PreHospital Trauma Life Support (PHTLS), Monterey, CA Feb 18-19, 2014

PreHospital Trauma Life Support (PHTLS) is an essential skill for emergency responder at  all levels. It is often compared to Advanced Cardiovascular Life Support (ACLS) as two of the most advanced life support trainings.

I am always interested in emergency medicine since I was young I have taken trainings for  EMT-1 (Taiwan), BLS for Health Care Provider, Combat Life Saver/EMT-T, EMT-B (without NAEMT cert test at the time.) So I went to Monterrey to take PHTLS in order to both learn new skills and to refresh my previous ones.

The course, offered by Downrange, was part of a combined training with Emergency Pediatric Care (EPC). But I only took the PHTLS sections (first two days) as EPC currently isn’t as relevant to me. According to my knowledge, I was the only civilian in the classroom, while everyone else was Army Medic, Navy Corpsman, or physicians employed by Department of Defense. I was also the only non-medical career personal. But the class was not overly difficult to me except setting up IV during the scenarios. So I used IO instead.

The class was organized into lectures and skills, like most medical training. But the instructors would alternate between both sections, instead concentrate them separately, which means we would have a lecture first, followed by the skill practice of the said chapter. I prefer this method over “concentration” one which I had in EMT-B trainings, since this “new” method would less likely overload student with information or bore them with presentation slides.

 

We went over different chapters of important topics. There was a large textbook (7th edition of PHTLS, about 700 pages) with the class, but it was used mostly as reference since students were supposed to know the material before attending the class. Since I can’t simply explain the whole training, I will just highlight some points I learned from each chapter.

 

Day 1:

-          Scene Assessment and Primary Patient Assessment:

Back in the EMT classes, we were told to take all types of assessments on the patient during the Primary. On the other hand, we were also taught not to stay in the scene longer than necessary. Since I never worked as an EMT, I always wonder how they could really take all the “textbook” (completed) measurements, such as Blood Pressure during the primary assessment. It turned out that we shouldn’t; it is simply not practical in real life to perform all of them under strict limitation of time. Emergency responders should identify the Mechanism of Injury/Nature of Illness as soon as possible, stabilize the patient, and then initiate the transportation. Experienced and well-trained responders could determine the situation in a timely manner and save precious time for the patient.

-          Secondary Survey

Since we can’t perform all the measurement in the field, they should be delayed until the patient is in the transportation, or if the transportation was delayed for some reason. All non-essential surveys, such as detailed BP, ECG, Blood Oximeter, SAMPLE survey should be performed during this time. Also, while not part of this chapter, but a later one, responders should not delay the transportation to start IV, it should only be performed here as well.

 

-          Airway, Breathing, Ventilation and Oxygenation:

This was the fun part of the day, since before this class I never practiced advanced airway placement. All I used were nasopharyngeal airway (NPA) and oropharyngeal airway (OPA). We were taught (while most other students were already familiar with these) and practiced King LT-D Supraglottic Airways, endotracheal tube and surgical airways on manikins.  Supraglottic was the easiest since it was designed for “blind insertion” (simply insert the proper sized tube through mouth and inflated the cuff). I used to think endotracheal tube was a difficult one from the demonstration I watched in the past, but in the actual practice, I successfully placed one on an infant manikin on the second try. I had some instruction with surgical airway in the past during Combat Life Saving training, but this was my first time practice this skill with real tools on a manikin. (We used real North American Rescue surgical airway kit for training.)

 

 

-          Circulation, Hemorrhage and Shock:

This is the last chapter for day one. It is a familiar topic for all of us, since we all went through TCCC type classes in the past. During the skill portion, the instructors demonstrated different types of pressure dressing and tourniquets, including several outdated version for historical reference. While many medical systems still discourage the use of tourniquets, American College of Surgeons and Committee of Tactical Combat Casualty Care recognized tourniquets as a reasonable safe and effective way to stop extremity bleeding. The experience on the battlefields demonstrated that proper tourniquets are safe to use up to six hours or more without permanent damage. Even if permanent damage occurred due to delayed transportation, the benefit of tourniquets still outweighs the risk of hypovolemic shock or death.

 

 

Day 2:

CNS Trauma, Injuries to Brain and Spinal Cord:

 

CNS related injury is common on trauma patients, any MOI with high energy or directed at head and spine could potentially cause damage. In the past, responders were taught to immobilize patients under most conditions. However, studies have shown that overly use immobilization could cause harm on the patients, especially on those with critical condition but did not meet the criteria for immobilization. So responders should consider the benefit and risk for using long boards or other immobilization devices. We then learned different criteria for C-Spine considerations. During the practice, we practiced and refreshed to uses of several different immobilization devices, from triangular bandage, SAM splint to advanced air splint, and Kendrick Extrication Device (KED) with longboard.

 

 

Special Considerations:

Some patients deserve special considerations from responders: elder, pediatric, patients with disability, or patients who do not speak the same language with you.  For example, many elderly people are prescribed with beta-blockers which prevent their heart rate to rise. This could be fatal, if ignored during a trauma situation.

 

Field Training Exercise (FTX):

Most of the afternoon was dedicated to scenario based FTX. All students were divided into two groups for different stations. As with military policy, the ones with least experience were appointed as team leader for leadership practice, which means I was leading the team for the first scenario.

The first scenario was a single vehicle accident during a warm day. The casualty was not wearing his seatbelt and impacted his head on the windshield. I have one team member to manually secure C-Spine, and another to provide BVM.  During the primary survey, we found significant blunt trauma on left side of skull and on the chest but with clear and bilateral sound of breathing, with a minor trauma on lower left leg. The patient had altered mental status yet still intolerant to artificial airway. Since head trauma contradicting the use of NPA, I ordered the team to use BVM only. The patient also showed the sign of shock with slightly low BP (84), high and weak pulse, and pale skin. Hence I requested helicopter, and ordered my team for repaid extrication (i.e. without using KED vest). Once the patient was out and secured to longboard, we conducted a secondary survey (did not find additional wound), attached ECG, Oximeter, BP cuff, set up IV, and dressed the lower leg wound while waiting for the helicopter. The scenario ends

 

I think it went well, especially consider this was my first time leading a med team. But my communication to the team, and initial response could be better. It took me a while to finish primary survey in this case.

 

The second scenario was led by another student. A woman was stabbed inside a park, with knife still imbedded on the back of her neck. She was bleeding profusely, unconscious, with clear sign of shock, and lying face down.  She also showed clear sign of un-compensating shock, with high but weak pulse, pale skin, and no radial pulse, but still with weak carotid pulse. (Which indicated her BP was between 60-80). The manikin had a simulation blood pack attached to it, which bleeds like real person does.  We have one person manually secure C-spine, several attempted to stop bleeding and secure the knife. We inserted a King LT-D Supraglottic Airway, attached to BVM and O2. Others prepared the long board for transportation. I called in the helicopter but told that there was a delay and wouldn’t arrive for another 25 minutes. We managed to immobilize her on a long board with C-collar, and didn’t find any other wound and temporarily stopped the bleeding. Then when we moved her to the LZ (a nearby parking lot), the bleeding recurred. We used all remaining bandage and dressing, along with a manual direct pressure to stop the hemorrhage again. The instructors then indicated that IV was not possible on her, so I did an IO on her right tibia instead. Her blood pressure was stabilized and radial pulse was felt. The scenario ends.

 

Instructors explained that it might be safer to lay her on the side instead of supine position since the knife was still imbedding on her back.

 

The last section of the class was a written test. It was not easy as “textbook” and practical procedure often contradicting each other. Our background in tactical medicine further complicated the answers. For example, one scenario question regards a man suffered significant laceration on both his arms and show clearly sign of shock. Many of us, including myself, answered to use tourniquets as the best treatment, yet the textbook answer was to attempt direct pressure. Both answers are probably true in the real world, depends on your training background and unit guidelines. Another question was regarding a victim with gunshot wound (GSW) on right temple, with apnea (no breath) and pulseless. The correct answer was simply to declare the patient was dead, yet I answered to initiated BLS, as EMT-B usually does not qualifies to pronounce death in the normal urban setting.

 

In conclusion, I found this class both intellectually challenging (Especially for a non-professional provider like myself) and exciting. I recommend this class to anyone who is interested in advancing their emergency medical management skills.