Getting ready, being ready, and having fun doing It (Proceedings)

Introduction

From the very first time I was faced with the responsibility of possibly having to respond to an emergency when I was a young boy scout (at age 11) to just yesterday when I was an emergency clinician at the Pet Emergency Clinic, the immediate goal was "to make everything ready". A pioneer in emergency care that coined the term "the Golden Hour" Dr. RA Cowley, was emphatic on the carrying out of this goal. Because time is one of the things that can be manipulated and saved when faced with emergencies. It is a savings of time that can make a difference between life and death. The information presented here on practical readiness is provided to help each clinician and staff the ability to to manage patients and the most efficient way possible. Some of the recommendations comes from my experience and training as a surgeon and emergency and critical care specialist as well as a fireman and medic on the front lines...being the one to have to provide the initial care to critical patients whether 2 or 4 legged.

Readiness is also centered on being ready to perform those techniques that must be done immediately when critical patients are first seen.

Readiness also involves the need to perform emergency procedures that one might not do very often when the crisis even occurs. The crisis can occur even during during "routine procedures" such as the adverse drug reaction leading to anaphylactic shock in which a tracheostomy may have to be performed prevent airway obstruction from the edema produced , to a rapid thoracotomy, aortic cross clamping , and cardiac massage, for the patient experiencing a sudden cardiac arrest secondary to a vasovagal response from moving the patient while under anesthesia. So the bottom line is that we must all be ready for critical life-and-death emergencies, all the time, even during a "routine" day .

Readiness involves being ready within the facility regarding equipment and supplies/drugs as well as knowing how to perform emergency procedures, operative techniques, and having the memorized knowledge of protocols that will need to be followed for the successful management of common emergency conditions.

These include: patients presented with difficult breathing, collapse, severe hemorrhage, an acute abdomen, parvovirus like syndrome with diarrhea and dehydration/vomiting, gastric dilation-volvulus, acute poisoning, snake bite and spider bite-toxic envenomation, seizures, heat stroke, severe hypothermia or hyperthermia, severe sepsis, severe burns, acute paraparesis – paralysis, anaphylactic shock, aortic thromboembolism, severe hemorrhage, severe pancreatitis, peritonitis, severe wounds and fractures, and urethral obstrction, severe arrhythmias, head and spinal cord trauma, cardiac or near cardiac arrest from many causes and many others that may occur as a "routine" case in general practice and the procedures necessary to prevent a catastrophic even from occuring.

Prevention steps

Those steps neccessary in the anticipation that something could go wrong are also imprtant to do in readiness. An example is the older patient with dental disease that has renal and cardiac compromise that requires anesthesia for dental prophylaxis and the removal of a suspected tooth root abscess. The placement of an intravenous catheter while the patient is receiving blow-by oxyge anf the injection of a "chemical courage" drug cocktail of ketamine, butorphenol and acepromazine are performed. These steps help preoxygenate the patient and decrease the patient's stress levels and provides a gentle and cardiovascular and renal protective strategy as a preanesthesia and the patient will accept, stress free, a mask for the delivery of 100% oxygen and assist ventilation with the BM (bag-valve) and reservoir attached.

Isoflurane is then added for induction after continuous arterial blood flow Doppler monitoring is added. This is accomplished by clipping the hair over the palmar arterial arch and adding ultrasonic jelly onto the ultrasound flat probe and the probe fixed in place tightly with adhesive tape on the central portion of the metacarpal skin above the metacarpal pad. This may sound complicated but is very easy to achieve.

Since blood flow is the most important to monitor, much more than arterial blood pressure or pulse oximetry, the continuous flow Doppler monitoring provides a key to the knowledge of the patient's cardiovascular status on anesthesia depth and influence on the patient's heart and kidneys.

Now with the addition of local anesthesia in the mouth where the tooth abscess is, with a combination of lidocaine, bupivicaine and the addition of diluted sodium bicarbonate to keep the injection for stinging, the pain that will caused by the tooth extraction and abscess debridement, is able to be managed before it starts. Techniques like this have saved many patient's lives and have "made my day" as one veterinarian said it. Yes many agree; doing a service like this for clients and their pets; being able to managed animal's medical conditions effectively, economically, and with safely make many a health professional team members day. Anticipating and being ready are KEY.

Being "in the ready" involves three areas:

The facility, drugs, equipment, supplies and layout-organization; having all areas "in the ready" for a critical trauma

When you go back to your practice look around and see how you can position materials such as drugs, supplies, and equipment, to make everything more ergonomicly efficient. An example is having a paper towel dispenser, and waste basket near the site where your hands are washed, and having this all necessary to do the washin. Having oxygen supplied to an AMBU bag with a cone mask attached and a PEEP valve also attached allows immediate oxygen delivery with positive pressure ventilation able to be perform. This BiPAP ventilation system has been very life saving in patients with congestive heart failure and pulmonary edema. A crash cart should be set up with suction, endotracheal tubes, laryngoscope, stylets, cuff inflation syringe, emergency drugs (epinephrine, atropine, sodium bicarbonate, calcium chloride, lidocaine, dopamine, etc.), ECG, defibrillator, Doppler unit, vascular cutdown and tracheostomy instruments, etc. (see below under Crash Cart)

I recommend setting up the OR with everything laid out (general pack, gowns, drapes, gloves, blade, suction, cautery, anesthetic machine and ventilator attached, monitors, IV pole with a bag of plasmalyte hanging and the drip set coilded up and ready to be used, lap pads, Balfour retractor, feeding tubes) everything needed to perfom a resuscitatitive throacotomy and aortic cross clamping).

The team of care givers; beginning with a veterinarian and including the support staff (technicians, assistants, receptionists, etc.).

A minimum of two people is recommended in the management of emergency cases. Emergency care is stressful but keep smiling. Power of Positive Thinking is very important. This also helps owners who are naturally worried and stressed. Communication skills are also important and each team member must be mentally ready to face the demands of emergencies; unsceduled, streswsful, long hours, after hours, and limited resources.

Practicing the assessments and emergency procedures , working together to perform them effectively and efficiently.

Having training sessions frequently is recommended. Using cadavers to practice procedures and having drills where senarios are worked thgrough is a great way to keep the team "at the ready".

What is provided first – putting it propective

That what we can provide first will have the most impact regarding how the patient ultimately does, such as applying that spica newspaper splint to a dog with a midshaft humeral fracture as apposed to putting on a Robert Jones made of cotton... the former giving the dog what he needs (stability and pain relief) and the latter only making the dog more painful and providing him with a "Ball and chain" to wear below the fracture and possibly causing radial nerve injury that will never heal... I have seen a number of these unfortunately. The veterinarian's intensions were good but the dogs suffered irreparable damage and never were able to use the limbs again and amputation followed.

Another example is Jake that underwent an emergency surgery for the removal of a foreign body. This required the removal a good length of bowel (approx. 50% of the jejunum). The bowel anastomosis that was done with 4-0 PDS and the simple interrupted sutures only had gasped the submucosal slightly. Five days later the dog represented with fever, vomiting and a painful abdomen... the bowel anastomosis had broken down and the leak of intestinal contents had caused severe peritonitis. If only the bowel anastomosis had been done with a non-absorbable polypropylene and serosally patched with nearby bowel loops as this has been proven to prevent anastomosis failures. The technique also has been very successful for the management of these breakdowns. Crowe, DT: Serosal Patch: Use in 12 Animals, Vet Surgery 13:29-38, 1984

Facility readiness

The operating room should be set up all the necessary equipment to perform emergency surgery at a moments notice. Having an instrument pack, gowns, drapes, headlight, electrosurgery unit, and suture laid out in ready is highly recommended. Simple things such as a baby monitor, duct tape, cardboard back boards made from cardboard boxes, flashlight, bubble wrap, newspaper and towels for splints and bandages are also recommended.

Crash cart

A mechanics cart (3 or 4 drawers) can be used as a crash cart. All four wheels should be made into swivel wheels to allow greater mobility. Go to a fabrics store and buy 1 ½ inch thick foam rubber sheets and line the two top drawers with it after you cut holes as needed to hold the emergency equipment items needed. The cart should be used for emergencies only and be restocked after every use. MODULES OR DRAWERS within cart or at least drawers designated Airway, /Breathing. Drugs, Other:

A. Airwav / breathing drawer or module: This top drawer or module should contain CLEAR plastic endotracheal tubes that have low pressure - high volume cuffs. Pick one of every 2nd or 3rd size of the following :2.0, 2.5 (uncuffed) 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0. 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, 9.5. 10.0. 10.5, 11.0, 11.5 and 12.0 are the sizes that can be represented. Those made of silicone will require a stylet. Those made of PVC do not generally require the use of a stylet (wire or plastic). Both are "kind" to tracheal mucosa compared to the red rubber varieties. If a drawer is used there is enough room to have each ET tube attached to a syringe loaded with enough air to inflate the cuff moderately. Each of the ET tube and cuff inflation syringe should be nestled in a cut out area in a sheet of foam rubber that should line the drawer. Each ET tube should be fixed with a section of intravenous administration tubing or umbilical tape. The polyvinylchloride tubing of the iv administration set variety when pulled tight around the ET tube, binds well and does not slip as gauze does. Attachment using a Larks Head knot is preferred in that it is very secure and can be adjusted easily, The PVC plastic tubing can be tied behind the head in a bow and can be untied very quickly. Bring the PVC tubing just behind the canine teeth and then below the patient's chin and cross the tubing under the chin and then bring behind the head 4.Tie the tubing firmly behind the patient's head in a bow. The airway drawer or module should contain a Laryngoscope handle and set of blades. A good inexpensive source is a set that has clear blades and lights the entire blade. They are disposable in EMS catalogs.

Other equipment needed in airway / breathing drawer or module should include:

1. Forrester sponge forceps, curved - to remove foreign bodies & grasp injured tongue/lung

2. Valsellum or towel clam to grasp slippery balls

3. Hemostatic forceps, curved -to remove foreign bodies. Etc. from small patients

4. Mayo scissors, curved. - to gain access to the trachea or chest

5. Strabismus scissors, curved - to gain access to the trachea in very small patients

6. Scalpel blades (10, 15, 11) for airway access and other accesses

7. Cole tubes 1, 2,and 2.5 mm – for very small airways and especially helpful for newborn puppies and kittens and rabbits

8. 14 g Nasal catheter with red rubber feeding tube with side port for attachment to 02

9. 14 g IV catheter, 12 ml syringe and No. 3.0 mm endotracheal tube connector for rapid transtracheal or transcricothyroid cannula placement. The No.3 mm connector allows connection to a BVM for breathing of high frequency ventilations (>150-200 breaths per minute of very small volumes)

10.Tracheal suction catheters - 4.7.11 Fr Yankauer and Dental suction tubing

11.Suction units. This should include a rubber ear syringe and a portable suction device. These can be purchased from EMT-Paramedic suppliers. A mechanics hand-held and activated system used to create negative pressure for engine work also can be used for airway suctioning and costs less than a medical hand activated system.

B. Breathing drawer or module: Breathing assisting equipment such as Bag Valve Mask (BVM) AMBU bag w/ reservoir. Oxygen w/ tubing. and masks (for positive ventilation breathing IPPB])

1. BVMs - should be each of three sizes: Adult (700 -900 ml), Pediatric (400-500 ml), and Infant (250 ml). Each must have a reservoir attached to provide 100 % oxygen. Without reservoir's the BVMs can only provide 45% oxygen concentrations. These are the best devices to be used for rescue breathing. The BVM's are attached to a source of oxygen such as an E cylinder and a regulator – flow meter combination.

2. PEEP valves - should be available and used to increase the functional residual capacity of the breaths because of the effect of the PEEP valve on exhalation. This is the best effective treatment for emergency treatment of cardiac congestive heart failure and other pulmonary conditions that decrease alveolar capacity and increase interstitial edema.

3. Y connector – to be used for connection into the anesthetic machine or other oxygen source after the flow meter, so that high flow oxygen can be provided.

4. Regulator and flow meter – to be used as an oxygen source to run the Ambu bag or other oxygen system

5. Oxygen Tank (E) Catty – not in the drawer but beside the crash cart – this allows oxygen to be taken anywhere in the hospital including the lobby – reception area.

C. Cardiovascular drawer or module: Atropine. Epinephrine. Lidocaine. Calcium chloride. Sodium bicarbonate. Hypertonic saline. DMSO. Desferoxamine. Dopamine, Dobutamine, Plasmalyte, Dextrose 50%, Diphenhydramine, one bottle of each should be considered as a minimum. Have each bottle of drug held within a space made in the foam rubber. This will keep the bottles from shifting. A space made next to each bottle should be filled with various sized syringes (1 ml-12 ml) loaded with 18 g and 22 g needles. Time will be saved. costs to those veterinarians that place order with them.

D. Defibrillator and monitoring equipment. This includes a doppler flow detector and pediatric flat probe. ultrasound gel. blood pressure cuffs (at least 2.3.4.5.6. and 7 cm widths or at least a newborn and infant cuffs. and an aneroid sphygmomanometer.. ECG. temperature & pulse oximeter, end tidal CO2 monitors. oscillometric blood pressure monitors and monitors that measure direct BP. ECG. Temperature. respiratory rate, etc. and are made specifically for veterinary use

E. Equipment (miscellaneous) that is essential. Suction tips: Yankauer. for suctioning of the pharynx; Endotracheal tube as suction catheter for suctioning the pharynx and airway when large pieces of vomitus, clots, etc., are present. Tracheal suction catheters for aspiration of the trachea . B lankets and Plastic Bags are important to keep patients warm. A warm water circulation system is also recommended. ThermoGear Warm Blanket or Bair Huggar or Warm Touch patient warmer are very good units that keep patients warm or can be use to reverse hypothermia. On the other end of the tempertaure spectrum it is recommended to also have saline in liter bags in the refrigerator and in the frozen section as well. Simple ice bags are also recommneded. New research has revealed that use of induced hypothermia to 31 degrees C to be life and heart and brain saving.

Surgical pack and sterile towels and laparotomy pads for emergency surgery

The towels are useful for packing. protecting and absorbing. Feeding tubes of various sizes and stop cocks are also needed to be used as IV catheters. and for vascular occlusion . Peritoneal dialysis catheters for diagnostic peritoneal lavage and for emergency dialysis. Thoracentesis sets made from an IV extension set with a stop cock attached on one side and an 18 gauge needed on the other side. A commercial centesis, mini chest drain can also be used and is recommended. 14 g IV catheters make very good mini chest tubes for small dogs and cats. Chest tubes with inner metal stylet for guidance into the chest cavity (size 12 to 32) (Kendall or other suppliers). You can use clear sterile disposable endotracheal tubes 2 mm to 10 mm OD as good substitutes for "chest "' tubes. A section of metal coat hanger or aluminum rod of small diameter than the ET tube can be used to guide the tube in place with care not to have them protruding from the end when using them. Anesthetic ventilator. Laboratory testing and immaging abilities (radiology and ultrasound) are also key as well as monitors for Doppler flow, BP. SpO2, ETCO3, temperature, etc.