Justin and Brad continue the discussion of pharmacology started last episode by talking about the MSMAID Acronym/Mnemonic and how it applies to the way SOF Medics should be practicing medicine in austere conditions. With Brad’s extensive experience in a variety of theaters and evac platforms, there is much we can glean to improve the outcome of our most seriously ill or injured patients. One way is by organizing our thoughts, team and equipment prior to attempting the under-appreciated task of sedation or IV/IO anesthesia. Listen to the podcast and read the rest of the show notes below to get a better understanding…
Applying an Anesthesia Checklist to SOF Medicine
Although the MSMAID acronym was designed as a pre-op checklist for the anesthesia provider, it is helpful for us medics when we need to decide what gear to bring with us and as a method to brief our non-medical help when we need to sedate someone. If you were working in the Operating Room, MSMAID simply walks you through an equipment check on your ventilator, wall suction, monitor, airway equipment, IV patency, and that you have the correct meds and enough of them for the case. The following is an explanation of how MSMAID can be adapted to help the SOF Medic and his team in the event that they need to sedate a patient. As usual, we’ve made some recommendations in the “minimum, better and best” format in order to give you options based on your mission. For example, if you are jumping in on a 5-day recce mission and only have so much room in your ruck, a finger pulse-ox is perfectly acceptable as a monitor (recognizing of course that it is not a great monitor). On the other hand, if you are deploying to a fixed facility and you can bring the kitchen sink, then we went ahead and recommended “best case” items as well.
MSMAID as a planning and gear selection guideline Simply put, if you are going to carry the heavy-hitters like Ketamine, Versed, Fentanyl, and Dilaudid, then you need to have MSMAID covered in some way no matter what the mission is. If you have these drugs in your aidbag, at a minimum you need to have a BVM, Suction Easy, finger pulse-ox, NPA, OPA, King LT, Cric kit, IV starter kit, IO device, and your drug box to include reversal agents (Narcan and Flumazenil). If you have the luxury of bringing a secondary bag with more space or if you are working out of a fixed facility, then check out the below examples for recommendations for how to increase your capability.
MSMAID as a pre-sedation checklist Before you sedate a patient in the PFC setting, we highly recommend that you brief your team using the MSMAID format to cover how you will handle contingencies if they arise. For example:
M- Machine: “Guys, if the patient stops breathing, we will need to assist him with the BVM. I will hold the mask to the face like so, and Jim, you will squeeze the bag when I
tell you. Use only 3 fingers to squeeze the bag, and ventilate the patient every time you take a breath.”
S-Suction: “If he throws up from the medication, we are going to place him in the recovery position immediately. I will attempt to clear his airway with the Suction Easy, but it is essential that we allow gravity to work in our favor.”
M-Monitor: “Bob, you will be the monitoring guy. I need you to watch the screen and tell me his pulse rate every 5 minutes. If he starts breathing rapidly, let me know. I need you to also watch his oxygen saturation and tell me if the reading starts to drop below 97%.”
A-Airway: “Guys, if he stops breathing at any time, we will attempt to ventilate him with the BVM, but if that isn’t working, we may need to put in the King LT to help us out. Let’s review how that works right now. Worst case, my Cric kit is located on the table.”
I-IV/IO: “Jim, please open the IV up and make sure it is still good to go. Let’s go ahead and start another line on his other arm. If we have issues, the FAST 1 is by my Cric kit.”
D-Drugs: “Guys, if I need to give the patient more Ketamine, my syringe is sitting right here. It is all drawn up, so if I ask you to give one more CC, it means you will need to connect it to the IV port and push from the 10 mark to the 9 mark, then open the IV up for a second to let it circulate