Over a year ago, I wrote about a product called LifeBot. This technology provides a way to join the ED and prehospital teams as they work on patients. This involves special monitoring equipment in the ambulance (cameras and other telemedicine equipment), a special tablet computing system for data input and imaging, and equipment at the ED base station.
Using the original LifeBot system, medics could relay vitals and EKG data to the base station in real time, receive orders from emergency physicians, and send video feeds and photos from the ambulance.
LifeBot Technology has now released LifeBot 5, the next generation of this system. The unit is now portable, and can be taken out of the ambulance at the scene. It is ruggedized and weighs only 15 pounds, which isn’t bad for field medical equipment. The system now includes a web interface that can mesh with some electronic medical record systems.
Expect to see more improvements (a defibrillator is slated as the next addition) as well as competing products soon.
What does it cost, you ask? A lot! As always, it’s tough to get exact numbers. The LifeBot 5 should be about $20,000. However, this does not include equipment cost for the base station, which is at least that much, if not more!
Bottom line: Expect further progress in blending the prehospital and emergency department environments. More products like this will become available, extending the senses of emergency physicians and providing additional assistance to prehospital providers.
Related post: The “super ambulance” of the future
Disclosure: I have no financial interest in Lifebot Technology
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.
- Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.
EMS policy and the trauma center verification process requires that all trauma patients delivered to a trauma center must have a copy of the EMS run sheet. Two parameters that are commonly used to monitor performance improvement (PI) in EMS are:
- accurate record of scene physiology (SBP, HR, RR, GCS)
- request by on-scene BLS for ALS assistance
A study looked at the impact of those criteria on patient survival. A total of 4744 patients from the National Trauma Data Bank were analyzed.
Physiologic data: About 28% had at least one missing physiologic data point, with respiratory rate being most commonly missed. They found that the mortality in the group with missing data was over twice as high (10.3%) as it was in the group with complete date (4.5%).
BLS call for ALS assistance: This assist was called for in 17% of cases. These cases were less likely to involve penetrating injuries and more likely to involve car or motorcycle crashes. Injury Severity Score was the same. Eventual patient mortality was the same for BLS calling ALS and ALS response alone.
So why does failure to record physiologic data translate into higher mortality? The initial response may be that the patient was sicker, and so they needed more intense care during transport with less time to record vitals. However, the researchers controlled for this and found it was not a factor. Other issues that may be a factor are EMS training and proficiency, leadership at the scene and enroute, and available staff and resources, among other things.
The researchers speculate that documentation might be a good global measure of appropriate or inappropriate prehospital care that rolls all of these possible factors into one easily identifiable audit filter. They recommend that this be used to focus performance improvement efforts and hopefully improve survival.
I recommend that the results of this study be taken to heart and used to help persuade EMS programs to get religious about recording complete vital signs and leaving the run sheet at the trauma center every time a patient is delivered. Documentation should be evaluated regularly, and all cases with any missing vital signs should be reviewed closely. Trauma Center PI programs should work with EMS to analyze this data and look for the patterns that increase mortality.
Reference: Lack of Emergency Medical Services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons, 210(2):220-227, 2010.
Most trauma professionals are shift workers to one degree or another. It is well documented that sleep problems and fatigue can occur with this type of work, depending on the structure of the shift. A number of studies have been carried out in physicians and prehospital providers. But what about prehospital air crews?
Air medical providers are faced with two challenges: critically ill and injured patients and a challenging work environment. Typically, work consists of 12 or 24 hour shifts, and all of this is conducive to sleep problems and fatigue.
The University of Pittsburgh looked at this problem, performing a battery of questionnaires and cognitive tests in their air medical service before and after each shift. They studied 37 subjects, and found the following interesting tidbits:
- 95% of all crew members had poor baseline sleep quality
- Fatigue levels decreased over the shift (both 12 and 24 hr)!
- Crews were able to get some sleep while on duty (1 hour in a 12 hour shift, 7 hours in a 24 hour shift)
- There was a mild increase in cognitive test performance at the end of the shift, although it was not statistically significant
Bottom line: Don’t anyone try to generalize these results to all flight crews! This was a sample of a single flight service, and is not necessarily representative of others. Poor baseline sleep quality is likely due to the fact that many flight nurses and paramedics hold other jobs. In this particular case, the decreasing fatigue may simply be due to the fact that they are encouraged to get some rest while on duty and actually do it. Make sure that your agency has fatigue reducing and fatigue avoidance policies and procedures. It’s for your safety as well as your patient’s!
Reference: The effect of shift length on fatigue and cognitive performance in air medical providers. Prehosp Emerg Care (early online, 2013)
One of the major components of any trauma system is the prehospital piece. These providers extricate, begin medical treatment, and decide where to take the patient. The choice of hospital can make a big difference, and the number of deaths can potentially be reduced by up to 25% by making the right decision. Where to take the patient is not necessarily clear cut, even though CDC guidelines exist to help. Geographic and weather factors can be a factor, as well as patient choice at times (unfortunately), local medical control, or even time of day (traffic).
Harborview and the University of Washington conducted a large retrospective review of the transport patterns for nearly 12,000 injured patients over a 5 year period. They specifically looked at whether CDC guidelines for field triage were being followed. About half were transported to Harborview, the only Level I center in the state. The remainder were transported to the 7 remaining trauma centers, levels III to V. There were a number of interesting findings:
- Patients transported directly to the Level I center were more likely to be young, male, injured by a penetrating mechanism, have worse vital signs and GCS and higher injury severity
- Older patients were less likely to be transported from scene to a Level I center
- The oldest patients were 89% less likely to be transported to the Level I center, either directly or after initial management at a lower level center
Bottom line: For reasons that are not clear, elderly patients were far less likely to be transported to a Level I trauma center by prehospital providers in Washington state. In fact, the guidelines were obeyed only about 50% of the time! Does this happen in other states or countries? We don’t know. Is this a problem? Unfortunately, we also don’t know how much lower the mortality in these patients is when treated at higher level centers. It seems to be, especially in the more severely injured patients. What we do know is that if the guidelines exist, adhere to them unless you have good reason not to. Their life may depend on it!
Reference: Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Amer Col Surg 215(1):148-156, 2012.