Random thoughts on battle prepping your med kit.

[Von Rheydt]

I recently heard a story from an ex Brit medic who talked about testing he did for a UK police job. When they were evaluating his skills, they had him do rescue breaths on a dummy. One hand was on top of the throat, so he could multi-task and check the carotid pulse. They evaluator sternly told him not to do that, because the public may think you were choking the casualty!

I can believe it. I experienced complete first aid training twice with the Police - once as a regular officer and I had to go thru it again as a reserve officer. They are only prepping you to do the St Johns Ambulance basic first aid exam ( a bit like a basic red cross first aid exam). The problem here is that the higher ups are mainly interested in projecting a politically correct appearance so that there are no investigations that may kill their careers.

A lot of our kit is Brit medical, from SP. I notice the Brits don't use saline locks unlike us Yanks.

My IV [needle] experience was gained in a hospital environment so I don't know what the combat troops are using in the field nowadays.

An EMT once told me about carrying some of those strong altoid mints in a tin. He said they helped when dealing with nasty situations that may cause you to vomit.

I learned the hard way to make sure I had vick with me to smear under my nose at post mortems.

[Gutshot John]

Certainly you "battle-prep" as much as you can, but for most here I'm thinking that means removing your tourniquet and practicing with it a bit. Dressings need to stay as clean/sterile as possible. In terms of infection risk, it's a risk but I'd take my chances with infection over imminent death. If all I have is a dirty NP and someone is going to die without it, it's going to get used.

I'm not sure what the story was on the throat. I don't see how checking a pulse can be construed by anyone as strangulation. If that's the reason given than it's completely retarded though I can certainly imagine some idiot saying it. That said I would discourage resting a hand on the airway as often under stress and with adrenalin you aren't really aware of how much pressure you're really applying. I've had a patient struggle under me as I was trying to work on them, thinking they were freaking out until I realized that my leg was across their arm. I didn't even feel it, but I managed to **** up his elbow. It takes much less pressure to crush a windpipe and so I'd find a better place for my hand. That's not to say it will happen, but it appears to add an additional layer of complexity where it isn't needed.

Medically I see no benefit to keeping your hand on the throat for rescue breathing. It sounds cool, but there is no substantive advantage. The effectiveness (or lack therof) of rescue breathing notwithstanding it's simply poor technique. Secondarily you can still have a pulse and be giving rescue breaths. All that said if you have to check for a pulse than you've moved beyond rescue breathing and into CPR. Moreover the carotid is on the side of the neck not the throat.

The effectiveness of mints in combating puking is dubious. Ask me how I know. With the exception of burns most puking in those cases is probably related to adrenalin than the smell. That said the scent of burning flesh cuts through just about everything. In a post-mortem different rules apply when you start removing intestines.

[MIKE G]

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[Gutshot John]

I think you understand the point was that as a general principle if sterility conflicts with imminent death there is no choice. Would a sterile NP be preferred? Of course, but if you don't have that option and someone's going to die...rinse with water and carry on. Would I put an NP into a patient that was dripping with another patient's blood? No but even rinsed off it's still "dirty." I do agree that an NP might not be the best example of this principle as you say the patient is probably dead anyway or can wait till a better option is available

As a general principle I've avoided NP airways at all costs. Sizing, fitting and insertion all present problems which limits their effectiveness. The only indication for an NP airway is for a conscious, borderline acute, patient. I've never found insertion "easy" and when faced with life-threatening scenarios I prefer ET primarily as a way of completely controlling the airway but also as an alternate means of introducing pharmaceuticals.

I'm skeptical of being able to clean an NP as you describe in the field and still be able to control an acute airway. IIRC alcohol (and most topical disinfectants) on mucous membranes is also contraindicated. Iso Alcohol on mucous membranes will irritate membranes to the extent that infection will be likely anyways. Irritated membranes from trauma or toxins like alcohol will become infected through environmental vectors but you've created the conditions in which they thrive. Having suffered through a lifetime of sinus infections I can tell you that they are mostly unavoidable if you have allergies for the same reason.

[MIKE G]

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[Gutshot John]

Maybe I am not clearly explaining my points. Iraq Ninja (IN) mentioned removing nasals from the packaging to streamline use in an urgent situation. My point was that the amount of time it takes to remove from packaging is not enough that it will effect patient outcome and that maintaining a CLEAN nasal is more important than the .5-1 second it would actually take to remove from the packaging.

In that I'd agree, I think my original point was that "battleprep" for most here is simply taking their tourniquet out of its wrapper.

As for placement, ease of insertion comes with practice and good form.

We tend to use what we're comfortable with. My experience has made me less comfortable with the general application of an NP airway. YMMV.

Insertion straight back instead of up while pulling the tip of the nose up into "piggy" form makes insertion very easy. Most adults can take a 28 or 30 french sized tube. If it doesnt fit in the right nostril it should in the left. Of the hundreds I have done on patients I cant think of one that didnt go in. Of the hundreds of students I coached to insert on fellow students I can only think of maybe 3 or 4 that couldnt take the tube, some of that could be discomfort vs structural inability.

I've never failed to get an NP in, but it usually takes several attempts. I don't know any medics that have put in that many NP airways but most I know view the NP as something of a "joke" unless the patient can't tolerate the alternatives.

Sterility or lack there of will not come into play when I have a guy dying in front of me BUT there is no reason not to take some minimal steps to proactively address infection. If I have to I will pack a wound with dirt as an improvised hemostatic agent but I am not going to bag it up in a ziploc to use as my first line.

I don't think I was implying that you should use a dirty NP tube as "first line." I'm pretty sure I said "if you've got no other choice."

I also play in much dirtier venues than most, managing a patient at the critical care level 4k into a wet cave teaches you that every little bit counts and mistakes made in the first 5 minutes of patient care can and will come back an haunt you in 3 days when you are still working to get the patient out of the woods/jungle/cave.

Once again, you take things as they are. Medical decisions in the field are almost always imperfect, that doesn't mean they're a mistake. If you don't save the patient within the first 5 minutes what difference does it make whether you've got an infection 3 days later?

Where they fall in the spectrum of adjuncts, I wouldnt put them in place of an ET tube either nasal, oral, or cric placement of the ET. I can place a nasal in a patient that isnt completely compromised and turn my back for a second to assess another patient or to improve ease of respirations, an ET tube is going to take much more attention and is a definitive airway. Not to mention the fact that there will be some patients that need airway assistance but it would be inappropriate to place an ET tube even nasally.

I have both. In certain defined circumstances I might chose the NP, but I certainly wouldn't use one as my "first line" when looking to control an airway. An ET requires more attention but in a MCI like you're describing, you make due. Again medical decisions in the field are often (if not always) imperfect, but with ET the airway is patent with no chance of aspiration (which will kill you quickly) like with an NP.

ETA: As for cleaning in the field, the residual alcohol from wiping a nasal down with an alcohol pad will be minimal if not zero particularly after you flap it around a little like a polaroid picture, I know because I have done this on myself in demonstrating nasal placement. I try to use new ones but often dont have a fresh nasal in the teaching box when I didnt prep it before class. Havent rotted my face off yet,

There are a whole lot of steps there that I don't really think are warranted if the airway is genuinely acute. Even if there is no alcohol residue (and you haven't re-contaminated the tube by flapping it around in a dirty cave), it's not sterile and so there is still risk of infection. If you're talking about using wipes you've also got to worry about the interior of the tube. At some point you just have to take say "**** it" and do the best you can.

[MIKE G]

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[Von Rheydt]

It is apparent you all have much, much, more experience than me and I personally appreciate the sharing of experience.

My exposure to bodily smells was gained as a LEO here in the UK. When I attended my first evidential post mortem I had to watch 2 before the one I was there to evidence. Added to which they had suffereded a fridge failure a couple of days before......... afterwards they told me about using vick. LEO's also have to attend fires and witness the body for chain of evidence if there is a death.

[Gutshot John]

It is apparent you all have much, much, more experience than me and I personally appreciate the sharing of experience.

My exposure to bodily smells was gained as a LEO here in the UK. When I attended my first evidential post mortem I had to watch 2 before the one I was there to evidence. Added to which they had suffereded a fridge failure a couple of days before......... afterwards they told me about using vick. LEO's also have to attend fires and witness the body for chain of evidence if there is a death.

I dunno man, you seem pretty competent to me.

Vicks is definitely an improvement and I've used it around helo crashes but I still ended up puking. The smell of burnt flesh and blood is something I can still almost taste. Mints did nothing really for me.

I never really had a problem in post-mortems but the smell (especially when they remove the intestines) still makes me a little queasy.

[ST911]

I gave up on the mints, gum, vicks, vinegar, and other remedies. Short of a respirator (and even then...) you're getting odor. I found that sometimes, the masking agent smell on top of the body/decomp made it worse.