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Quality Corner: Ambulance Supplies for the 21st Century
Every state has a list of equipment and supplies ambulances are required to have in order to be certified to serve the public. Like most everything else which makes up EMS in 21st century, some states are more progressive than others when it comes to these requirements. There is typically no prohibition against progressive EMS agencies stocking additional items on their ambulances as they see fit.
The following are some items I believe could enhance lifesaving capabilities in 21st century EMS. The below list of items is the sole opinion of this author and does not reflect the opinion of EMS World.
Tourniquets
No discussion of recent changes in emergency medical treatment modalities would be complete without mentioning commercial tourniquets. When mass shootings or IED attacks are perpetrated by terrorists—foreign or domestic—tourniquets have proven to be the greatest single lifesaving modality. Historically, most of the lives saved in these instances have been by makeshift tourniquets because commercial tourniquets were not readily available. The advantages of commercial tourniquets include; being specifically designed for this purpose, being designed for quick application and being designed with effective locking mechanisms so, once applied, the rescuer can quickly move on to treat additional patients. But the benefits of tourniquet application are not just limited to terrorist attacks. Once commercial tourniquets are put on ambulances and personnel trained in their use, they are much quicker to utilize them in other cases of life threatening extremity bleeds.
Duct tape
As the saying goes, duct tape can fix anything. It will also adhere to anything. Long gone are the days when I believed that even the widest medical tape could effectively secure a chest seal or adhere to skin if the skin is even the least bit moist. Medical tape was designed to secure clean dry bandage onto clean dry bandage. Duct tape very effectively adheres to just about anything.
Battle dressings or elastic bandages
Many state lists have included elastic bandages for decades. When you need that extra tightness for a pressure dressing or as a compression bandage for sprains and strains, elastic bandages can’t be beat. A variety of the latest battle dressings such as the Israeli Battle Dressing used by the military has added a thick gauze pad onto an elastic bandage. The Olaes Battle Dressing follows this same basic design, but also includes ten feet of additional gauze tucked inside for wound packing as well as a plastic eye cup for eye injuries attached to the back of each bandage. Both of these battle dressings are reasonably priced enough to be included on all ambulances. If all you need is an elastic bandage for orthopedic injury, simply cut the dressing pad off and wrap away. Additionally, in cases of a flail chest, applying a bulky dressing approximating the size of the defect then securing it with either a battle dressing or elastic bandage wrapped circumferentially around the chest has proven to be the most effective way to stabilize this type injury in the field.
Disposable cardboard splints and SAM splints
A wide variety of splints can be found on ambulances currently. With all of the different splints to choose from, I suppose this is to some extent more a matter of preference than anything else. Unlike many people who find a piece of equipment they like and stick with it forever, I’ve always been more than willing to switch my allegiance to anything which proves to easier or more effective to use. And it is with this in mind that while I still love my pillow splint, I’ve come to prefer the disposable cardboard splints with a towel added for extra padding or the SAM splint. There’s nothing you cannot quickly and effectively splint with those two items and the fact that they are both designed as one-use items makes them hygienic as well.
Hemostatic agents
Just as has always been taught, most bleeding can be controlled with direct pressure, including many arterial bleeds as long as you can afford to totally dedicate yourself to treating just that injury. As rare as they are in the non-tactical civilian environment, major vessel bleeds not amendable to direct pressure such as junctional wounds of the groin, axilla and neck are extremely difficult to control and will rapidly become fatal if not quickly controlled. The only option in these cases is to pack the wound with roller gauze, Kling or Kerlix. If packed hard enough the axilla and groin-wound packing can be very effective.
Wounds involving the major vessels of the neck are the most deadly and difficult to control. There are several major vessels in close proximity to each other all responsible for keeping perfused the most vulnerable and sensitive of all human organs—the brain. Cut off blood flow to any section of the brain or allow air to be drawn into a disrupted artery feeding the brain and the brain, and possibly the entire patient, could die quickly. While there is a bone in relative close proximity to the major blood vessels of the axilla and groin, the only bone in the neck is the cervical vertebra at the back of neck far away from Carotids and Jugglers. The soft, hallow trachea is close, which is incapable of aiding in the compression of the bleeding vessel, and pressure sufficient enough to stop the bleeding could potentially compress the trachea enough to occlude the airway. The best chance of saving these patients is packing the wound with a hemostatic agent and covering it with an occlusive dressing. As previously stated, these are rare injuries for civilian EMS, but they do occasionally happen and in those cases where you need a hemostatic agent, you need a hemostatic agent and nothing else will do. There is also a large patient population on a variety of blood thinners where hemorrhage control can be more difficult to attain. In such cases hemostatic agents can provide a huge live saving advantage.
With the availability of affordable hemostatic agents such as QuickClot, Celox and HemCon Chitogauze, it is reasonable to stock them on your ambulances along with such other rarely used but critical items as a cricothyrotomy and pleural decompression kit.
Best pleural decompression equipment
There are several pleural decompression kits on the market, some which include a 14 or 15 gauge needle plus a stopcock attached to plastic tubing which connects to a one-way flutter valve enclosed in a plastic chamber. The purpose of this design is to prevent air from being sucked through the needle and into the thoracic cavity. But, the risk of any air being sucked into the thoracic cavity through a 14 or 15 gauge needle, even with a normal intrathoracic pressure which is typically 6 mmHg below atmospheric pressure, is non-existent.
What all of those superfluous attachments to the needle do is add complexity with the risk of inadvertently closing the stopcock instead of opening it, rendering the lifesaving procedure useless. Additionally that tubing with the flutter valve chamber hanging off the end presents a significant hazard of catching and dislodgement especially in the rough and tumble world of pre-hospital emergency medicine.
While a large diameter needle such as a 14 gauge is preferable another important characteristic to consider is needle length. There are many needle lengths being marketed for the purpose of pleural decompressions; anywhere from 2 inches to 3.25 inches. The latest recommendation, based on multiple published studies, says a needle length of 3.25 inches is optimal since it has been proven to have a 99% success rate of penetrating the chest wall of various sized patients and reaching the thoracic cavity. It may also be worth mentioning that the cost differential between a 3.25 inch 14 gauge needle and the multi-piece pleural decompression kit described above is $10-$15 versus $150-$160 respectively.
The latest on chest seals
EMTs and paramedics have been taught forever to cover any open chest wound with an occlusive dressing typically comprised of any type of air-tight. Commercial chest seals designed explicitly for this are now available and relatively affordable, though with a wide price range. Until recently these commercial chest seals were mainly just large adhesive pads which significantly improved their capacity for maintaining their seal by adhering to more surface area of the skin as opposed to just tape around the edges. Defibrillation pads can double as a chest seal in a pinch.
In 2013 the Committee on Tactical Combat Casualty Care reported that vented chest seals were much more effective in preventing development of a tension pneumothorax in patients with open chest wounds than unvented chest seals. If your transport time to a hospital or trauma center is relatively short, non-vented chest seals with continued monitoring of the patient should suffice, especially if you’re an ALS unit with pleural decompression capabilities. If your transport times are extended or you are a BLS unit unable to perform pleural decompressions, Israeli Battle Dressing vented chest seals may be a better choice.
IV fluid warmers
Many EMS systems now have the capability to administer both warm and cool IV fluids in appropriate instances. The most common reason for chilled fluids is post-resuscitation therapeutic hypothermia. Much more commonly and critically important is warm IV fluids for trauma patients since hypothermia has proven to dramatically increase mortality rates in seriously-injured trauma patients. Recent studies have shown that although IV fluids warmed to the normal body temperature of 98.6 degrees Fahrenheit or 37 degrees Celsius is good, of even greater importance is simply not adding insult to injury by dumping cold or room temperature IV fluids into trauma patients.
IV warmers and coolers are readily available to EMS. IV warmers can range anywhere from $165 to $1,200. If the cost of these commercial IV warmers is too much for your budget, simply laying a bag of IV fluids on top of a heating pad can help.
As previously mentioned, the importance of these items is the sole opinion of this author and the greatest value of this article may be nothing more than instigating debate. From time to time, it may be beneficial for the EMS supply officer to consult with the quality coordinator, the medical director and the EMS providers to consider what items may be beneficial to add to their life-saving tool box.
Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He serves as the quality coordinator for both of these midsize third-service agencies in Southeastern Pennsylvania. Joe has over 35 years’ experience in EMS. Joe is also the author of the book; CQI for EMS–A practical manual for QUICK results and, in 2014, founded the National Association of EMS Quality Coordinators (NAEMSQC). Contact Joe at jhayestpc@gmail.com.
