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A Hartford publication addressing articles Vol. XII No. 4, Spring 2004 of interest to emergency and critical care personnel

standing of each of these gas laws is needed to needed to allow nitrogen to be reabsorbed. If Case Study: dive safely and to treat injuries should they the diver ascends to the surface too rapidly, AIR GAS EMBOLISM occur. nitrogen can bubble out of the blood stream and By Steven Haemmerle, RRT, EMT-P Boyle’s law states that at constant tempera- become lodged in tissues and in the vasculature, ture, the relationship between pressure and resulting in decompression sickness Type I, also n June 8, 2003, the Stonington Fire volume are inversely related. In other words, air known as “the bends.” Divers experiencing DCS Department was dispatched to Ston- within the lungs and sinuses will shrink when a Type I may complain of a slowly progressing Oington Harbor to aid 53 year old diver descends underwater and expand upon pain or numbness in the limbs. Joint pain or pain Stephen Grady, who was found unresponsive and in severe respiratory distress after an early morning scuba dive. Stephen, an experienced commercial diver, was performing a routine salt- water dive at a depth of no greater than ten feet. Immediately following ascent, fellow divers found him apneic, cyanotic and unconscious. Rescue breathing was initiated. Stephen soon became conscious and resumed spontaneous but labored respirations. An air gas embolism (AGE) was suspected and LIFE STAR was requested to transport this patient to for hyperbaric treatment. LIFE STAR physical exam revealed an alert male in moderate respiratory distress. Wheezing was noted in all lung fields and an albuterol neb- ulizer treatment was started. He denied any chest pain or aches in his joints, ears or back. No subcutaneous emphysema was noted. He moved all extremities equally and had no evidence of facial asymmetry. y Hyperbaric Chamber at Hartford Hospital During preparations for flight, Stephen in the muscles or back that worsens with move- suddenly became anxious, combative, air hun- ascent. While breathing compressed gas at ment can also be present. Mild symptoms such gry, cyanotic and dyspneic. He was promptly depth, a diver should never hold his breath as these are not life threatening but may require medicated and intubated, with improved aera- while ascending to the surface because the vol- treatment. DCS Type I may be potentiated by tion to all lung fields resulting. A 12-lead EKG ume of air trapped in the lungs will expand, air travel soon after a dive, or by multiple dives completed during transport showed no acute resulting in a pneumothorax, pneumomedi- per day. ischemic changes. astinum or air gas embolism (AGE). AGE A more severe form of decompression sick- Stephen was ultimately transported to Nor- formation will quickly evolve into unresponsive- ness (DCS Type II) occurs when nitrogen walk Hospital for hyperbaric therapy. His ness or cardiovascular collapse immediately bubbles out of the blood stream and affects the treatment included three “dives” in the hyper- upon ascent. These complications can be avoid- nervous or cardiopulmonary systems. The bub- baric chamber, in addition to comprehensive ed simply by exhaling while slowly ascending to bles can travel to the heart causing cardiac care. He was discharged home several days later the surface. arrest, to the pulmonary vasculature causing res- and has completely recovered from this injury. Henry’s Law describes the ability of a gas to piratory distress or arrest, or to the brain to dissolve into a solution when increased atmos- cause a stroke. Dyspnea, chest pain, severe Discussion: pheric pressure is exerted on the gas and liquid. headache, altered mental status and shock may An example of this is an unopened bottle of occur. Since the formation of these gas bubbles Breathing compressed gas above ambient pres- soda. Few, if any, bubbles are visible before the is related to the time spent underwater and the sure potentially exposes all divers to an array of bottle is opened because the carbonation has depth of the dive, strict adherence to dive table life-threatening injuries including air gas been added to the liquid under pressure. Once depth and time ratios is crucial. embolism (AGE), pneumomediastinum, pneu- the cap is opened, pressure is released and the A thorough history regarding the dive and mothorax, and decompression sickness. The gas bubbles quickly come out of the solution. the relationship to the onset of symptoms is key genesis for each of these types of dive injuries is As a diver breathes compressed gas at in diagnosing a potential dive injury. Important directly related to the physics described by depth, nitrogen becomes dissolved in the blood information to obtain includes: the depth of the Boyle’s and Henry’s gas laws. A thorough under- (Henry’s Law). A slow ascent to the surface is dive; bottom time; decompression stops; past

Continued on page 2 A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel 2

Embolism continued from page 1 Another Airway Adjunct: THE BOUGIE diving accidents and past medical history. Phys- ical findings such as hemodynamic instability, By Steven Neher, RN, CEN, EMT-P ficult airway. To use the bougie, laryngoscopy subcutaneous emphysema, decreased function must reveal at least a view of the epiglottis. Once of extremities, difficulty breathing, or altered Poor vocal cord visualization due to debris, the epiglottis is identified, a well-lubricated mental status strongly suggest a life-threatening soft tissue swelling or anatomic variants can make bougie is advanced past this structure with the dive injury and should be addressed during the intubation difficult. Further complicating matters, angled tip pointing anteriorly and midline, allow- primary survey. Abdominal pain, joint pain and patients may be in compromising positions on ing the device to pass through the glottic paralysis are also common signs of this type of scene, neck movement may be contraindicated or opening even when the vocal cords are injury. Although physical exam and history can lighting may be inade- not visible. be highly suggestive of dive injury, differential quate. The LIFE STAR Bougie placement into the trachea is sug- diagnoses such as hypoglycemia and head team has added use of a gested when a washboard or clicking sensation is injury must be considered. gum elastic bougie felt as the bougie tip moves over the tracheal Timely recompression in a hyperbaric (pronounced ‘boo-jee’) rings, or resistance is met as the device encoun- chamber is the only definitive treatment for a to facilitate intubation ters the carina. The bougie should be advanced serious dive injury. Pre-chamber treatment goals when laryngoscopy until the lips fall between the two black parallel are aimed at rapid patient transport to a hyper- provides a less than lines found proximally on the device. At this baric medicine center and supportive care. LIFE optimal view of the depth, the distal tip is beyond the cords and there STAR is often used to meet these goals for crit- glottic opening. is enough length proximally to use the bougie as ical patients. The altitude changes occurring The bougie is a an introducer. Once in proper position, an endo- during typical LIFE STAR transport are not sig- disposable, low cost device made of latex-free tracheal tube is threaded over the bougie and nificant enough to negatively impact a patient polyethylene. Measuring 5 mm in diameter and advanced to an appropriate depth. The bougie is with a dive injury. 60 cm in length, it is a semi-rigid plastic rod that then removed and endotracheal tube placement The Diver’s Alert Network (DAN), is a has a 36 degree angled tip and a rounded end to must be confirmed and secured. tremendous resource for anyone who suspects prevent airway trauma. The small diameter, shape Although not commonly used in the pre- they may have a dive injury, or for and elasticity of this device may allow it to pass hospital environment, the bougie has easily providers with acute questions regarding the through the vocal cords more easily than an transitioned into LIFE STAR practice. treatment of dive injured patients. The 24-hour endotracheal tube. Our team has used this lightweight, inexpen- DAN Hotline number is 1-919-684-4326, and The bougie, first described by Macintosh in sive tool on several occasions to secure emergency collect calls are accepted. More 1949, is widely accepted by anesthetists as an a difficult airway. A continued improvement in information about the Diver’s Alert Network alternate method to achieve intubation of the dif- difficult intubation success rates is anticipated. can be found at www.diversalertnetwork.org. Today, hyperbaric medicine is used to treat many different diseases including AGE, DCS, The LIFE STAR Communications Center carbon monoxide poisoning, gas gangrene, crush injuries, wounds resistant healing, blood By John Grenier, Communications Specialist STAR crew. Map books, aviation sectionals, and loss anemia, intracranial abcess, necrotizing soft Delorme Street Atlas Software are all on hand. tissue infections, osteomyelitis, delayed radia- Located in the at The Yeoman, an electronic marine navigation tion injury, compromised skin grafts and Hartford Hospital, the dimly lit LIFE STAR plotter that utilizes various area maps to immedi- thermal burns. In , only Norwalk Communications Center buzzes 24 hours a day. ately identify latitudes, longitudes, headings and Hospital and Hartford Hospital offer hyperbar- As the coordination point for two full-time rotor distances, offers quick directional precision. A ic therapy. Norwalk Hospital has offered wing aircraft, 125 Security and Fire Safety Connecticut grid map (a state DOT tourism map hyperbaric care in its mono-place chamber for Department personnel, and the Connecticut printed with a grid overlay) may also be used to years. Offering a multi-place chamber that can Children’s Medical Center critical care ground pinpoint scene locations. Since these grid maps accommodate up to ten patients at a time, Hart- transport team, continuous radio chatter and are located in all regional dispatch centers, in our ford Hospital’s recently opened Center for ringing phones are baseline quiet for the center. communications center and in both aircraft, the Wound Healing and Hyperbaric Medicine is Full throttle multitasking and seamless transi- continuity of information and accuracy on scene now one of the largest hyperbaric facilities in tions are the norm. work is extraordinary, allowing us to respond to New England. Safety and quality assurance are top priori- and locate scenes efficiently and safely. ties in our communications center. The In 2003, our eight communication special- environment is technology intensive, relying on ists used their 61 years of combined experience References: 1. Campbell, Ernest S. Decompression Illness in Sports two Motorola Centracom consoles, advanced to field 2,367 LIFE STAR requests and coordi- Divers: Part I. Medscape Orthopaedics & Sports Medicine camera systems, Aeromed software, and WSI nate 176 critical care ground transports for eJournal. 1997. www.scuba-doc.com/DCSPartI.html weather monitors to keep operations flowing Connecticut Children’s Medical Center ground 2. Kaplan, Joseph. Emedicine. July 23, 2003. About. smoothly. A digital based recording system capa- team. Impressive numbers, but contributions Sept. 20, 2003 ble of long-term storage, quick playback, and extend far beyond the console. Education, par- www.emedicine.com/emerg/topic53.htm. enhanced sound quality has recently been added, ticipation in community outreach programs, 3. Walker, Stuart. Hyperbaric Medicine Unit. Sept. 2, 2003. and plans for improved rooftop weather moni- navigation, documentation, customer service, About. Dec. 26, 2003. toring, remote headset communications and mission coordination and many other activities www.hyperchamber.com/decompression_illness/. automated flight following are underway. make the LIFE STAR Communications Center Indications for Hyperbaric Oxygen Therapy. From the console, communication special- not only the primary link to our customers but Undersea and Hyperbaric Medical Society. ists can access multiple tools to generate also a major link in our team. www.uhms.org/Indications/indications.htm essential navigation information for the LIFE 3 A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel

Connecticut Children’s Medical Center & Hartford Hospital: PURSUE JOINT PEDIATRIC STATUS

By Scott James, RN, Trauma Coordinator Preparations for joint trauma center verifi- cation have provided many enhancements to the The Connecticut Children’s Medical Cen- care of patients at Connecticut Children’s Med- ter (CCMC) continues its preparations in ical Center. The hospital announced a formal partnering with Hartford Hospital as a joint Pediatric Trauma Program, which works collab- level I pediatric trauma center in Fall 2005. To oratively with the Hartford Hospital Trauma further this endeavor, CCMC underwent a con- Program, LIFE STAR, the CCMC Injury Preven- sultation visit by the American College of tion Center, and the Department of Pediatric Surgeons Committee on Trauma in late April Surgery. The Emergency Department renovated 2004. The purpose of the visit was to provide its resuscitation room to include a trauma bay a comprehensive assessment of the pediatric that caters to the potential needs of the trauma trauma system to date, and to render guidance in patient while department staff underwent spe- furthering the hospital’s goal. cialized training for assessing and caring for the Joint pediatric trauma center verification important role in assisting prehospital providers pediatric trauma patient. Most importantly, between CCMC and Hartford Hospital was in triaging patients to the most appropriate CCMC implemented a three tiered trauma identified as a best practice model for both insti- emergency department. response system, each with pre-determined tutions to provide expertise in caring for The acceptance of injured children at Con- resources that are dedicated to the pediatric traumatically injured children in the region. necticut Children’s Medical Center from other trauma patient throughout their admission in Under the joint trauma center status, the most has also been enhanced. With the goal the hospital. Numerous other changes have critically injured children continue to be trans- of streamlining acceptance from outside referrals, occurred to facilitate optimal trauma patient ported to and resuscitated at Hartford Hospital’s CCMC’s “Transport Line” offers the referring care. Emergency Department. A pediatric trauma physician an ability to have a pediatric trauma Questions regarding the Pediatric Trauma team from CCMC responds and oversees care of patient transported directly to CCMC when clin- Program at Connecticut Children’s Medical the child. The child is then transported to an ically appropriate or when an assessment at a Center can be directed to Scott James, Trauma appropriate in-patient unit at CCMC. Children Level I or II trauma center has already occurred. Program Coordinator, at (860) 545-9810. who are not critically injured are transported to Referring physicians can call (860) 545-8989 and and treated by the CCMC Emergency Depart- immediately speak to an Emergency Medicine ment. Medical control at CCMC plays an Attending Physician at CCMC.

them on to our communications center at 860- New Crew Pilots’ Corner 545-4369. In addition, if you haven’t had a

By Bob Dziezynski, Pilot safety patch done recently, please call us to set one up. A reminder that the minimum size for Flight Respiratory Therapist our landing zones has increased from 60 x 60 Michael Murphy, RRT, EMT-P: Thanks to all of the Hospital Security, Fire, feet to 75 x 85 feet or twice the width and Mike joined the LIFE STAR Police, and EMS personnel out there, I am length of the aircraft. team in August 2003. He has happy to report that we had no incidents or Here’s an interesting thought that I read in three years of respiratory accidents (or even close calls) while operating the February issue of AOPA Pilot Magazine: “A care experience in the ICU at in and out of or landing zones this wise grandmother once suggested that you can Hartford Hospital and has worked as a para- past winter. Great job! Accurate and timely tell a lot about a man by looking at his shoes. If medic in CT for the last 10 years. He holds an communication between ground personnel, the he shines his shoes, he usually does so for him- Associate’s Degree in Respiratory Therapy from aircraft, and LIFE STAR dispatch helped to self, as an act of personal pride. He doesn’t do it Naugatuck Valley Community College. contribute to this success. Michelle North, the former director of to impress others, because most folks don’t seem Safety at Rocky Mountain Helicopters, had a to pay attention to a man’s shoes.” conviction: “In almost all cases, someone on the Many pilots have specific behaviors that they perform in airplanes to please only them- Flight Nurse Roberta Wood- ground or in the aircraft had a piece of informa- selves, not others. Taxiing on the centerline is Lantz, RN, CEN, NREMT-P: tion, which if passed on, could have prevented something I do for just for me. Whether or not Roberta brings 10 years of an aircraft or ground accident.” A tree branch the nose wheel remains glued to the yellow line critical care experience to her sticking out of the snow may not seem impor- or wanders probably doesn’t amount to much at new flight nurse role. She tant, but with the rear of the helicopter only all. Yet I find enormous satisfaction in trying to worked in the Emergency eleven inches off the ground, it would cause keep the nose tire planted there. A few weeks Department and Cardiothoracic ICU at St. major problems if it is not seen. If landed on it ago, I was taxiing behind a small U.S. Air Force Francis Hospital in Hartford for many years, may puncture a fuel cell. Please pass on ANY Minijet and noticed that the nose wheel never and spent one year working in the Burn Unit at information, no matter how trivial it may seem. left that line for nearly two-thirds of a mile. No Straub Hospital in Honolulu, Hawaii. She is a We are in the process of updating our radio fre- doubt the pilot’s shoes were shined, too. graduate of Quinsigamond College and current- quency logs. We can now program digital PLs ly attends Sacred Heart University. into our radios. If you have any frequency changes, additions, or deletions please pass A Hartford Hospital publication addressing articles of interest to emergency and critical care personnel 4

Crew Member News Briefs: FYI Bowling for Dollars Spotlight: NEAA Summer Conference LIFE STAR recently participated in the Country LIFE STAR was proud to host the summer edu- 92.5 “Super Bowl” for St. Jude’s Children’s ROCKY 1, RICH MAGNER cational event for the North East Air Alliance Research Hospital. The event, which took place on January 30th at AMF Silver Lanes in East By John Grenier, Communication Specialist (NEAA). The conference was held on June 3, 2004, at Foxwoods Resort and Casino in Hartford, had more than 100 teams participate It was 1985 when Rich Magner answered LIFE Ledyard, CT. Educational topics included and helped raise close to ten thousand dollars for STAR’s original call for pilots. Nineteen years of hyperbaric medicine, nitric oxide use and a his- St. Jude’s Hospital. service later, the fit continues to be just right. torical perspective on air medical transport. Born and raised in St. Joseph, Missouri, The North East Air Alliance is comprised of Rich has always been interested in aviation. seven air medical programs servicing CT, MA, After being drafted NY, NH and ME. By fostering collaboration, by the United States NEAA’s goal is to enhance safe operations in the Army in July of air medical environment, address public health 1967, Rich volun- issues and promote quality patient care through- teered for flight out the region. school, completed the AH-1G Cobra transition course and was then shipped to Our new email address is up and running, Vietnam. In his [email protected]. Feel free to use the fourth month of duty site to ask general questions about the program on March 8,1969, Rich was wounded while on a or to provide feedback on our operation. We mission and spent the next three years of his look forward to hearing from you! LIFE STAR crew members: from left to right: John Grenier, Army career on patient status at Fitzsimmons Michael Frakes, Paul Mangini, and Jodie Russo. Also in Army Medical Center in Denver. For questions about merchandise or catalog, the picture are morning radio personalities Dave Mester (standing) and Cory Myers (seated). Rich resumed flying in 1976. He began his please contact the LIFE STAR Communications long air medical industry career at St. Anthony Center (860) 545-4369 or call Barker Specialty Hospitals in Denver, and eventually joined the directly 1-800-BARKERS (227-5377) Baptist Life Flight team in Pensacola, Florida. Five and a half years passed. In 1985, Rich relocated to Connecticut to Factoid: LIFE STAR FACTS LIFE STAR Lines Staff: help establish the LIFE STAR program. He is the From December 1, 2003 to only original LIFE STAR crew member still with Editor: Lisa Duquette, RN March 31, 2004, LIFE STAR has: our team. Rich has flown countless miles, com- Nicole Wilson, Communications Specialist pleted over 5,000 LIFE STAR missions and has Medical Director: Kenneth Robinson, MD, FACEP • Completed 375 patient missions logged more than 2,750 flight hours. An icon in Advisory Board: Scott Palmer, Communications Manager • Flown 25,759 miles the air medical industry and a well-known figure John Fisher, RN, Chief Flight Nurse • Worked with 150 different fire, throughout our service area, LIFE STAR is privi- Lee Monroe, Director of Public Relations police and EMS agencies and leged to have Rich on our team. Printing Advisor: Reginald Leonard, Director of Printing Services more than 65 hospitals.

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