Possible TCCC change

Chuckman

Chuckman

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This probably won't apply to 99% of the folks here, but @phideux , @Sneakymedic , and others, TCCC may be moving away from needle decompression as first line procedure for tension pneumothorax and going to finger thoracostomy.
I've done a few of these in life tissue training, procedurally it's pretty easy. I will be curious to see how IFAKs and kits are sold (with or without a needle).
 
Chuckman said:
I will be curious to see how IFAKs and kits are sold (with or without a needle).
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Quite a valuable experience to perform this procedure on a live tissue patient!

With how needle Ds have always been a fairly easy treatment for dummies/grunts😉 thus far, It will definitely be interesting to see if and how issued ifaks and tccc training evolves in the next few years.
 
thanks for posting.
this is something
i never knew
was possible
until today.
 
I don't see our training officer and medical director letting us do that on the ambulance in the near future. I've done a few Chest tubes, done a ton of Needle DCs. I carry a 10ga with my tourniquet.
 
It's about time....
There are a few EMS systems that have already approved this for their providers. We did it on cadavers a while ago.
Austin Travis TX being one of them.

It's actually easier than NDC in my opinion.
 
georgel said:
Looks more sutiable to sterile hospital/medical setting than field expedient to me.
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It's actually pretty fast. The only hard part is navigating the landmarks. Interesting data on needle decompressions are making the CoTC3 place heavier emphasis on this. Edited to add, I don't think civilian non-med folks should be doing needle d's much less this. I shared because I know med guys on here may see changes in protocols in the future.

NCMedic said:
It's about time....
There are a few EMS systems that have already approved this for their providers. We did it on cadavers a while ago.
Austin Travis TX being one of them.

It's actually easier than NDC in my opinion.
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I have a friend who is a flight medic in Georgia, he prefers this to NDC. I have done it on cadavers, too, and on LTT (goats), so that is my only context. I thought it was pretty easy. And two steps away from a full chest tube.
 
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Avery said:
Quite a valuable experience to perform this procedure on a live tissue patient!

With how needle Ds have always been a fairly easy treatment for dummies/grunts😉 thus far, It will definitely be interesting to see if and how issued ifaks and tccc training evolves in the next few years.
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My guess is the needle will still be an issued item in the IFAK for the non-med guys, and the med guys will have both needles and tools for this procedure.
 
When I broke my back in a treestand fall in 2007 the medics (and I use that term loosely) who responded thought I had a collapsed lung. All because I couldn't take a deep breath due to a burst fractured L1 vertebra. So before I could tell him that's why I couldn't breathe, he needled me.

Then as the duke life flight nurses took over and got me on the helicopter the needle got ripped out by the seatbelt and flung across the helicopter. The life flight nurse lost it. The medic crew didn't tell him they'd done that. As he said, "the good news is you didn't need it anyway."
 
RR said:
When I broke my back in a treestand fall in 2007 the medics (and I use that term loosely) who responded thought I had a collapsed lung. All because I couldn't take a deep breath due to a burst fractured L1 vertebra. So before I could tell him that's why I couldn't breathe, he needled me.

Then as the duke life flight nurses took over and got me on the helicopter the needle got ripped out by the seatbelt and flung across the helicopter. The life flight nurse lost it. The medic crew didn't tell him they'd done that. As he said, "the good news is you didn't need it anyway."
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Yeah, you and I have talked about that before. A pneumo from blunt trauma can be difficult to assess/diagnose; every swinging you-know-what wants to call 'diminished breath sounds' a tension pneumo. Most of the time those 'diminished breath sounds' are just because of all of the ambient noise and the breath sounds are actually OK. If I am 'on the fence' as to whether someone may have a pneumo based on breath sounds, I look at other symptomology: pulse ox, HR, chest expansion (equal or no), color changes, complaints of breathing difficulty, etc. If none of those are present, I hold the dart until those signs/symptoms occur.
 
Chuckman said:
Yeah, you and I have talked about that before. A pneumo from blunt trauma can be difficult to assess/diagnose; every swinging you-know-what wants to call 'diminished breath sounds' a tension pneumo. Most of the time those 'diminished breath sounds' are just because of all of the ambient noise and the breath sounds are actually OK. If I am 'on the fence' as to whether someone may have a pneumo based on breath sounds, I look at other symptomology: pulse ox, HR, chest expansion (equal or no), color changes, complaints of breathing difficulty, etc. If none of those are present, I hold the dart until those signs/symptoms occur.
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The crew that responded to my accident were shut down about six months later. Apparently they were notorious for their cowboy antics.
 
RR said:
When I broke my back in a treestand fall in 2007 the medics (and I use that term loosely) who responded thought I had a collapsed lung. All because I couldn't take a deep breath due to a burst fractured L1 vertebra. So before I could tell him that's why I couldn't breathe, he needled me.

Then as the duke life flight nurses took over and got me on the helicopter the needle got ripped out by the seatbelt and flung across the helicopter. The life flight nurse lost it. The medic crew didn't tell him they'd done that. As he said, "the good news is you didn't need it anyway."
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The thought of a large bore 3.5" contaminated needle fly across a small confined space made me pause. 😮
 
When I did my trauma room rotation during paramedic school, the doc at shock trauma did this prior to placing a chest tube. That being said, I can’t imagine them changing TCCC at the basic level for this. It’s very invasive and requires a sterile procedure be followed. Can’t imagine doing this in the field. I wont dare argue the science, people way smarter than me figure that out. Im gonna reach out to my best friends son who just graduated from SOCOM last week. He was telling me that they are adding blood transfusion kits to many basic load out, so who knows what’s coming down the pike. It’s amazing that exponential changes that have occurred over the years. When I was in Iraq in 2003, we still didn’t have tourniquets but we did have the first generation of Quik Clot (the exothermic kind). We’ve come a long way in twenty years.
 
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I’ll be asking the doc at the next sage class about this procedure to see if it’s filtered down the SF medics yet.
 
georgel said:
The thought of a large bore 3.5" contaminated needle fly across a small confined space made me pause. 😮
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In all fairness it was only the plastic catheter HOEFULLY, the needle had been removed after the decompression was performed.
 
Chdamn said:
I’ll be asking the doc at the next sage class about this procedure to see if it’s filtered down the SF medics yet.
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It has. I am about to go to work teach new docs ATLS, I get a minute I will post the reply from the NCOIC of the trauma III bloc in SOCM.

Edited, here is his response:

"Simple answer is TCCC guidelines recommend needle D and that's it I believe. This upcoming release I believe is going to recommend only finger thor....needle D is a stopgap until you can make a larger hole...think of as least invasive to most invasive. Also due to MOI our guys have more hemo's than pneumo's."
 
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cap688 said:
When I did my trauma room rotation during paramedic school, the doc at shock trauma did this prior to placing a chest tube. That being said, I can’t imagine them changing TCCC at the basic level for this. It’s very invasive and requires a sterile procedure be followed. Can’t imagine doing this in the field. I wont dare argue the science, people way smarter than me figure that out. Im gonna reach out to my best friends son who just graduated from SOCOM last week. He was telling me that they are adding blood transfusion kits to many basic load out, so who knows what’s coming down the pike. It’s amazing that exponential changes that have occurred over the years. When I was in Iraq in 2003, we still didn’t have tourniquets but we did have the first generation of Quik Clot (the exothermic kind). We’ve come a long way in twenty years.
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It's definitely invasive, but if you hit the right landmark it is low risk. Prehospital it is a clean procedure and not sterile. This will unlikely supplant needle decompression in TC3 for non-medical providers, but be in the TC3-MP curriculum.

The units in SOCOM are doing ROLO (Ranger O-neg low titre) blood transfusion, every person gets one or two blood bags and a transfusion kit. The team medic/corpsman has a list who are O negative and they are automatically tapped as the on-site blood donor. It is extremely forward thinking. We'll never see that outside of the military and some select civilian LE agencies, and for good reason.

Regarding hemostatic dressing, looking at 20 something years of outcome data, there's no statistical significance in outcome between people who got hemostatic dressing versus non hemostatic dressing, so we might see kits being issued without quik clot, etc. All that is to say you are right, who knows what will be coming down the pike.
 
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Chuckman said:
Simple answer is TCCC guidelines recommend needle D and that's it I believe. This upcoming release I believe is going to recommend only finger thor....needle D is a stopgap until you can make a larger hole...think of as least invasive to most invasive. Also due to MOI our guys have more hemo's than pneumo's."
Click to expand...

This was always my argument, it's dumb to dart someone 4-5 times and they look like a porcupine exploded in their chest at the 2nd ICS when they have a hemothorax and they have used 2" 14ga caths.

Where civilian EMS has failed is the education of the difference between a hemo and pneumo.... at least in modern EMS training... Everything is a TPX now.

Hemothorax = dull (hypo-resonance) to percussion.
There is no JVD (neck veins are flat). 4th or 5th ICS decompression

Pneumothorax: tympanic (hyper-resonance) to percussion.
Unless there is hypovolemia, there is JVD (distended neck veins). 2nd ICS decompression.

But one too many paramedic stabbed someone in their liver and many places took MAL at the 4th or 5th away despite it having the higher success rate.

https://rebelem.com/what-is-the-best-anatomic-location-for-needle-thoracostomy/
 
NCMedic said:
This was always my argument, it's dumb to dart someone 4-5 times and they look like a porcupine exploded in their chest at the 2nd ICS when they have a hemothorax and they have used 2" 14ga caths.

Where civilian EMS has failed is the education of the difference between a hemo and pneumo.... at least in modern EMS training... Everything is a TPX now.

Hemothorax = dull (hypo-resonance) to percussion.
There is no JVD (neck veins are flat). 4th or 5th ICS decompression

Pneumothorax: tympanic (hyper-resonance) to percussion.
Unless there is hypovolemia, there is JVD (distended neck veins). 2nd ICS decompression.

But one too many paramedic stabbed someone in their liver and many places took MAL at the 4th or 5th away despite it having the higher success rate.

https://rebelem.com/what-is-the-best-anatomic-location-for-needle-thoracostomy/
Click to expand...

I believe you are correct, and your post has a lot to unpack. Failure of education + inexperience of medics + low volume procedure = high outcome of bad things. Like I said in my response to @RR , too many providers needle just based on breath sounds without looking at the overall clinical picture or symptomology. As a clinician and educator that really bothers me. Now with the prevalence of hand-held ultrasound we may see more better diagnostics to help determine when/if to needle and do a finger thoracostomy.
 
Chuckman said:
It has. I am about to go to work teach new docs ATLS, I get a minute I will post the reply from the NCOIC of the trauma III bloc in SOCM.

Edited, here is his response:

"Simple answer is TCCC guidelines recommend needle D and that's it I believe. This upcoming release I believe is going to recommend only finger thor....needle D is a stopgap until you can make a larger hole...think of as least invasive to most invasive. Also due to MOI our guys have more hemo's than pneumo's."
Click to expand...

His point about point about hemo vs. pneumo is really what it comes down to. It really does make sense. And in the battlefield this will absolutely make a difference and save lives. My time as a civilian paramedic was definitely different from what I saw in Iraq. Although the area I worked was loaded with significant traumas (gsws/stabbings almost daily) we could be to a trauma center with 10-15 minutes tops. A needle D on a hemo instead of a pneumo typically wouldn’t have a negative impact. Not that it would help either.
 
cap688 said:
His point about point about hemo vs. pneumo is really what it comes down to. It really does make sense. And in the battlefield this will absolutely make a difference and save lives. My time as a civilian paramedic was definitely different from what I saw in Iraq. Although the area I worked was loaded with significant traumas (gsws/stabbings almost daily) we could be to a trauma center with 10-15 minutes tops. A needle D on a hemo instead of a pneumo typically wouldn’t have a negative impact. Not that it would help either.
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No. At that point they are buying a chest tube anyway.

I agree about the nature of MOI in civ trauma vs mil trauma. Not just in terms on treatment, but also how many patients and how long you may have to hold onto them before definitive care. The military as a whole is transitioning away from care on the X and rapid evac to prolonged field care, which is making for better clinicians.
 
Chuckman said:
I believe you are correct, and your post has a lot to unpack. Failure of education + inexperience of medics + low volume procedure = high outcome of bad things. Like I said in my response to @RR , too many providers needle just based on breath sounds without looking at the overall clinical picture or symptomology. As a clinician and educator that really bothers me. Now with the prevalence of hand-held ultrasound we may see more better diagnostics to help determine when/if to needle and do a finger thoracostomy.
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This is true, the "I can't breathe".. "it hurts to breathe" doesn't = pnemo or hemo, you just got shot or stabbed in the chest or whacked your torso off a steering wheel.. It's going to hurt.

The "art of assessment" is just that and it's something being lost on new providers, combined with silly things like "10 minute scene times" or 400 other things that dilute the Paramedical profession, it hampers the advancement of procedures that have true impact like this or surgical crics and the people in the field are left with "safer or better" adjuncts such as decompression needles or quick trachs.

I'm getting off my soap box now.... 😂
 
Chuckman said:
The military as a whole is transitioning away from care on the X and rapid evac to prolonged field care, which is making for better clinicians.
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And the next MCI that occurs in the civilian setting will show the most EMS systems are woefully under prepared to even begin to understand the concept of PFC.

I just had this discussion with several people about MASCAL or ASHER and asked what the plan was for PFC until they could be transported.... The looks on the faces.
 
NCMedic said:
This was always my argument, it's dumb to dart someone 4-5 times and they look like a porcupine exploded in their chest at the 2nd ICS when they have a hemothorax and they have used 2" 14ga caths.

Where civilian EMS has failed is the education of the difference between a hemo and pneumo.... at least in modern EMS training... Everything is a TPX now.

Hemothorax = dull (hypo-resonance) to percussion.
There is no JVD (neck veins are flat). 4th or 5th ICS decompression

Pneumothorax: tympanic (hyper-resonance) to percussion.
Unless there is hypovolemia, there is JVD (distended neck veins). 2nd ICS decompression.

But one too many paramedic stabbed someone in their liver and many places took MAL at the 4th or 5th away despite it having the higher success rate.

https://rebelem.com/what-is-the-best-anatomic-location-for-needle-thoracostomy/
Click to expand...
Our protocols don't allow us to stick them 4 or 5 times. We get one stick, in the 2nd ICS, after that, if they need another we can call the doc and get an order for a second stick, that one goes in the the 5th MAL. They are trying to change our protocol to get away from the the 2nd ICS, they say the MAL is better, I carry a 3.5" 10ga for chests. I always percuss before I stick and carry a good scope and been around long enough to know how to use it. You will rarely see the "textbook"signs of a Tension Pnuemo, that's all pretty much late stage stuff, probably also some Hemo involved, and they need a big hole.
 
Chuckman said:
Regarding hemostatic dressing, looking at 20 something years of outcome data, there's no statistical significance in outcome between people who got hemostatic dressing versus non hemostatic dressing, so we might see kits being issued without quik clot, etc. All that is to say you are right, who knows what will be coming down the pike.
Click to expand...
Another good point. Hemostatic Agents are magical voodoo, it requires proper wound packing AND holding the pressure there. I think too many folks think that you just jam it in the wound and it works its magic. Hardly the case. In my personal IFAKs I don’t carry any hemostatic agents. First of all, I hope to never use any of my personal stuff, second, I don’t think for the cost, the juice is worth the squeeze.
 
I got some combat gauze. That and an Israeli type pressure bandage work really well from my experience with using it.
 
cap688 said:
Another good point. Hemostatic Agents are magical voodoo, it requires proper wound packing AND holding the pressure there. I think too many folks think that you just jam it in the wound and it works its magic. Hardly the case. In my personal IFAKs I don’t carry any hemostatic agents. First of all, I hope to never use any of my personal stuff, second, I don’t think for the cost, the juice is worth the squeeze.
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I've used hemostatic dressings exactly twice in 25+ years of EMS. There are a couple of points to using it.... The wound has to be large enough to pack it and you have to be comfortable with actually packing it.... Otherwise it's just really expensive gauze and it has to be somewhere that is otherwise non compressible. If I had to pick better hemostatics or an OLEAS bandage, I'd get really good with and understand how to actually work an OLEAS to it's full potential.
 
So I talked to my nephew yesterday. He just completed SOCM. He said finger Thor is indicated after two failed NDT attempts. But it’s for higher level care. He did not learn it at Fort Sam for 68W, only at Bragg. It’s not going to be a TCCC change at this time.

ETA: forgot to add that he said the protocol is to give blood before finger Thor. So after failed NDT, give blood, then finger Thor.
 
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