As the New Year progresses forward into the spring, I thought it might be a perfect time to look at some of the more unique and sometimes dangerous devices and procedures that have long since disappeared from both the BLS and ALS scopes of practice. As the theory of EMS blossomed in the early 70s, the procedures and devices utilized in the field were taken from military medical personnel who had operated in Vietnam. For the veteran street-level paramedic, file this article under a trip down memory lane. Please keep in mind that the following medical devices and procedures, although sometimes questionable, opened the doors leading to the modern practice of street medicine we employ today.
Disclaimer: The devices and procedures presented in this piece were once validated by our leaders and peers. This article in no way suggests that the highlighted procedures and devices negligently caused harm. We didn’t know what we didn’t know. Let us not forget that the delivery of prehospital medicine has always been an art as much as a science, both of which require continuous practice to maintain competence, as well as heavy scrutinization of equipment which may or may not improve patient outcomes.
One of the most prolific medical procedures of our time, made famous by the movie Pulp Fiction, is the administration of intra-cardiac adrenaline by paramedic personnel. Rural and big city EMS services in the late 1980s authorized paramedics to administer high dose intra-cardiac epinephrine as a last-ditch option during resuscitation of both medical and traumatic cardiac arrest. The early editions of Dr. Nancy Caroline’s Emergency Care in the Streets defines this skill as relevant to the paramedic scope of practice while clearly stating the high-risk nature of this procedure.1 The delivery of intracardiac epinephrine requires the provider to insert a 9-inch 21-gauge needle attached to a pre-loaded syringe. The syringe is then blindly advancing the needle through the lower left anterior thorax just above the diaphragm, where it punctures through the pericardial sac and into the inferior heart to deliver a dose of epinephrine directly into the thickest portion of cardiac muscle. Without the aid of modern imaging to locate internal landmarks, complications were highly probable as paramedics (and physicians) would sometimes push the needle all the way through a ventricle or miss the heart all together, lacerating any number of vessels or organs along the way.
What we eventually understood over the years of seeing poor results and less than desirable survival rates, this skill was an ultra-high risk/no benefit procedure that did not improve cardiac arrest survival past the ER. Even If the patient obtained ROSC there were usually serious complications associated with the procedure including cardiac trauma, pericardial tamponade, pneumothorax, hemothorax and pericarditis. Though the intra-cardiac delivery of medication looks quite dramatic, often portrayed as a miracle procedure on film, it took us over a decade to finally figure out that it had no relevance or place in standard civilian street level resuscitation, but don’t tell Mia Wallace that.
The best way to take a know-it-all trainee down a few pegs is to have them retrieve a non-rebreather mask from the ambulance, a seemingly elementary task. Usually, the rookie provider reacts confidently as they hand over a PRB partial rebreather mask. I remain perplexed as to why even today that some of the best EMS instructors continually refer to the PRB mask as a non-rebreather mask. This confuses students and imprints a less than stellar impression of our professionalism on those in-hospital clinicians that know the difference.
The non-rebreather mask with the proper liter flow, delivers high concentrations of oxygen with an fiO2 of > 90% by allowing the patient to draw pure 100% oxygen from the reservoir bag as two laterally located one-way valves prevent ambient air from being drawn into the mask and diluting the concentration of oxygen delivered. Conversely, the NRB mask permits CO2 to be pushed out of the device through the valve ports during exhalation.
The catalyst to the downfall of the non-rebreather mask can be traced back to EMTs arbitrarily treating non-psychogenic induced hyperventilation by applying a NRB mask without any flowing oxygen. Treating hyperventilation secondary to pulmonary embolisms, AGE’s, or sickle cell anemia with an oxygen mask void of flowing O2 is nothing short of negligence as it can lead to a major hypoxic event, tissue death and irreversible neurologic damage. Paramedics who thought they were slick were just as notorious for using the NRB mask to administer nebulized medications by removing the reservoir-bag and attaching a low-flow oxygen driven nebulizer, but forgetting to remove the mask’s one-way valves.
In the mid-90s, several EMS systems started to document a disturbing trend. Cases of acute respiratory distress with refractory bronchoconstriction were arriving to the ER with gross hypercarbia, leading to irreversible metabolic acidosis and death. To combat unintentional CO2 retention, the PRB mask with its wide-open exhalation port replaced the NRB becoming the industry’s go-to oxygen delivery device. Even with low-flow oxygen, the PRB prevents the rebreathing of absorbent amounts of CO2 thus preventing systemic acidosis. For lack of a better term, the PRB mask is “paramedic proof” and still delivers an approximate max fiO2 of 70%. Regardless of the device used to deliver oxygen, referring to a PRB mask as a NRB mask is a rookie mistake that is made all too often by experienced providers.
This piece of OG (original gangster) equipment had its place in the treatment of respiratory arrest, cardio-pulmonary arrest, CHF and drowning induced pulmonary edema, long before the days of BiPAP and CPAP. The complications that these devices caused could be traced to the delivery method of pressurized oxygen. With just the pull of the trigger the Elder Valve delivered a non-precise burst of oxygen at up to 40 LPM at about 20 psi. If this device’s pop-off valves failed it could result in more problems for the patient. The use of this device was shown to cause air trapping, CO2 retention, severe pulmonary injury and barro trauma in patients with bronchoconstriction. Additionally, oxygen-powered PPVD often led to profound gastric distension and the occasional tension pneumothorax, especially with an overzealous provider on the trigger. The Elder Valve PPVD lost its favor as we adopted data-driven treatment guidelines like BMI-based tidal volume limits and the use of advanced equipment like transport ventilators and CPAP devices with PEEP.
California’s tempered climate and sea level elevation gives comfort to those with chronic respiratory issues. Based on the rules of probability, Southern California paramedics see a lot of respiratory cases and often become ultra-proficient at managing patients with severe respiratory distress caused by CHF-induced pulmonary edema. One of the more unique procedures from the 80s and 90s used to treat CHF was the application of rotating tourniquets. This procedure in theory was supposed to tamponade distal venous circulation limiting the amount of blood and interstitial fluid (pre-load) returning to the heart and lungs. For those patients with acute pulmonary edema, special reusable leather or rubber tourniquets were applied to one or two of the patient’s extremities with varying proximity to the core and then switching (or rotating) the tourniquet(s) to the opposite extremities. The procedure itself presented very little risk to the patient, however it wasted valuable time that could’ve been better spent on more useful things like airway management, oxygenation and transport to the hospital. With the advent of NTG, morphine, and lasix to the paramedic pharmacopoeia, the use of rotating tourniquets in the field was eventually discouraged by the AHA and finally removed entirely from the ECC guidelines and the NHSTA curriculums.
MAST trousers came from military application, first for pilots countering the effects of g-forces during flight and later to auto transfuse blood during combat medicine application for shock-trauma. The MAST suit was considered standard load-out on all U.S. ambulances in the 70s and 80s.
First described in 1903, the pneumatic anti-shock garment was designed to auto-transfuse up to 25% of the total blood volume from the legs and lower abdomen to the core, while in the same moment restricting “less important” circulation to the lower extremities. The problem was that some studies suggested that there was considerable risk of airway and breathing problems and disruption of the clots above the garment. Because of the pneumatic nature of the PASG device, malfunctions were a regular occurrence. Cracked hoses, leaking airbladders as well as easily misplaced foot pumps plagued every system in America. In addition, the increase of blood pressure created by the PASG was only short lived and failed to prove useful in a majority of field specific studies. Lastly, sudden rapid removal of these devices by overzealous ER nurses happened quite frequently and would often cause an immediate hemodynamic “crash” which the patient rarely recovered from. The PASG makes an excellent splint for multi-location lower extremity trauma and pelvic fractures, but the many risks associated with its use eventually cancelled this device from our culture.
The long back board itself has not disappeared by any means, as you can find many of these devices in various states of existence at any public pool, hospital, or fire station in America. However, the backboard is no longer the key piece of equipment it once was due to the advent of the selective spinal motion restriction criteria and procedures built to avoid unnecessary immobilization.2,3,4 As it turns out, strapping a patient in the supine position to a hard non-flexible piece of wood for long periods of time can cause breathing issues and often does more harm than good.2 In some studies, backboards have been shown to exacerbate the severity of spinal injuries as well as cause airway problems and tertiary soft tissue injuries. Don’t worry though, the spine board still serves as a rapid extrication device to quickly move incapacitated or neurologically compromised patients from the point of injury to the pram or ambulance.2 It is safe to say that if more EMS providers realized the benefits of the “scoop” or break-away stretcher as a transfer, immobilization and extrication device, we would gather up the country’s remaining spine boards (including that weird looking half-back board that is currently rotting in the M-tank compartment of your bus) and have one heck of an EMS bonfire.
Back in the early days of EMS, mechanical electric suction had two intensity settings – off and on. Overzealous use of unrestricted non-adjustable electric suction was often associated with fatal neonatal hypoxic events which led to mechanical electric suction becoming contra-indicated during neonatal care. Instead, EMS providers were taught to use the Delee suction device (or Lukens Trap sputum device) to clear newborn airways. However, the Delee suction device was not connected to mechanical suction. Instead, the suction was created by the provider sucking on the non-business end of the device. You read that correctly. Again, the EMT would lock their lips around the device’s mouthpiece and suck on it like one would suck fluid through a straw. The first time I saw this procedure demonstrated at a NALS class in 1991, I thought the instructor was joking. Need I explain why this device is no longer in use in the prehospital arena?
Back in the day, the average belt-mounted EMS tool kit often came stock with all kinds of rescue gadgets including a ring cutter, a window punch, hemostats, steel bandage scissors, an over-size plastic tongue depressor (bite block) and a jaw screw. Let’s look at the most barbaric of the gadgets; the jaw screw or “Trismus Tree.”
The jaw screw was a medieval looking plastic device designed to facilitate airway management for patients with a clenched jaw, aka Trismus. The oral screw was usually deployed during a seizure and used to pry open the teeth to access the oropharynx. The provider rotated the screw into the mouth, gradually separating the teeth to access the upper airway. It was not uncommon in the 70s for ambulance personnel to routinely use the screw to forcibly open the jaw of a seizing patient, mid-seizure, to facilitate placement of a plastic bite block as a method to protect the tongue. Use of the jaw screw sometimes led to permanent dental injury and the procedure itself bordered on assault and battery to the untrained eye.
The EMS intellects of the time eventually accepted the fact that people don’t swallow their tongues. When the industry recognized tongue abrasions, temporary oropharyngeal obstruction and soft tissue trauma were just minor consequences of a seizure, the bite block and jaw screw faded from the industry. By the late 70s and early 80s, the screw was replaced gradually by blind nasal-tracheal intubation and nasal pharyngeal airways as those became the new standard in most major EMS systems across the country. Eventually, the jaw screw disappeared from the leather hip holsters of America’s ambulance attendants only to be used to cap half-full wine bottles or framed as a piece of EMS history that we should probably forget.
This is usually the point where I close the education loop with a summarization of content and end the article. This time however, I would like to make this an open discussion with the JEMS audience, as there are many other tools and procedures that are no longer part of modern EMS curriculum. Post a comment and remind us of other devices and procedures that belong on this list of abandoned practices that were once commonplace in our profession. With your help, I can continue my quest to bring into focus those blurred memories from the frontier period of America’s prehospital tradecraft. To be continued.
1. Nancy Caroline’s Emergency Medical Care in The Streets, 3rd Edition. ISBN13:9780316128797 Release Date: April 1987 Publisher: Lippincott Williams & Wilkins
2. Jones and Bartlett Learning – NAEMT Pre-Hospital Trauma Life Support Manuel 9th Edition ISBN 978-1-284-04173-6 (2019)
3. Stiell I, et al. The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 349: 2510–2518, Dec 2003.
4. Hauswald M, Braude D. Spinal immobilization in trauma patients: Is it really necessary? Current Opinion in Critical Care 8(6):566–750, Dec 2002 .
5. Spinal Injuries: Debunking the Myths of the Long Backboard Author: Joslyn Joseph, DO (EM Resident Physician, Morristown Medical Center) and Joshua Bucher, MD (EM Attending Physician/EMS Fellow, Morristown Medical Center) Published on the WWW at Spinal Injuries: Debunking the Myths of the Long Backboard | Hatzolah International Forum (hatzforum.com).