Commentary, Patient Care, Training

Where in the World of EMS is (Flat) A.J. Heightman?

It’s not yet noon and I’ve got my finger poking through the side of a sow, knuckle deep. The large surgical lamps are beating down upon me and the other five members of my group and, combined with the assortment of protective gear we’re wearing, we’re—well, sweating like pigs.

The lung at my fingertip continues to expand and fall as we imagine it belongs to a man who just fell from a third-story window. Ten minutes prior, it belonged to a geriatric man who’d crashed his motorcycle. Before that, our swine was a woman ejected from her vehicle during a crash.

This is all part of the porcine lab conducted at Baylor College of Medicine (BCM) for the paramedics at Montgomery County Hospital District (MCHD) in Texas. Pigs are anesthetized and placed in different scenarios for the paramedics to respond and react to while a BCM resident monitors the vital signs to ensure the animal never feels a thing.

MCHD Clinical Services Manager Jordan Anderson, Medical Director Robert Dickson, and Quality Coordinator Kevin Crocker with the system’s first simple thoracostomy save.

It’s a level of training that can only come from working on a living, breathing creature. In the first scenario, our patient has been deeply cut in four areas and she’s hemorrhaging fast. The crew is soaking up blood with 4x4s but the fear of her exsanguinating is too real.

And that’s where this training lab excels. It’s one thing to teach a medic how to pack a wound with QuikClot, but it’s another to have to scoop out the pools of blood that keep refilling before the QuikClot can make contact.

“Because the porcine is alive, there’s a sense of urgency that’s very hard to mimic when in a high-fidelity environment simulation, because deep down, everyone knows the manikin is plastic,” says Lee Gillum, clinical education coordinator at MCHD.

I’d call it a once-in-a-lifetime experience, but the paramedics are required to do it 1–2 times a year. Actually, my group is so at ease in the scenarios they sometimes prompt the instructor to keep up, and the lack of constant physician oversight seems trivial. If the lab paired these highly-skilled medics with emergency medicine physicians, they’d be unstoppable. MCHD is a highly advanced system with the power to influence the future of EMS by doing stuff no other system is doing.

This lab in particular is part of their simple thoracostomy training—a procedure MCHD implemented two years ago in an attempt to save trauma-induced cardiac arrest patients who didn’t improve from needle decompression.  In simple terms, when sticking a needle into the pleural space to release a tension pneumothorax doesn’t work, the medics use their finger.

“We decided that we should treat a pneumothorax with the same proven method that hospitals do,” says Kevin Crocker, quality supervisor at MCHD. The group is also currently developing a procedure to insert a cuffed endotracheal tube using a bougie-assisted method to ensure integrity of the thoracotomy and allow for ease of conversion to standard chest drain on arrival to hospital.

Flat A.J. visits the The Woodlands Central Fire Station Dalmatian Relay.

“We knew the simple thoracostomy procedure could be considered overly aggressive, so we had to ensure the training was sufficient for our providers to master the skill,” adds MCHD EMS Director Jared Cosper. “I could immediately tell the value of the training far outweighed the cost. It was evident that no simulated training could prepare our providers for simple thoracostomy as well as this simulation.”

Due to the grim indication of the procedure (you have to be dead first), it’s only been performed in the field about 30 times so far. But after my pig has dutifully given its life for the advancement of prehospital medicine, a group from MCHD takes me to a rehab hospital around the corner.

Sitting in a wheelchair in a room on a top floor is a bright-eyed 19-year-old, a tad alarmed at the large ensemble of strangers that just waltzed into his room.

Flat A.J. hitches a ride on the back of an MCHD ambulance.

My cohorts introduce themselves as the team that saved him. He doesn’t remember the incident, but a year ago, a mobile home fell on his back as he was sitting Indian style beside it. Needle decompression didn’t work, but guess what did? He’s the only simple thoracostomy save so far, and as he excitedly shows us how he can lift himself off the seat of his wheelchair with his arms after months of physical therapy, the idea of sticking fingers in patients’ pleural spaces as an attempt to save them seems too obvious.

Of course, this isn’t an inexpensive procedure to implement into a system. But if the money and the skilled staff are there, adopting protocols for prehospital simple thoracostomy could be, as cliché as it sounds, a real lifesaver—especially with highly trained, intellectual paramedics under the license of a forward-thinking medical director.