The Q Word Podcast
“Dear ER Nurse, Love The Flight Crew”
Lisa: Welcome to a new episode of The Q Word Podcast! Hey, Nyssa! How's it going today?
Nyssa: Hey, Lisa! So do you realize that a month from now I will be in Boston with you?
Lisa: I am so excited. We're going to visit some of the ERs while we're here, hopefully hand out some of our brand new stickers which are coming down the line.
Nyssa: Yeah, so we're going to pull a stunt and see if we can stay awake for 24 hours and hit all of the ERs in the greater Boston area.
Lisa: Oh, that's a lot! Maybe a few of them…
Nyssa: Yeah, well ok… A lot of the ERs! So if you're in that area and you want us to come hit us up, but the trick will be to see how many triage nurses we can schmooze into letting us into the back so we can get access to the nurses and employees of those ERs. So that's the challenge. And we will be giving out a little bit of swag and we'll be talking to them and
letting them have a little sample of the podcast.
Lisa: I'm looking forward to doing my first all nighter in the hospital where I'm not actually on a gurney as a patient.
Nyssa: Yeah, it's a good time. And we've got a lot of really delicious meals planned. I'm excited about fish sandwich and lobster roll and pho.
Lisa: I believe it's called “pho.”
Nyssa: Yeah... So if I said “pho” in the deep south, people would think I was saying something really offensive so it's gonna have to be pho until I come to you. And then I can say “pho.”
Lisa: You can code switch when you get here.
Nyssa: What the “pho”?
Lisa: I actually think there is a “pho” restaurant that has that as a title somewhere, too.
Nyssa: That's the one we're going to then.
Lisa: Absolutely. So what are we talking about today?
Nyssa: Today, I have an open letter to the ER nurses, “Dear ER nurses, with love from the flight crews.” So here's the thing, we do things in the flight environment differently than we do in the ER environment. The medications that we use are a little bit different. The dosages that we use are a little bit different. The approaches are a little bit different. So what happens is, sometimes when I bring a patient to the ER or this also happens most frequently in the Neuro ICU, I get a quizzical look, or if it's a neuro ICU nurse, I get a stank eye when I tell them what I have done to the patient, and it's because they, you know, there's just a different approach. And so my hope is that I can kind of explain why it is that we've made the decisions that we've made in the flight. And then maybe we can all sing Kumbaya at the end and be, you know, all on the same page and have an understanding of one another. Because I work on the other side, I work on the ER nursing side, I get why they're, you know, like, “You did what?!” But I want them to see from my side now, like, this is why we did what we did.
Lisa: Alright, so am I the ER nurse here in this? Or am I the person standing on the outer ring of the ER nurse and the helicopter nurse asking the dumb layperson questions?
Nyssa: No be the ER nurse. That's awesome. This is preparation for Boston.
Lisa: Oh, okay, great. So I'm the ER nurse and you are coming into my hospital with a patient on a gurney that you just flew to me. What's the first thing that you want to say to me? I'm listening.
Nyssa: So thank you for listening. So when we both use oxygen- the ER nurses, ICU, everybody uses oxygen- when we use it on a helicopter, what you may find is when we bring our patient in, particularly patients who are on the ventilator, so the standard title volume is like 450 mils for a female and 500 for a male- that's kind of generic- but you're going to find that we're going to bring them on some really weird title volumes. Like you might see 385 for example, or 415, or 505, some unique numbers. And I wanted to explain that the reason that we do it that way is we customize it per patient according to their ideal body weight. So we're doing a calculation based on patients ideal body weight as a jumping off point for their ideal title volume. So instead of using kind of just a generic number for male or female, we're dialing it in to this particular patient.
Lisa: So wait up. So ideal body weight, meaning not what they actually weigh, but what they're supposed to weigh?
Nyssa: That's right, it's sometimes called a predicted body weight. But ideal body weight is another way to say it and a difference in a title volume of 500 versus 525, or 450 versus 430... It's pretty nominal. But the reason I bring this thing up is because there's actually more and more research being done on dosing medications per ideal body weight, predicted body weight, or actual body weight. Nurses, in particular ER nurses, are a little bit like a carnival sideshow freak. We can look at you and come within probably 10 kilos of how much you weigh.
Lisa: Oh, cool. That's a fun party game.
Nyssa: Yeah, maybe even five kilos of how much you weigh. We're pretty good at it. We're pretty good at guestimating weight. The way that some of this research is going- and this is one of the trends that we we like to talk about- it may be more important for us to be able to estimate your height, which is how we figure out your predicted body weight, in the future. So there are more and more medications and more and more research that's finding that certain pain medicines should be given based on ideal body weight. One of the paralytics should be given ideal body weight, another one of the paralytics should be given actual body weight. So I predict that in the future there's going to be more of this delineation between this medication is dosed ideal, this medication is dosed actual. Some of the examples would be antibiotics, pressers are going this way, even fluid resuscitation and sepsis, which is an overwhelming infection, there is talk of moving toward ideal body weight for this. So I think this is something we're going to see more of.
Lisa: So why would ideal body weight be an applicable measurement for somebody who's either extremely obese, or vastly malnourished or underweight?
Nyssa: That's a great question. So let's talk about it in the framework of oxygen. So let's say that you have someone who is morbidly obese. Their lungs don't change size. No matter how big or how small they are, their lungs are the same size. So if you calculate a weight based title volume on their actual weight, you may be giving them one and a half times what they actually need and that can actually blow out along. So the lung size doesn't change even though the body habitus might be really big or really tiny. So that's one of the reasons why we titrate oxygen in that way. The other drugs are similar. Your vasculature may or may not change based on your body habitus. How much fluid resuscitation you need may or may not change. So that's what the research is finding and trying to figure out which drugs are best dosed off of which body weight: the ideal or the actual.
Lisa: Okay, so this is just one more thing that I do need to be self conscious about not being at my ideal body weight.
Nyssa: It's something that you might find us asking you more and more... “How tall are you?” versus “How much do you weigh?”
Lisa: Great... Because, as you know, very well, I am not tall at all.
Nyssa: You're a little vertically challenged... you’re fun size. You’re snack size.
Lisa: Oh, yeah, I hate both of those. Thanks so much for for throwing those at me. I noticed that the chart that you have here on this PowerPoint presentation that we're sharing starts at five feet in terms of height and so I'm already off the chart... below it. I’m under the chart.
Nyssa: You're on the Broselow tape. That's what we use for kids. Just pull the Braselow tape out for you.
Lisa: Okay, so tell me more.
Nyssa: The next medication’s kind of not really medication. It's a little bit of a cheat, but we put it in the category of medication, and that is blood products. Some of the air medical companies carry blood products. So that's going to be packed red blood cells or liquid plasma. And this is a great addition to our toolkit in the pre-hospital environment when you have someone who is hypovolemic due to-
Lisa: Blood loss?
Nyssa: Blood loss! Yes. Thank you. Blood loss.
Lisa: Hmm. Cool. Look at me learning something!
Nyssa: Yeah. So the part of this that I want to particularly mention is the liquid plasma. It's kind of special. And you can see the color in the image that we've got here... It is called liquid plasma. It is actually liquid gold-
Lisa: It looks delicious. It looks like Tang.
Nyssa: Oh, wow. Yeah.
Lisa: Yeah, I see fresh frozen plasma. I imagine pulling it out of the freezer section at like Whole Foods. And mmm! I'm gonna make a nice sauce for this and put it over some fish.
Nyssa: So, so gross. It's really hard to gross out an ER nurse. You just did it. When we bring in a patient that we have administered blood products to, you're going to find that we have given the plasma first and then the packed red blood cells. That's different than the way it's done in most hospitals, at least right now. The rationale behind that: the liquid plasma is given for clotting factor. So when we pick up a patient, they have probably already been given a liter of fluids, maybe even two liters of fluid by ground. That is diluting their clotting factors. It's giving them volume, but it's diluting the clotting factors. And the clotting factor is what they need to stop the bleeding.
Nyssa: So we're giving this plasma in the hopes that it will help them with this clotting factor, then they're going to get the red blood cells right behind that. We carry two units of each on our helicopter, other people may vary. We're learning a lot more about liquid plasma and and how great it is. So in the hospital, we have what's called fresh, frozen plasma. So our trauma patients, they are at risk for bleeding out; coagulopathy. Not just because we've diluted their clotting factors, but also because they naturally become hypothermic and acidotic. And so that makes their clotting even more complicated and weaker. So we call these three factors “The Trauma Triad” or “The Triad of Death.” Dun dun dun!
Lisa: Is the “dun dun dun!” always included after you say “Triad of Death?”
Nyssa: For me, it's mandatory. Yeah.
Nyssa: What's great about liquid plasma, and again, this is research that is kind of cutting edge, it reduces the permeability of the endothelium… so it helps that this body does this thing where it just leaks, and the liquid plasma helps to thwart that and to hold things into place on the endothelium. It's actually healing the part that's been torn or ripped. And it helps with the thrombin and the clot formation. So this is really clutch and we love, love, love our liquid plasma.
Lisa: Has this been used for a long time? Is this a new development or? Just curious.
Nyssa: What's been used for a long time is the fresh, frozen plasma. So they keep it frozen in the blood bank and then when we have a need for it, they rapidly rewarm it or thaw it. That causes a little bit of a delay, but you could see that in the pre hospital environment, that's not an option. We don't have the option of freezing and then thawing something so we had to go to the liquid plasma. Simultaneously the research is coming out that shows that the liquid plasma does two or three extra things besides just restore the clotting factor; that it actually promotes the thrombin formation and helps to heal that ruptured, damaged, torn endothelium. So it's a great benefit and the hospitals may be moving towards more and more use of liquid plasma as well.
Lisa: Very cool. The next thing I see here... oh, let me try to pronounce this... Tran next and mean nick acid.
Nyssa: Yeah! Nailed it!
Lisa: What does that mean?
Nyssa: So we call it TXA, as you can see why now? Yeah.
TXA is an old drug. It's been used in the labor and delivery setting for a really long time for postpartum hemorrhage. Your body does this miraculous thing where when you are bleeding, it forms a clot. But sometimes we have clots and places where they're not supposed to be. So the next part of the cascade is that your body starts breaking down the clot? Well, when you have an actual bleeding diagnosis, we don't want that clot to be broken down. So what TXA does is it steps in that part of the cascade, and it blocks the breakdown of the clot. Okay, so it was used for a long, long time on mothers who had delivered babies and had postpartum hemorrhages. There was a some research that came out recently, a couple years ago that showed that it is applicable in the trauma setting as well. So it's a good medication for an acute bleed. And you might find that we have given this bolus dose, even sometimes hung the continuous drip after that, on the trauma patients that we're bringing to you in the ER.
Lisa: How does that affect how the ER then deals with that patient?
Nyssa: So if they have the capability, they will continue the drip for the next eight hours. Also a lot of level one trauma centers are doing a testing that's come out in the last few years called a TEG which is thromboelastography that is a really cool map that shows you where your patients clot is weak if they have a weakness, where their clotting is weak, TXA has an impact on one of those maps.
Lisa: Why would an ER nurse be confused by seeing TXA given to a patient coming off of your helicopter?
Nyssa: It's not really something that we're using in the ER and a lot of ours, we're not really using it. So it has to be given within a specific time frame from the time of bleeding, from the time of injury. And oftentimes by the time they get to the ER that time frame may have passed, especially if they are a transfer. So they've gone to a small outlying facility. It's been some hours since their injury. They're no longer in the window for that TXA bolus. So this is something that is time sensitive in the pre hospital world.
Lisa: After TXA, there's this really disturbing image of what looks like a broken leg. And different amounts of trauma around that break in the leg and the word ancef is under it. What does this mean?
Nyssa: Ancef is an antibiotic. And those are open fractures. And so when we pick up a patient who, you know, you have a regular fracture where the bone stays inside the skin where it's supposed to be, and then you have an open fracture where either something has gone in like a bullet, or a stab wound or a car part, gone into the body or the bone has come out of the body. And so you have a break in the skin integrity, which is your barrier to infection and your barrier to germs and bacteria. Once that has been broken, there's a really high risk for infection.
Nyssa: We can give antibiotics in the pre hospital environment to go ahead and start protecting your patient until they can get to the OR, get that wound cleaned out, debrided and repaired. And the earlier you get the antibiotics on board, the better the patient does- less likelihood of infection.
Lisa: This may be a tangential question, but do you give this to everyone or do you only give it to people for whom you have established no allergic reaction to antibiotics?
Nyssa: That's a really good question. So if we are able to obtain that information, we absolutely want that. If we are not able to obtain it, what I like to do is hang it in a 100 cc bag and give it slowly instead of giving it as a push. I like to give it (and when I say slowly ER terms slowly means 10 minutes). So I'm going to hang it and give it over 10 minutes and watch my patient for reaction. So if in the first few minutes, they start to have a reaction, I can stop it, and then treat them for those symptoms. If I bomb it in in a push dose, and they do have a reaction, now I've just given them the entire amount and now I'm chasing their reaction. So I like to give it in 50 or 100 cc bag a little bit more slowly.
Lisa: Okay, so the images that I'm seeing here go from just a maybe a small cut on the outside and a fully broken bone behind the skin all the way to this way it looks 3C level, which is a very massive open wound and shattered bone. So the amount of ancef that you deliver, is it proportionate to the size of the wound, or is that not the way it works?
Nyssa: No, not the way it works. So you've got this puncture wound all the way up to like a crush injury. Either way, the bacteria is getting into the bloodstream, they're going to get the same dose of ancef. It's a generic dose.
Lisa: Okay, and then how would this confuse an ER nurse if they are to see it?
Nyssa: So it wouldn't confuse them. But it's something that normally is done in the trauma bay as soon as it's recognized. But the great thing about the service that we've provided is that we've taken care of that for you. I would just say it's important to know and report if this has been done pre hospital so they don't get a double dose.
Lisa: Oh, okay, great. All right, that makes perfect sense. Ooh, I've heard of this one. Ketamine.
Nyssa: How have you heard of ketamine?
Lisa: Isn't it something that people get addicted to?
Nyssa: It can be yes.
Lisa: It's one of those painkillers like Oxycontin that is a narcotic and has and it's part of our opioid crisis. Am I wrong?
Nyssa: It's not an opioid, but it is something that is used on the street. That's true that people can get on the street. Yeah.
Lisa: Okay. All right. So tell me about it.
Nyssa: Ketamine is the belle of the ball in the pre hospital environment. We love, love, love some ketamine. In my ER experience ketamine was particularly used for sedation in the pediatric population, and then that was pretty much about it. In the pre hospital environment, we use it for all sorts of things. And that's one of the reasons we love it so much is because it has so many various uses. So we can use it as a pain medication. And basically it changes the uses change based on how much of it we give. So whatever the doses, we're changing.
Lisa: Whatever you are using it for. You changed its application.
Nyssa: Yeah. So based on the dose, it changes the application of the medication, right.
Nyssa: So the first one is that we can use it as a pain medication. We give a teeny tiny little 0.25 milligrams per kilo, for pain medication. This is great when you have a patient that has a terrible, terrible injury and the regular opioids that I'm giving them, the morphine or the fentanyl just aren't touching it. So I'm thinking of a guy that I had motorcycle pinned between a car his leg was just absolutely crushed from the knee down. I gave him 200 micrograms of fentanyl. Say: Oh! 200!
Lisa: Oh! 200!
Nyssa:That's right. That's a really high dose. And it still was barely barely containing his pain. So after opioids have failed, we can move to ketamine. It has a different mechanism. And so it will often augment those opioids really, really well. So when you have a really painful injury, ketamine is a great option. I will tell you the other population of patients that I use ketamine for pain down here in Georgia, we have people who take methadone. And if you take your methadone, your dose of methadone for 24 hour period, you are blocking many, many, many of the opioid receptors, not all of them, but most of them. That's the whole point of methadone. So I can give you as much morphine or fentanyl as I want, it's going to have very, very little impact on your pain, because your methadone is doing its job and it has blocked those receptors. What's great about ketamine is it works in a whole different way. So I can give patients who take methadone, I can give them ketamine and actually help control their pain via a different route.
Lisa: And how would you know this in advance, and presumably, the patient tells you this?
Nyssa: If they're awake, they can tell us. So I've had two patients in the past that have told me, you know, when you ask them about their medical history, or you know what medications they take, that's a typical question that we ask, and they'll tell us. So that's an important piece of information to know, I did have a patient who was on the ventilator one time, so he was unable to tell me that he was a transfer out of a hospital. And we were giving him truckloads of medication, and could not get him comfortable and get him relaxed on the ventilator. And as I'm digging into his past medical history, boom, there it is. Now I can see on his home medication list. Oh, here's the reason why, let's go to ketamine.
Lisa: Is there any reason why you wouldn't give ketamine without knowing that prior to finding out that they're on methadone?
Nyssa: There are very few contraindications for ketamine. The main one is ketamine will often do give a little bit of a bump in blood pressure. So if your patient already has a high blood pressure, this may not be a good choice for that patient.
Lisa: That makes sense. What do you want ER nurses to walk away from now that you've told them about this?
Nyssa: So that's just the pain dose, the sedation dose is a little bit higher, we give 0.5-1 milligram/kg for sedation. And that's the one that probably the ER nurses are most familiar with, especially in the pediatric population. This is also one of the most controversial dosages because it's, it's called a dissociative. So you're dissociating your patient. In basic terms, you're sending your patient on a trip. This is why it's a medication that is popular on the streets as well. It's like a high, it is a high and you have to be careful because your patient can have, just like LSD in the 80s, can have a really bad scary trip, or they can have a really great trip. And there's a couple of things that nurses can do to lead them down the happy trip trail instead of the scary one.
One is you push this medication very, very slowly. The other one is kind of unique, you're going to dust off a tool that you probably haven't used since nursing school. Back in nursing school, we learned about something called guided imagery, where you are with your patient, and you were actually making suggestions to them about: Mr. Jones, imagine that you're at the beach, feel the sand between your toes? Yeah, it's funny.
Lisa: Oh, what do you give them a puppy?
Nyssa: Oh, I would love puppy therapy in the helicopter. How can we do that?
So this is guided imagery, it's research has shown that you can actually lead your patient into a good trip. If, as you are administering this medication, you are also suggestive of which path they can take.
Lisa: Wow, I could see how a nurse can really really screw with somebody.
Nyssa: I think this really speaks to the power of the brain. We don't really understand a lot about why it does this or why some people go one way and other people go the other way. But it's a really interesting comment to me on the human brain.
Lisa: Yeah, it's very interesting.
Nyssa: And the the last indication or the last way that we use ketamine is for an induction agent. So this is when we need to put a tube in someone's trachea to put them on the ventilator and breathe for them. So you want them deeply deeply sedated at this point. So we're going to give one to two milligrams per kilo. I usually go big, I usually go two milligrams per kilo. And the great thing about this medication, we have other induction agents, this one does not impact the blood pressure like the other ones do. The other one will dip it down and can cause hypotension, which is really dangerous. That's one of the reasons we love ketamine.
Lisa: Alright, so when you're saying the dosage is based upon per kilo, you mean the body weight of the patient?
Nyssa: That's right.
Lisa: And this is what you're eyeballing? Or is there some sort of, there's no scale built into the gurney? Have you gotten to the hospital to show you how much they weigh?
Nyssa: So some hospitals do have beds scales, if we're picking them up from a scene, though, it's just our Carnival sideshow freak mind, estimating their weight. Maybe the patient can tell us, maybe we can look on a driver's license, but it's going to be our best guess.
Lisa: Is there any danger if you are widely off base?
Nyssa: Nah. That's the great thing about ketamine.
Lisa: All right. So it's basically it's a rule of thumb, X amount of dosage per kilo of a person's body weight, but you've got plenty of room to live with.
Nyssa: That's right. It's a jumping off point. Some people will need more, some people can go with less.
Lisa: Okay, cuz I mean, I know I look like I weigh a lot, but really, I'm clocking in at, you know, clocking in right where I belong.
Okay, so there's also this drug here called rock, rocuronium. What is that all about?
Nyssa: So there's an article that has come out that kind of states that ketamine and rocuronium are the new etomidate and succinylcholine. If you asked a lot of pre hospital clinicians they would say yes, it absolutely is. They are using ketamine and roc for induction as much, or more, than etomidate and succinylcholine. So etomidate and “sucks” as we lovingly call it, are the typical go to. it's what I still see used mostly in the hospitals for induction both in the ER and in the ICU. The problem is etomidate has what we were talking about, that property where it dips the blood pressure, and oftentimes these people cannot afford it. They are already hypotensive and that puts them in a really dangerous place. Ketamine will not dip the blood pressure as often or as much. Succinylcholine has a ton of contraindications. And a lot of those contraindications you may not even know about your patient when they come rolling in the door in a desperate situation and need to be intubated. Rocuronium has very few side effects. You know, succinylcholine has a very, very short half life. Rocuronium has a very, very long half life. So some clinicians are very leery of putting their patient down for a long time when you have sucks where you can just kind of get in and get out. But there's actually advantages to keeping them down for a long time.
Lisa: All right, but you're basically saying that you're substituting Captain and Tennille for like Sonny and Cher here, right? These were things that were worked in pairs. And now you're swapping out a new pair but you never bring the captain with Sonny and Cher with Tennille? (Kids ask your parents about Captain and Tennille and Sonny and Cher).
Nyssa: What would be the modern day version of that it would be like, let's see, it would be Beyonce and Jay Z.
Lisa: And Jay Z versus, what, Kim and Kanye?
Nyssa: Yeah, yeah, there you go.
Lisa: Okay, yes, we are so hip.
Nyssa: Yeah. But we actually I do like to mix and match. So I will do ketamine and succs occasionally. I don't know that I've ever done etomidate and rock. But I have done ketamine and succs before.
Lisa: And what made up your mind to mix and match like that?
Nyssa: So the theory is that, if you're unable to tube them, let's say it's a really difficult airway, and you're unable to tube them after five or 10 minutes, the succs wears off. And whatever spontaneous respiration they had before will resume. The rocuronium puts them down for 45 to 60 minutes depending on their metabolism. So if you don't get the tube, you have just made a long term commitment. The thing is in the ER and in the pre hospital environment, we don't ever let them go back to those spontaneous respiration. We have a backup to our backup to our backup and they're going to have some kind of advanced device or airway before it's all said and done. It's kind of a moot point, which is why I'm willing to try the rocuronium.
Lisa: Okay, so what is it about the use of ketamine and rocuronium in the pre hospital environment that might confuse or surprise an ER/ICU nurse that you're bringing a patient to?
Nyssa: Etomidate and succs is almost what still exclusively used in the hospital. And ketamine is really only used in sedating peds patients. So nurses and even physicians look at me with surprise when we say that we administered the ketamine. Yeah. When we did induction with ketamine and rock, some physicians, some nurses will, that will be a surprise to them.
Lisa: All right. So don't be surprised if you use ketamine or if they receive a patient that's been dosed with ketamine in order to intubate them or to take away their pain, right or keep them sedated.
Nyssa: And so ketamine and rock is something that all ER nurses will be familiar with. They just may not be familiar with it in that role.
Lisa: Okay. Alright, cool. So what about these push dose pressors? Um, I remember Donna saying stuff about pressors on our very first episode and our first interview when I was just a wee, neophyte nursing podcaster, and I didn't know what the hell she was talking about, I'm beginning to see the word more often. Now I see how it's spelled. Explain it to me.
Nyssa: So a pressor is a medication that, it's really, it probably should really be called a squeezer. Because it, it squeezes your vasculature to bring your blood pressure up. So if your pipe is open wide, the same amount of fluid is in there, your blood pressure is going to be low. If you squeeze it tight, it's going to bring your blood pressure up. So pressors squeeze or whatever. And the way that it's traditionally used is in a drip, we hang a drip or two on you to help that squeeze effect and bring your blood pressure up. What we're doing now, in the pre hospital environment is we're giving just a push dose, like a little, a little whiff of it to bring your blood pressure up generally for intubation. Because again, as I mentioned before, we don't want a hypotensive patient who's also struggling with an airway or, or having a hypoxic event. So it's really important to keep your brain perfused at that moment. And so push dose pressors is a great option. We are using two different ones, we're using vasopressin for our trauma patients. And we're using phenylephrine for our medical patients.
Lisa: Okay, got it.
Nyssa: So we may roll into your ER or your ICU and tell you that, you know, for intubation purposes, we had to use a push dose pressor and this is the reason and this is what we're using.
Lisa: And then you'll tell them what how much and how often?
Nyssa: Yeah, we can do it every two minutes, if necessary. And this is another trend that I predict is not going away. I think you're going to see more and more of push dose pressor use.
Lisa: Okay, the last thing that you've got is high doses of medications. What do you mean by that?
Nyssa: So in the ICU, in the ER we resuscitate a patient and put them in a nice temperature controlled, quiet, dark room and keep them very well sedated and pain free with a continuous dose of medication. In our environment, in the helicopter environment, right? Even in the back of the ambulance. And between the two between the hospital that we are taking it out of and bringing them to you from the ambulance to the helicopter once in the helicopter. Once we're on the helo pad, all of that is stimulation we are moving that patient. We're juggling them. There's vibration. There's the smell of jet fuel. There is lots and lots of noise. And then you have the outside environment. So it's really cold in the winter and very hot in the summer. And so your patient is experiencing maximum stimulation of all the senses. In addition to that, they are in their most hypermetabolic state right there, because they've just had an acute insult of some sort, whether it was a heart attack or a stroke or a traumatic event, they will burn through medication much, much faster than in the other environment where they are in a in a calm, still quiet, environmentally controlled hospital room.
Lisa: Because their heart rate is going faster, their adrenaline is pumping, right? All of that extra stimuli just makes the medicine were off that much quicker, right?
Nyssa: That's right. And so sometimes I will have nurses be very, very surprised by the amount of pain medication or the amount of sedation that I have given in a very short time. So I'll give you an example that won't mean much to you. But it will mean a lot to nurses, 20 milligrams of verseid in a 30 minute flight is a truckload of medication. And so when I tell them that, they look at me like holy cow! You know? In contrast, they may be getting five milligrams an hour, in a hospital room and a different a very different scenario, very different environment. So sometimes it helps, it's helpful to explain that our world is very, very different, and it causes patients to just really burn through this medication.
The other thing that I wanted to mention is about my neuro ICU nurses. So neuro ICU nurses love a medication and many of our nurses do, too. I love a medication called propofol, jokingly sometimes called milk of amnesia. It's the medication that killed Michael Jackson, most famously. And so the reason why this is a great medication is it keeps patients sedated. And when you turn it off, within just a few minutes, the patient can be waking up and coming back to you. So neuro ICU nurses and ER nurses that are receiving a neuro patient, it's really, really important to be able to assess that neuro status. Propofol is a very gentle sedative. So you can imagine in the pre hospital environment, it does not do much for patients. But so a lot of pre hospital clinicians will look at it and go, that stuff is garbage in my world, and so they'll take it down and throw it in the trash can. I have learned the hard way that if the patient came in with a really high blood pressure, propofol brings blood pressure down. And so if the patient has come in with a really high blood pressure, I will take the propofol, leave it hanging at the current dose, knowing that I'm going to have to augment it with some versed or some ketamine. But what I have learned is that if I throw it in the trash, I will be fighting both sedation and blood pressure at that point. So I like to go ahead and take it if the patient was hypertensive when they arrived at the hospital. So sometimes you will see clinicians just take it down and throw it away, or pull out versed to have at the ready in addition to the propofol. That is why it's a great drug in a lot of environments. Not super great in our environment.
Nyssa: The other thing that I want to tell our neuro ICU friends and and the ER nurses who are receiving a neuro patient: I totally get that you want to do a really comprehensive neuro exam on arrival; I get how important that is. There are some times in the pre hospital environment where I have to give the patient a paralytic. And that's that rocuronium that we were talking about. That's going to make the patient not have any movement, or any be able to respond for a really long time. And I know that neuro nurses are really frustrated when I roll in and say that I have had to paralyze their neuro patient because it delays their neuro assessment. But sometimes I'm having to choose between keeping that tube in their airway. So if the patient is very difficult to sedate, in that high stimulus environment, and they are reaching for that tube, or they are risking coughing out or compromising that tube, I have to choose airway over disability, I just have to. And so it doesn't happen a lot. But when it does, I'm making a choice that that airway is more important than that neuro assessment exam. And I know that's frustrating, and I apologize. But love ya, mean it.
Lisa: So as an ER and a flight nurse, you get to play both roles. When you're standing in the ER and you're receiving patients from life flight transfers do you find yourself on the questioning side? Or is it immediately apparent why you're getting patients the way that you're getting from helicopters? And are you able to communicate better with your ER team? What's going on?
Nyssa: I hope so. I hope that, you know, if I make that decisions, for instance, to paralyze a neuro patient, I'm going to give a different report, you know, I'm going to lead with “Look, I know you know, this is not ideal, but here's the deal: it was that or the airway”. And then so when I can paint the picture of what was going on it’s more well received. And really when clinicians are making decisions, especially in a pre hospital environment, where you have a lot of autonomy to make independent decisions, the way that I handle a certain patient may be completely different than the way another flight nurse handles it. Sometimes it is a personal preference. Like what I was saying about propofol, you know, I like to keep it, a lot of people don't. So it's a personal preference. So yeah, I do try to put myself in their position or try to understand the position that they're coming from.
Lisa: So let's flip the script a little bit. What advice do you have for your fellow life flight peers, when they're bringing patients into the ER? How can they better communicate to the ER nurses some of the decisions that they've made, so that they're, they can avoid those quizzical looks or that dubiousness? What should they be saying in order to better pave the way for this transfer to take place?
Nyssa: I think that it cuts both ways, I think that both ends need to have an open line of communication. So it's on the flight crew to paint a good picture of what was going on and to give a good report about why they made the choices that they did. It's also on the receiving nurse, whether it's an ER or an ICU nurse to understand some of the reasons why we do things, why we give plasma first, why we chose ketamine versus an opioid or ketamine versus etomidate. It is two different two very different environments, same patient, same patient population in many cases, but a different type of nursing. And that's what I'm hoping that people will kind of understand.
Lisa: And so when you give the ER nurses this information, clearly it's going to affect the way they then follow up with their treatment of the patient. Does it throw more complications? You've already said that it may affect their ability to do a neurological assessment, because now it's delayed until the person can start moving again. But are there other things, like for example, going all the way back to oxygen, if you give them oxygen based on their actual weight, when they're in the helicopter is that going to affect the way the ER nurse then continues the administration of oxygen once they get to the hospital?
Nyssa: You know, I mean, they can then change it to their personal preferences too. I would think if my patient is doing well, on the settings that I have that it might be, you know, good continuity of care to continue those settings. And that's something we work with respiratory with, we work with nursing staff with. So I think the key one, the things that I love about the pre hospital environment is being able to customize the care to the patient, and seeing that continue on to the next place to the ICU or to the ER, even if it's not the same way that I customized it, but customizing it to that particular patient instead of that generic diagnosis is I think when an advanced clinician does.
Lisa: Got it. That makes perfect sense. Okay, so how do you want to sum this up? Like, what's your final paragraph in this letter to your ER nurses?
Nyssa: Oh, that's a good question. Um, I would like to think that this is our patient. And when I'm talking about “our” I'm not meaning me and my medic partner, I mean, all of our patient. And I also, when we give care, like to keep the next caregiver in mind, that I am turning this patient over to you and knowing what you need to do in your next step. So I do keep you in mind, I'm not ignoring the things that you need to do. And I just want you to know that I'm being mindful of the next step in some of the decisions that I'm making, and not just thinking I just need to get this patient there and dump them off on the next guy.
Lisa: Got it. So it's not about taking care of the patient just while they're on the helicopter for your own convenience, but you are preparing the patient for the care that they're going to receive when they get to the hospital in the best possible way that you can, given the circumstances that you're surrounded by.
Nyssa: Wow, you said that so much better. Exactly. And then I would end it with love, from the flight crew.
Lisa: Perfect, little little kissy faces, kissy faces, emojis, things like that.
Lisa: Alright, so that is our letter from the pre hospital to the ER nurse. We hope that you ER nurses will hit us back with some comments about maybe some things that you've seen that have confused you. Maybe ask us some questions about what your EMS and your HEMS folks bring to you that have maybe made you scratch your head or look at them funny and go, what the hell were they thinking when they did this in the hospital, uh, when they did this before they brought them to my hospital? Hit us back with some of those questions, and maybe we can respond to them.
Nyssa: Yeah, and an open dialogue is ideal. And I also you know, I've I've said it before, I invite you to come and do a third ride with us and see exactly what it is that we're doing and how we're doing it.
Lisa: In the meantime, if you like what you hear, rate us on iTunes or Spotify or whatever your podcast platform of choice is. Check us out at theqwordpodcast.com where we will put all of our Show Notes for this episode, or email us at . But for now, that's it folks!
Nyssa: Putting a stamp on that letter.
Lisa: And sending it in the mail.
Nyssa: So old school.
*Some articles are abstracts only.
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patient, pre hospital environment, ketamine, medication, nurses, hospital, ER, plasma, helicopter, ER nurse, blood pressure, opioids, sedation, clinicians, neuro nurses, ventilator