Remote Medical Thread

[MickAK]

I work in an industry that regularly deals with medical emergencies without the availability of the immediate intervention of qualified medical personnel. Recent circumstances might point a good deal of useful attention to this thread, so I thought it might be a good time to make it.

This is NOT a Coronavirus thread. There are two good threads dedicated to that subject, one to the situation and one to the politics/economic fallout of it. Please direct all COVID-19 related questions/information to those threads.

Tourniquets/CPR/AED usage has been well covered in other threads. It's more than welcome to be discussed in this one, but please use the search function and gather the good information that has already been covered here.

The biggest takeaway I got from my remote medical classes is how little you can really do. Outside of CPR/AED usage, the biggest takeaways I have remembered are:

1. The acronym ACSpine. Easy to remember, easy to follow through. Airway, Circulation, Spine injury. Make sure they're breathing and that blood is getting oxygenated, which easily progresses to circulation, is the blood staying in the body and reaching all important areas, which leads to is their nerve system getting signals. I find it easier to remember than other mnemonics and more useful.
2. Supplemental oxygen. Of the few things you actually CAN do, this struck me as one of the most useful and the best one to study for emergency response. Learn when to give it and learn the rare situations when you should NOT give it. Learn how, why, and keep the equipment around.
3. Antibiotics. Learn why antibiotics are given and why they are not, and why the recent reticence towards handing out antibiotics came about.

I'm mainly trying to open a discussion here, but I will give one recent lesson learned to spark it. A sober and respected member of my crew came to the wheelhouse and informed me that a man down in the freezer hold had broken his back. I obtained an emergency navigation watch and went to check on the situation and found the injured party being precariously carried on a 2X12 beam by other untrained members of the crew. I immediately ordered them to lay the man down, then conducted an ACSpine check which was inconclusive to a back injury (Spoiler alert, a 44lb case of frozen fish had fallen and hit his hip and he had lost all feelings to his legs). We brought down a back board and made ready to appropriately move him from the -20F freezer hold. Turns out, we had no ability to lift him from the freezer hold on a back board. The only other option was to remove a ~1700 lb steel hatch in potentially unsteady weather. During the decision making process, the injured party grew very cold (-20F is fine when you're humping 44lb cases, terrifying when you have no choice but to stay motionless). We brought blankets down to warm the injured party but with impending hypothermia we quickly assessed a lack of back injury and drug him to his bunk by a harness. He turned out to be fine, just suffering a 'funny bone' reaction that mimicked a spinal.

Lessons learned: Always have an effective means to warm/cool a potential injury. A $50.00 electric blanket would have bought us time to assess the man properly without rushing due to hypothermia/shock concerns. Always ensure you have a means to remove someone from an area on a backboard without causing further risk.

Questions:
1. Has anyone used standard commercial Pulse-Oximeters in sub zero temperatures? I didn't think about this until today and I don't feel comfortable asking to go in a local walk in freezer to check.
2. Anyone have a good idea to have a fitting available to filter welding oxygen for medical use? In an emergency I would just do it but I would rather have a good filter setup available to alleviate any concerns. I'm aware welding oxygen is not certified for medical use, but it's the same thing, just not filtered to the same standard.
3. Antibiotic usage is a quickly changing field. Any recent information is welcome. We have a good 24 hour medical service and we just follow their advice, but I'm always curious as to how they make that determination.

[TGS]

In my diving days we had a standard D-bottle of oxygen for moving a patient, but also had a t-cylinder of oxygen on the boat that was specifically for patient care.

I can't remember the fittings we had to use it for O2 administration, but I'll do some digging. Depending on your situations, you could also use a SCUBA cylinder.

FWIW, we never did welding O2 but used aviation O2, not just for emergency but we usually filled our regular decompression bottles with aviation 02 as well, since most suppliers would not sell medical grade without a prescription. I've never seen any indication (written or actual life) that it's unsafe to use.

[Nephrology]

3. Antibiotic usage is a quickly changing field. Any recent information is welcome. We have a good 24 hour medical service and we just follow their advice, but I'm always curious as to how they make that determination.

Antibiosis should be done by a licensed physician or midlevel practitioner. Antibiotics are usually prescribed on the basis of the clinical syndrome and presumed causative pathogen. They can be prescribed empirically (i.e. without sending it to be identified in a lab) for uncomplicated infections, but ideally if you think you need antibiotics you should be escalating their level of care to an MD/PA/NP.

That said, here is a really nifty resource for antibiotic usage made here in Denver. I use it all the time.

[SeriousStudent]

......

That said, here is a really nifty resource for antibiotic usage made here in Denver. I use it all the time.

I have an itchy, itchy rash.

Asking for a friend......

[TGS]

Okay, I've had a little more time to dig.

First, have you taken the Medical Person In Charge (MPIC) course? This should really be your first step. MPIC is designed specifically for people in remote situations where they might have to provide medical care at a level higher than usual, and the courses are pretty exclusive and get rave reviews. It's very common to use a subscription medical direction to guide you through things such as antibiotic administration (@Nephrology). MPICs are very common or research vessels and whatnot. Even if you don't have a medical director, the course would be very useful and 100% applicable to you.

Here's an 02 regulator that will attach to a standard t-cylinder: https://www.amazon.com/CGA-540-Style.../dp/B006GERK0M

That setup will provide about 9 hours of 02 at 15lpm. The downfall is that it's immobile, and you'll need to patient to remain wherever the oxygen cylinder is robustly affixed. Would that work, or do you need smaller cylinders that can be moved around the boat?

[TheRoland]

1. Has anyone used standard commercial Pulse-Oximeters in sub zero temperatures? I didn't think about this until today and I don't feel comfortable asking to go in a local walk in freezer to check.

Yes. The small, self-contained ones work but not for long. The cold temperature is destructive to the crappy batteries they tend to run on. The versions with a bigger battery are fine.

[MickAK]

Okay, I've had a little more time to dig.

First, have you taken the Medical Person In Charge (MPIC) course? This should really be your first step. MPIC is designed specifically for people in remote situations where they might have to provide medical care at a level higher than usual, and the courses are pretty exclusive and get rave reviews. It's very common to use a subscription medical direction to guide you through things such as antibiotic administration (@Nephrology). MPICs are very common or research vessels and whatnot. Even if you don't have a medical director, the course would be very useful and 100% applicable to you.

Here's an 02 regulator that will attach to a standard t-cylinder: https://www.amazon.com/CGA-540-Style.../dp/B006GERK0M

That setup will provide about 9 hours of 02 at 15lpm. The downfall is that it's immobile, and you'll need to patient to remain wherever the oxygen cylinder is robustly affixed. Would that work, or do you need smaller cylinders that can be moved around the boat?

I have taken the Medical Care Provider course which is the first 4 days of the 10 day Medical Person In Charge course. I have been looking for a better MPIC certified course than the one offered at the place I took the Medical Care Provider course. It was a good course but I have seen some remote EMT courses that looked better but lacked the MPIC certification. If I'm going to pay for certification beyond my requirements I want to get the best instructors, curriculum, etc.

Thanks for the link on the regulator. In the MCP class, we were instructed not to use welding oxygen due to the less stringent filtering requirements. They used to advise you to use it. Seems like every couple of years we get told contradictory information. I would of course use it in an emergency but it would be nice to have a little inline filter to avoid any legal complications if we did use it. Probably not worth worrying about. If we were in a situation where we were resorting to welding oxygen we would manage to get the cylinder to the patient somehow.

[MickAK]

Antibiosis should be done by a licensed physician or midlevel practitioner. Antibiotics are usually prescribed on the basis of the clinical syndrome and presumed causative pathogen. They can be prescribed empirically (i.e. without sending it to be identified in a lab) for uncomplicated infections, but ideally if you think you need antibiotics you should be escalating their level of care to an MD/PA/NP.

That said, here is a really nifty resource for antibiotic usage made here in Denver. I use it all the time.

Thanks, that's a good resource. Our first step is always a call/email to our 24 hour medical service. They do a great job.

[TGS]

I have taken the Medical Care Provider course which is the first 4 days of the 10 day Medical Person In Charge course. I have been looking for a better MPIC certified course than the one offered at the place I took the Medical Care Provider course. It was a good course but I have seen some remote EMT courses that looked better but lacked the MPIC certification. If I'm going to pay for certification beyond my requirements I want to get the best instructors, curriculum, etc.

Thanks for the link on the regulator. In the MCP class, we were instructed not to use welding oxygen due to the less stringent filtering requirements. They used to advise you to use it. Seems like every couple of years we get told contradictory information. I would of course use it in an emergency but it would be nice to have a little inline filter to avoid any legal complications if we did use it. Probably not worth worrying about. If we were in a situation where we were resorting to welding oxygen we would manage to get the cylinder to the patient somehow.

Moving a full t-cylinder on a boat at sea is not something I would consider to be a good plan, given the likeliness for mishap. If the nature of your boat means that you'll have to bring the 02 to the patient but you still need a few hours worth, I'd stock a couple of larger scuba cylinders.

Again, you don't have to resort to welding 02 anyway. Just fill it with aviation 02. Or if you have a subscription medical control, you should be able to get a medical 02 fill directly from any of the major compressed gas suppliers.

[Josh Runkle]

1. I have used Sp02 monitors in sub-zero C (below 32 degrees F). They do not work well because they need to be placed on a distal extremity which has poor circulation due to the temperature. The handheld (non monitor ones) also use batteries which may fail in the cold, although those work fine for me down to about 10F-ish. End-tidal CO2 monitoring will work. Obviously, remove someone from those temps before treating if you can.

2. Use separate O2 tanks from welding tanks. It will take so much longer to find and switch out the regulators than to just find the emergency O2 tank with the regulator attached.

3. I use Sanford Antimicrobial Guide, Up-to-date and lexicomp for antibiotics. You’re gonna need a good decade of learning in order to use antibiotics without harming someone, though. Don’t mess around. Your post reads a bit like, “I just got my CCW. What’s the best radar-guided missile defense system for me to use for home defense?”

4. I strongly recommend taking a basic EMT course and MPIC. (You might find a combined course). That way, you can focus on the dumbed-down most basic essentials of treating unexpected emergencies. This would be the equivalent of taking a basic pistol fundamentals course. Learn how it all works first so you can actually start learning what might be applicable to you, then you can start training.


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