Call for ideas: Improvising in the field

MrJones

Iconoclast
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In one of your hands on portions of the class, ask a couple of the members of the class to imbolize a patient with only these items

  1. 2 1000cc bags of NACL
  2. 1 LSB
  3. 2 towels
  4. 1 short roll of duct tape
  5. 3 triangular bandages

Stand back and watch them scratch thier heads.... make it more interesting offer a bonus if they can do it NREMT style (and pass)

Am I correct in understanding that this is a response to icefog's request for improv ideas in general and not the side discussion of wilderness medicine?
 

AK_SAR

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Veneficus & mycrofft:

Not sure what the fuss is about? Some improvs work great, some sorta' work, some don't work at all. That would be true of any improvisation in any facet of life, not just EMS.

Yes, it is worthwhile to try to sort out the good from the bad from the ugly. However, you guys give the impression (whether intended or not), that you think ANY improvisation is misguided. And you act kind of snotty about it, in my opinion.

Improvisation is not something most EMS providers working in urban settings are going to do in their normal day to day work. Nor should they. However, when out in the bush, one sometimes has to do the best one can with what one has. The same would be be true in a major disaster scene. In that case your well stocked ambulance will soon run out of stuff, and you will .... do the best you can .... with what you have.

One needs to learn the basic theory first. 'What is it we are trying to do?...why do we want to do it?....how does the store bought stuff do it?....' After that, some freewheeling experimentation in a class is a good thing, in my opinion. Put it together, then try it out. Try to make it fail. See what works and what doesn't.

I've spent a fair bit of time knocking around the bush in Alaska, and I've seen some pretty wierd looking but ultimately successful improvisations in all sorts of areas, not just first aid.

That's my $.02
 

Veneficus

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Veneficus & mycrofft:

Not sure what the fuss is about? Some improvs work great, some sorta' work, some don't work at all. That would be true of any improvisation in any facet of life, not just EMS.

Yes, it is worthwhile to try to sort out the good from the bad from the ugly. However, you guys give the impression (whether intended or not), that you think ANY improvisation is misguided. And you act kind of snotty about it, in my opinion.

It is not that I am against improvisation, I have done well more than my fair share of it. I will let Mycrofft speak for himself, but we are not the new guys to this.

My problem comes in when improvisation is taught as a series of skills to be performed and try to disguise it as "education" which it certainly is not.

My point is that doing such things needs to be goal oriented, understanding and working towards the underlying principle.

As you can see from my comments to Rocketmedic, I very highly appreciate the ability to improv.

As I said, I further have a problem with "schools" or "classes" that use these feeble and often unused in reality drills and take peoples money for it. As I said, I think it is dishonestly taking advantage of people who do not know any better.

I am highly educated, experienced, and well spoken. (despite this really crappy keyboard and my deteriorating spelling in English from being away from it so long) I have even been called "smart" from time to time too.

I don't like to be patronized or spoken to like I am an idiot. Esecially with elementary, misleading, or disingenious argument.
 

NomadicMedic

Pot or Kettle? Unsure.
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Folks, I've already removed some posts from this thread and infractions are forthcoming.

I suggest you all play nice and keep this thread on topic and polite.

umymehu8.jpg
 
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icefog

icefog

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WuLabsWuTecH, that's definitely the best way to go, I'll set up some realistic scenarios and see what they come up with and how we can improve. The goal won't be for them to get a list of tips and tricks they can whip out on scene and peruse until they find the fitting answer, but rather to get them to act in a goal-oriented manner, think out of the box and - why not - have some fun. Well, after getting drilled on how important sticking to protocols is, once we're done, they'll either buy me a beer or shoot me :)

Veneficus, I agree that the only way to come up with adequate solutions is to have a solid knowledge base to work with. On the other hand, I won't be teaching "core improvisation skills" or handing out leaflets on "7 steps to successful problem solving as an EMT". It's not mandatory training, nobody's shoving this course down anyone's throat. All participants will be at EMT-I level or above and have at least 2 years of experience, so I assume they can make their own decisions - if they wouldn't be able to do that, I wonder what they'd do out there every day. Perhaps I should have provided more info in the beginning, but I'm trying to avoid a TL;DR issue here (for instance, I also left out the fact that there will be evaluators present to assess my instructor skills). To clarify, it's not a course for WEMTs or one on survival techniques, but one for regular EMT-Is and EMT-Ps - although I think examples taken from emergency situations out in the bush or suggestions coming from WEMTs can be very valuable.

Actually, there are a ton of "different" optional courses in our region, ranging from "Emergencies in red light districts" (sometimes it's fun to work in Europe) to "Krav Maga self defense for EMTs". Not being a stranger to that last subject, I admit I was highly prejudiced about someone claiming to teach effective self defense in 6 hours, but ultimately I was pleasantly surprised. Long story short, the SciFi/Bruce Lee tactics I expected never came up; instead they placed a lot of emphasis on deescalation and ways of avoiding direct engagement and saving your neck in a tight spot.

Brandon, your videos gave me an idea, I'll take some of the tricks they should already know (like using a BP cuff as a tourniquet) and see if they watch out for the dangers and complications that could arise and how they deal with them.

mycrofft, the legal issues in the EMS field are pretty interesting in Germany, we're almost always is a "gray area" when we work on our patients. Ask 10 paramedics here and you'll get 11 different opinions on what's legal and what's not, but the bottom line (supported by court rulings) is: any [invasive or improvised] measure that would save the patient's life or prevent further damage to the patient's health or well-being, undertaken in an extreme circumstance (even if it's against the law or against local protocols) is acceptable (will not be prosecuted and cannot be a ground for termination of employment), if (A) the same results could not have been achieved using a traditional or less invasive measure, and (B) the provider is "adequately trained" for carrying out that specific measure. In the course, I intend to emphasize the fact that to go outside protocol (or, perhaps more pertinent to the issue at hand, to break the law forbidding the use of medical equipment in a manner for which it hasn't been certified) might be accepted as adequate, but every one of them must make their own informed decision with regard to their own specific situation.

schulz: I'm a paramedic working in Germany, but I'm neither German nor American; I'm originally from Romania, I moved to Germany looking for better EMS training. However, I've got my doubts about how long I'll stay here, considering the general attitude towards the EMS and the unclear legal situation I've mentioned.

Everyone, thanks a lot for all your comments and suggestions, they really come in handy!
 
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RocketMedic

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Please never use a BP cuff as a tourniquet. Its not good patient care, and theinstant someone taps the velcro, it blows.

Either use a commercial one or get two triangle bandages (cravats) and a thick stick. A pocket flashight works. Open one cravat, keep it folded but unrolled straight. Loop it around limb proximal to wound, tie a tight square knot on top, put in stick, tie another square knot reversed to the first. Spin the stick to tighten. Use second cravat to tie down the stick.
 
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icefog

icefog

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Please never use a BP cuff as a tourniquet. Its not good patient care, and theinstant someone taps the velcro, it blows.

Either use a commercial one or get two triangle bandages (cravats) and a thick stick. A pocket flashight works. Open one cravat, keep it folded but unrolled straight. Loop it around limb proximal to wound, tie a tight square knot on top, put in stick, tie another square knot reversed to the first. Spin the stick to tighten. Use second cravat to tie down the stick.

This is exactly what I'm talking about. You're perfectly right, a commercial tourniquet is the best option. But what if you don't have one? Many regions here refuse to allow them. And assume you're reaching for the triangle bandage when the physician on scene says NO, we'll use the BP cuff. We can talk about proper training and keeping up with the times on this thread all day long, but out there, you can't very well start a polemic while treating the patient. So in this particular situation (which occurs very often over here), I'd prefer to know that the paramedic is aware of the risks involved with using a BP cuff and the way to manage them and secure it properly.
 

Brandon O

Puzzled by facies
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Please never use a BP cuff as a tourniquet. Its not good patient care, and theinstant someone taps the velcro, it blows.

Either use a commercial one or get two triangle bandages (cravats) and a thick stick. A pocket flashight works. Open one cravat, keep it folded but unrolled straight. Loop it around limb proximal to wound, tie a tight square knot on top, put in stick, tie another square knot reversed to the first. Spin the stick to tighten. Use second cravat to tie down the stick.

Disagree. Working, well-maintained BP cuffs allow for carefully-titrated pressure (to a specific pressure in fact), evenly applied over a wide circumferential band, and they're both available (usually in multiple sizes) and -- most importantly -- familiar to us. I agree that the two main risks are leaking and slipping. I knot or clamp the tubes to prevent the former; if your velcro is intact and applied properly the latter shouldn't be a huge problem, but you can always wrap a few loops of tape around the whole apparatus for security if you'd like.

Now, I wouldn't try to haul someone off a mountain like this, but for the typical civilian EMS environment, I think it fits the bill. I know that Dr. Weingart likes them in the ED as well.
 

RocketMedic

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This is exactly what I'm talking about. You're perfectly right, a commercial tourniquet is the best option. But what if you don't have one? Many regions here refuse to allow them. And assume you're reaching for the triangle bandage when the physician on scene says NO, we'll use the BP cuff. We can talk about proper training and keeping up with the times on this thread all day long, but out there, you can't very well start a polemic while treating the patient. So in this particular situation (which occurs very often over here), I'd prefer to know that the paramedic is aware of the risks involved with using a BP cuff and the way to manage them and secure it properly.


I would challenge that MD and use the option that doesnt suck. If he insists, its his patient. If its one of my patients or joes, he gets politely ignored. A smart doctor wouldnt trade a good TK for a cuff. Dumb calls dont get listened to if they are abjectly dumb and I can articulate my reasoning for it.

An improvised tourniquet is also tension and size-adjustable and far less prone to failure.
 

RocketMedic

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Disagree. Working, well-maintained BP cuffs allow for carefully-titrated pressure (to a specific pressure in fact), evenly applied over a wide circumferential band, and they're both available (usually in multiple sizes) and -- most importantly -- familiar to us. I agree that the two main risks are leaking and slipping. I knot or clamp the tubes to prevent the former; if your velcro is intact and applied properly the latter shouldn't be a huge problem, but you can always wrap a few loops of tape around the whole apparatus for security if you'd like.

Now, I wouldn't try to haul someone off a mountain like this, but for the typical civilian EMS environment, I think it fits the bill. I know that Dr. Weingart likes them in the ED as well.


A bp cuff is not optimized to maintain high pressures, tape or not. If the air balloon ruptures, no pressure, no TK.
Physicians that choose to use BP cuffs as prehospital tourniquets are idiots. Theres research and data available showing why the idea is bad. It is an idea on par with using rotating tourniquets for CHF instead of BiPap.
If a true tourniquet scenario comes up, its way better to use the commercial or improvised before you get weird.
BP cuff makes a little sense in the ER, but not prehospital. I dont care about patient comfort or the pressure involved. I care about stopping bleeding. There is no such thing as "a little reperfusion by loosening it". I would go so far as to say all civilian medics have a serious misconception as to the negative effects vs rewards of tourniquets.
 

Brandon O

Puzzled by facies
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A bp cuff is not optimized to maintain high pressures, tape or not. If the air balloon ruptures, no pressure, no TK.
Physicians that choose to use BP cuffs as prehospital tourniquets are idiots. Theres research and data available showing why the idea is bad.

I'm interested to see the research you mean. I'm open to being wrong.

I'm guessing that you have a military background? I do think there may be a disconnect there. I really doubt that a BP cuff would make an adequate tourniquet for a combat environment; you need something that allows for mobility (potentially self-mobility), easy application, and potentially long duration. For most of us in an urban civilian setting, the demands are much simpler.
 

RocketMedic

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Brandon, I do, but there really isnt a difference. For research, look at the Army's tourniquet studies. Plenty of alternates are in there, to include BP cuffs if I recall correctly. Simple, mechanically-locking Velcro devices like the CAT are the most effective devices to put on and the hardest to dislodge. Your BP cuff is literally one jerk away from total failure, not to even begin to include the possibility of the bladder failing or an ignorant provider assuming youre trying to take a BP.

If anything, a military unit does massive hemorrhage way better than a civilian team. We dont hesitate with tourniquets, we dont loosen them, and we dont fear them. All are massive problems in civilian EMS. As for the demands being simpler. I disagree. I had a shooting tonight. Protocols insisted I backboard, start multiple IVs rapidly and transport emergently. Fire got excited and jostled him a littld in the load process...no harm, but a bp tk would probably have popped off.

If the front-lind infantry forces ofthecivilized world swear by them, its because theyre vastly better than the alternatives.
 
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Brandon O

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Brandon, I do, but there really isnt a difference. For research, look at the Army's tourniquet studies. Plenty of alternates are in there, to include BP cuffs if I recall correctly. Simple, mechanically-locking Velcro devices like the CAT are the most effective devices to put on and the hardest to dislodge. Your BP cuff is literally one jerk away from total failure, not to even begin to include the possibility of the bladder failing or an ignorant provider assuming youre trying to take a BP.

If a civilian unit carried a well-designed, purpose-built tourniquet, then obviously that would be ideal. However, many don't, which means you're left trying to improvise something. A cravat or two is probably the most likely, but I don't like 'em; once you tighten it it turns into a very narrow band, and it's not as easy to deal with as it might seem unless someone practices the technique.

Again, I would submit that while there's much to learn from the military's work on trauma (as always), the requirements and demands are not identical to civilian EMS. I think the way to go is to take what they've learned and use it to understand the principles, not necessarily try to duplicate them in all respects.

(We're required to carry a couple tourniquets in my state... which my service interprets to mean that we should have a couple rubber venous tourniquets. Gonna go great if someone tries to tie off a leg with that...)
 

EpiEMS

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Military tourniquet study for those interested: http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA480277

"Improvised tourniquets were ineffective 67% of the time (10 of 15 limbs, 15 patients, 16 tourniquets) with 10 morbidities (6 amputation injuries, 3 fasciotomies, 1 palsy), and seven limbs continued to bleed. The wider improvised tourniquets (cravats and windlass type, especially when two were used side by side) were effective in 42% (3 of 7) of limbs, whereas the narrower ones (strings, i.v. tubing) were effective in 25% (2 of 8) of limbs. The mortality rate in patients with improvised tourniquets was 0% (0 of 15), and the amputation rate was 40% (6 of 15, all 6 were traumatic amputations). Tourniquet ineffectiveness, (visible bleeding or distal pulse remained), and morbidities corresponded. "

:O
 

VFlutter

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Anesthesia uses pneumatic tourniquets, similar to BP cuffs, for Bier blocks which produce a bloodless anaesthetized extremity. However these are purpose built and not realistic for the field.
 

Summit

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I was taught the backwards KED for a hip. I had one situation where a KED would have been useful to immobilize a really really weird fracture, but I was misheard on the radio and brought a KTD. The solution ended up involving miles of tape, kerflex, 4 SAM splints, and a snowshoe.

I think splinting is the area where the most improvisation occurs. I've seen shovels, poles, sticks, paddles, etc.

Some of my favorite improvisations are using camelbacks as an airsplint. You have to watch and continuously adjust air pressure due to temp/pressure changes (particularly if going downhill). You can also use them with real splits to have a conforming liquid cooling option to help with pain and swelling! It is better than a cold pack! For litters, frame packs with sticks and hiking/ski poles, webbing, tarp, and cordellete are actually impressive if done right , and don't take too long (and use what people commonly have). Rope stretchers are a waste and nobody remembers how to do them.

There are definitely some improvisations that work, and others that don't work very well or may be harmful. I'm a pretty pragmatic guy.

As far as the discussion on practicing or taking classes on improvised care techniques, I think that it an get the gears turning if the provider has not been presented with the need to improvise before. For EMS providers specifically, I think courses like WEMT upgrade etc also help enforce the idea of preventing problems and thinking beyond 5, 10, 15, 30 minutes, thinking about limited resources and wilderness extrication, etc when making care decisions and plans. They'll think about it. They may even remember some ideas and techniques that they might even be able to apply with some level of effectiveness.

I will agree that the courses are rife with gee-whiz improvisations that nobody (besides the instructor) would remember how to do effectively, much less ever choose to implement in the real world. My favorite example is the rope litter. It looks neat, requires practice, and sucks even when done correctly. But I can surely go grab a book, Dr. Aurebach's giant wilderness cornucopia or ASHI's Wilderness manual and see an example of how to make your very own rope litter. Sure, I learned how to improvise a traction splint from ski poles or paddles and webbing... they were even timed drills. I could still make one easily, but I cannot think of a situation where one would be better off with an improvised traction splint versus a litter+splint and padding.

I am uncertain why a BP cuff is a bad idea for an improvised TK. I'd like to see the study showing that?
 
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mycrofft

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I'm not fussing. I've had to improv too (cutting the O2 line at a bias behind the female fitting to create a sort of male end is know as the "Mycroft Maneuver", didn't you know?) :cool:

Teaching improvisations is a slippery slope. If they're that good, include them in protocols, or make a protocol appendix of acceptable substitutions or extemporaneities. Otherwise students, especially the bright eager and impatient students, will seize on these at least mentally, especially if they are off the clock or freelancing without employment since they won't have the real equipment.

A cook learns recipes before improvising; a good and experienced driver will be more liable to get out of an unexpected situation, and less likely to get into one, than someone who has studied "improvs" but has no firm grounding*. Ditto medical staff.

Again, I think teaching about both the dangers of improvs, and the ones we see come up so often and so ineffectively, is as important as teaching how to use a suction machine as a nebulizer compressor or vice versa.

(oops.....)

(In fact, EVOC should be limited to drivers with ten years' experience...how's that?).
 
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