats. Professor of Emergency Medicine. Leicester University,
>>> UK.
>>> -----Original Message----- From: McSwain, Norman E Jr.
>>> [mailto:nmcswai at tulane.edu] Sent: Tue 9/16/2008 4:14 PM To: Trauma
>>> &amp; Critical Care mailing list Subject: RE: Needle Decompression
>>> See my comments from the two previous postings this morning. I
>>> would only add that I have used it several times in the field
>>> myself with apparent success. I say apparent because there were no
>>> radiographs to prove a anatomical pathophysiological improvement.
>>> General improvement in the patient's condition that made me believe
>>> that something had been accomplished by it
>>> Norman
>>> Norman McSwain Jr, MD FACS Trauma Director Charity Hospital  
>>> Professor of Surgery Tulane University School of Medicine 504 988
>>> 5111
>>> -----Original Message----- From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org 
>>> ] On Behalf Of
>>> kmattox at aol.com Sent: Tuesday, September 16, 2008 9:23 AM To:
>>> Trauma &amp; Critical Care mailing list Subject: Re: Needle
>>> Decompression
>>> I for one have never been impressed, nor seen real benefit from
>>> needle decompression of the chest.
>>> K
>>> ------Original Message------ From: Dr Ross Hofmeyr Sender:
>>> trauma-list-bounces at trauma.org To: 'Trauma &amp; Critical Care
>>> mailing list' ReplyTo: Trauma &amp; Critical Care mailing list  
>>> Sent: Sep 16, 2008 9:04 AM Subject: RE: Needle Decompression
>>>> You put in in for proper indications ( decreased breath sounds,  
>>>> decreased oxygenation) then is doing its job allowing the lung to
>>>> expand (blood or air they both can compress the lung).
>>> *Screeches to halt*
>>> Holdonamminit - how, pray tell, does a cannula in the chest help
>>> the lung expand?  Do you mean a cannula PLUS non-return valve of
>>> some form?
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