Stuck in the Middle With You Ep. 3 - Carl Flores
Ring Rescue’s COO, Blake Smith, recently interviewed Carl Flores, who has over 30 years experience in the medical space, with expert knowledge ranging from EMS to burn injuries and more. Flores was the Chief of EMS for the City of New Orleans, working his way up the ranks over 30 years. He is currently the Burnout Reach Coordinator at the University Medical Center in New Orleans. Earlier in his career, Flores’ earned certifications such as Instructor Licenses and Certifications in Rescue Response in Light, Medium and Heavy Rescue.
You might ask, how do burns and ring removal cross paths? They may seem like very unrelated topics. Carl Flores’s response to this was, “One of the major pieces of burns is to stop the bleeding process and the other thing is remove all constricting things; so this fits right in my wheelhouse with Ring Rescue.”
Now that you’ve got some background information on Carl and how burns relate to stuck ring removal, let’s get into our THIRD episode of our Stuck In the Middle With You series! The video is two parts, but we rounded up all the questions in one, spot just for you!
Q: How often do you guys come across stuck ring scenarios?
A: For us it’s seasonal like anything else; we have these Mardi Gras Festivals and we’ll have 12 ring removals in this two week span of Mardi Gras. On average, we probably see about two dozen a year in the city of New Orleans.
Q: What type of stuck ring scenarios might you come across in your different fields?
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We had one most recently in our state, where we had a hydrofluoric acid release. A gentleman who is not used to going out there, checked the valve and had no PPE and wound up having some issues where they had to rapidly get in and remove clothing. That would be the most recent thing from the burn standpoint.
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From an EMS standpoint I can’t tell you all the rings or even other items that you’ve had to cut off of individuals that you would not imagine, but people get into precarious situations.
Most notably for us, we had a little event annually here in New Orleans [Mardi Gras] where things get stuck all the way around because they have a little bit of spirits that go on and next thing you know people are trying each others rings on, kids are putting things on their fingers that they find on the street and next thing you know it gets stuck. We’ve had to resolve several of those issues throughout my career.
Q: Did you ever receive any training on the EMS side for stuck ring removal?
A: No, not really. Growing up it was mainly “try and not agitate the finger”. The Internet wasn’t around when I took EMT classes. Now as this video’s going to air, anyone can Google anything and YouTube it. I think the biggest thing I noticed during instructing classes; a lot of people are quickly bringing up these videos they see. People look at the traditional things today, like [the band from] the oxygen mask.
What I’m cautious with individuals about is to let them know that it has to be case by case dependent. While I get that you are not ready to call on other resources and have them come to the scene, if you have an angry finger (where someone has been trying for days on end and their finger is swollen) or it’s some other piece and you could cause further damage to the point of skin rupture or even some nerve damage by hitting some vessels. I think that's the cautious thing that I would tell medics is, don’t get in there and be quickly evasive because you don’t know what that patient has done before you got there. You have to ask “what are the interventions?” and that’s a big cautionary component when we teach even from the light to heavy rescue side.
Q: How important is it to have a procedural approach to not only ring removal but everything?
A: That was a secret sauce to our success in New Orleans. You build a process for everything. You might as well do it from the ground up. Once you set that basis, that’s what you maintain. Even in something that seems simple.
We know how to intubate and we know how to do this, etc. so we created clinical policies and procedures, [stuck ring removal procedure] would be along that same line. When you train, you create policies or procedures or components in your training to incorporate. So yeah, absolutely, 100% a procedural approach is important because then it becomes regimented, it becomes a routine as you begin to practice.
Q: Have you seen any stuck rings on the burn side in the past?
A: We tell the medics from the get-go, to have the equipment off, get those rings off before you bring them in because the issue is a burn is never going to get better immediately, within the first 24 hours. A burn that may look second degree now but will only get worse as time goes on over the 24 hours.
I was just teaching a class to an EMS group, and a lot of people forget, remember to elevate. That is a big, big deal. It resonates even when you have to get a destructive device because it goes back to the basics. You need to elevate to allow blood flow to go back to the heart, and if you don't do that then things are going to swell. It’s the same thing with burns, that is why I always elevate a hand and the same thing with ring removal because you want to get that fluid flowing back.
Q: What ring removal methods did you use before the Ring Rescue Compression Device?
String Wrap Method
A: We went really old school because an ambulance can only hold so much and you’re already holding a lot. From a viscous perspective, there’s not much we can keep on there, the main thing is the water soluble, K-Y jelly. So 9 times out of 10 we’ll be at someone's house and ask them if they have something more viscous than what we’ve got on the ambulance. They usually do have something like cooking oil, but then again, if they’ve already caused damage, our guys always have to be cautious of that. We’ve tried the tugging and pulling, the two technicians approach to help, and of course you’ve got the string or the band from the oxygen mask method.
The only time we really want to cut it is when it is an emergent, emergent, emergent perspective. But it is an unfortunate thing you have to do. I think the ones that hurt the most are that elderly female who has been married to her husband for 50 years, that's the ring you don't want to cut. That’s what keeps you up at night and hurts you. So if you can get it off by some other means, let me tell you the elation that that patient will have and admiration for you after saving that is remarkable. You’re able to save that memory for them.
Q: Is there any ring removal that stands out to you particularly?
A: I have had one that was bad; it was a hand crush issue that went into a machine. The gentleman not only crushed his finger but crushed the ring too and it came with a partial degloving because the ring buried into his skin and he didn’t even realize because the nerves were badly damaged. So as he pulled, the ring continued to bury in his skin. That alone was traumatic.
We had to take a moment to say “pause”. Because we didn’t even know what we were dealing with; the anatomy changed, there’s blood everywhere. We had to irrigate it and then still get the rest of his arm unstuck. That’s remarkable because we don’t know what metal we’re dealing with, what product we’re dealing with, and again, when you crush something, especially a metal and it gets super heated, it kind of fuses on itself and makes it harder to cut. We were having difficulty even gaining access to cut the ring. This is where we could’ve used something more engineered, if you will, to have a cutter that cuts through just about any metal. We had to pause and not do anything because that was beyond our scope at the time. We had to pass it off to the hospital and let them figure it out.
Q: What surprised you the most when you came across our Compression Device?
Ring Rescue Compression Device
A: I think my first feelings were “why didn’t I think of it?!” It’s so simple to think about a product that you use all the time, which is a blood pressure cuff, and then to have a simple solution that is already in that field. It takes someone with an outside perspective.
Then it was relieving to know that “oh my god, I can do this and not have to stress about it” and you can actually take a process to avoid someone having to take an ambulance trip or a ride to the hospital, which could cost exorbitant amounts of money for them them to get seen in an emergency department.
Q: If you were giving advice to your peers in the burn or EMS space, what would it be?
A: I think I would say, just pause, take a deep breath and do a size up like you would in any incident. Know what’s beyond your scope and what resources you have. And if you don't have the right resources, don’t further agitate. You want to sit there and really look at this because you could cause irreparable damage to someone’s finger if you continue to pull.
Even if you do or don’t have a Ring Rescue Device, you need to get a detailed history just like you would on a patient with cardiac issues. You need to find out; what have you done so far? What have you put on this finger? Is it just red? Is this your normal skin tone? Have they caused micro-abrasions to their skin that if we put something else on here, would it cause further damage? I think you need to ask those kinds of questions as a technician going in. And then finally, are you comfortable with your steps? And if not, then review it when you go through in taking this ring off. Pause and just know that time is going to be your friend in compressing this down.
Q: What space do you feel like the Compression Device has the best fit?
A: You look at it in different layers; from a prehospital perspective; I see it in EMS, I see it in Fire, Hospitals, etc.
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As I go across the country, as I get to travel, fire is blended with EMS. Out West you have a lot of fire based EMS, even some on the East Coast. Here in the South, you have some standalone EMS vs. fire and a lot of private agencies. I think it can be applicable in just about every arena because you don’t want multiple responders going to the same incident because that it’s a time wasting component.
EMS has a unique ability to have a lot of oversight that can sprint certain things out. From a fire perspective, this is almost a staple of any rescue unit.
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Obviously, for any hospital, I would think any ED [emergency department] could have a use, and anywhere that has outpatient surgeries because they’ve got to get the ring off before surgery.
Urgent Care would be another one that could have it because this is where we’ve educated the community, you don't need to go to the ED, you should try Urgent Care. They’d need these for sure. Finally, one that I didn't even think of in the process, but when showing people the device, is the mortuary side. I didn’t realize how much they struggle with this as well.
Q: Would you recommend the Ring Rescue Compression Device?
A: Oh yeah, absolutely. 100%. I think it’s just a new evolution. When you can ease the burden on your patient. An ambulance trip can cost, across the country, anywhere from in the lowest regions, $400 to $2,100 to step in the back of an ambulance. Is that going to be covered at all for ring removal? We don’t know. But the reality is, you needed the assistance.
If you can help your community stay at their house and fix their issue there, it then clears you off for another call to help another person in need. Those are major components.
From an EMS perspective, we’ve already recommended it to fire locally and every one of them says “why didn’t I think of this? We could’ve used this on this call or on that call”. And that’s from fire, EMS, hospital arenas. All of them have some story where they say “man I wish I had this”. It’s almost like a no-brainer to put it in your toolkit and have it, not a matter of if you’re going to need it, but when you’re going to need it.
Key Takeaways
Stuck ring cases tend to increase significantly during city events and celebratory times
Many EMS professionals don’t receive formal training for stuck ring removal. They use past experience and what they can find online
Each ring removal is different, you must go into it case by case and make sure you are assessing everything, especially the patient's history
A procedural approach in not only important for ring removal, but every process. It is important in EMS because it creates policies, procedures and builds a routine
Flores sees the Compression Device as an important tool for many areas; fire, EMS, hospitals, Urgent Care, surgery, Emergency Department and even mortuaries
Carl’s main advice is to know what is in your wheelhouse, what you are comfortable with and train on every topic
To watch the full interview, click the play buttons below.
Stuck in The Middle With You Episode 3, Part 1
Stuck in The Middle With You Episode 3, Part 2
