Tag Archives: prehospital

The Prehospital “Nonstandard Patient Position” Sign

Prehospital providers follow protocols for securing and transporting trauma patients. These may include cervical spine stabilization and short or long backboards. Every once in a while they can’t follow protocol, and in my experience it usually means that something is very wrong. 

There are three typical problems leading to nonstandard transport positions:

  • Occult airway injury – These patients have either blunt injury to the neck, smoke inhalation, or penetrating injury to the submandibular area. They tend to have problems protecting their own airway when they are supine, so they insist on being transported in an upright position.
  • Impalement – Since the general rule is to leave foreign objects in place to avoid potential bleeding, the patient is positioned in an odd way to accommodate both them and the impaling object. 
  • Life-threatening bleeding – Patients with exsanguinating hemorrhage who are awake tend to insist on transport in certain positions. Most with serious chest hemorrhage complain that they can’t breathe and want to sit upright. Those with severe pelvic fractures complain of pelvic or back pain and may prefer lying on their side during transport.

Bottom line: If prehospital providers bring a trauma patient to you in a non-supine position, be very afraid. If not done already, activate your trauma team. Talk to the medics to find out why they had to use a nonstandard position. Then rapidly assess the patient to rule out life-threatening issues.


Related posts:

Prehospital Attitudes About Analgesia

Pain relief is important for two reasons: it’s the humane thing to do for someone who is suffering, and just as importantly, it assists in the physiologic response to trauma. There are several papers that have shown that prehospital providers may not use pain medications as much as they should. Why would this be?

Researchers at Yale released a paper describing a number of interviews with prehospital providers to get the answers to this question. They did individual and group interviews with five EMS agencies in the states of New Hampshire, Massachusetts and Connecticut. Eight individual and 2 group interviews were conducted, with a total of 15 paramedics in the study.

The results were very interesting and several themes emerged:

  • There was a reluctance to give opioids unless objective signs were present (deformity, hypertension)
  • There was a preoccupation that patients might be malingering
  • Paramedics were not clear on what the pain control target should be (complete relief vs “taking the edge off”)
  • Fear of masking symptoms with pain medicine
  • Reluctance to use large doses (e.g. using no more than 5mg morphine)

Bottom line: This study is very small, which is a problem. But it also used face to face interviews, so a lot of information was obtained. It’s hard to say if this work is representative of other agencies or countries, but it is thought provoking. My take is this: trauma hurts like hell. Patients really do need the medication. And they are not going to get addicted from a few doses while enroute to the hospital. Whether the cause of their injury was truly accidental or the result of poor choices, it’s not our place to judge because we don’t know the full story. Give pain medication and be generous. You’re not going to make the symptoms go away. But do use judgment to make sure they keep breathing all the way to the emergency department.

I’m very interested in EMS comments about this study. Please comment or tweet!

Reference: Paramedic attitudes regarding prehospital analgesia. Prehospital emergency care; Online ahead of print, Sep 2012.

The EMS Second IV In Trauma

One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?

The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.

The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?

A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.

Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.

Reference:

  • Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.

The EMS Second IV In Trauma

One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?

The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.

The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?

A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.

Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.

Reference:

  • Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.

Prehospital Lift-Assist Calls

Here’s something I was completely unaware of until just a few years ago. A number of 9-1-1 calls (quite a few, I am told) are made, not for injury or illness, but because the caller needs help getting back into bed, chair, etc. It is also common that prehospital providers are frequently called back to the same location for the same problem, or a more serious one, within hours or days.

Yet another study from Yale looked at the details of lift-assist calls in one city in Connecticut (population 29,000) during a 6 year period. The town has a fire department based EMS system with both basic and advanced life support, and they respond to 4,000 EMS calls per year. 

Some interesting results:

  • Average crew time was about 20 minutes
  • 10% of cases required additional fire department equipment, either for forced entry or for assistance with bariatric patients
  • About 5% of all calls were for lift-assist, involving 535 addresses
  • Two thirds of all calls went to one third of those addresses (174 addresses)
  • There were 563 return calls to the same address within 30 days (usual age ~ 80)
  • Return calls were for another lift-assist (39%), a fall (8%), or an illness (47%)

Bottom line: It looks to me that we are not doing our elderly patients any favors by picking them up and putting them back in their chair/bed. Lift-assist calls are really a sentinel event for someone that is getting sick or who has crossed the threshold from being able to live independently to someone who needs a little more help (assisted living, etc). Prehospital personnel should systematically look at and report the home environment, and communities should automatically involve social services to help ensure the health and well being of the elder. And a second call to the same location should mandate a medical evaluation in an ED before return to the home.

Reference: A descriptive study of the “lift-assist” call. Prehospital Emergency Care, online ahead of print, September 2012.