Tag Archives: EMS

General

The EMS Second IV In Trauma

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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.
General

Lack of EMS Documentation is Associated With Increased Mortality

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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.

General

Shift Work And Fatigue In Air Medical Crews

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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!

Related posts:

Reference: The effect of shift length on fatigue and cognitive performance in air medical providers. Prehosp Emerg Care (early online, 2013)

General

EMS: Do We Actually Follow the CDC Triage Guidelines?

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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!

Related posts:

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.

General

Trauma Patient Stability

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EMS in the field and physicians in the ED are faced with rapidly assigning some degree of stability to the patients they treat. What exactly are the shades of stability, and what considerations are there for each degree?

In my mind, there are three levels of “stability”:

  • Unstable – this one is easy to figure out. The patient has obvious physiologic compromise, which may be objective (low blood pressure, low GCS or poor neuro exam, etc) or subjective (just plain looks bad). 
    EMS: These patients need transport to an appropriate level trauma center (I or II) immediately. If they need airway control or IV access that can’t be obtained in the field, stop at the nearest Level III or IV for assist, then continue on your way FAST. 
    ED: These patient must be a trauma activation. If not activated as your top-tier trauma, activate or upgrade now! These patients must be seen by a trauma surgeon immediately, and can only go to the OR. No diagnostics outside the resuscitation room are allowed unless they can be converted into one of the two stability levels below.
  • Stable – this one is usually easy to figure out, too. These patients look good, have good vitals, and a low to moderate energy mechanism for their trauma. Look out for those few patients that may be hiding something like moderate bleeding into some body cavity.
    EMS: Follow your usual transport protocols to select the closest, appropriate hospital.
    ED: Follow your standard protocols for trauma activation if needed. Transport for standard imaging is fine.
  •  Metastable – this is a term I invented. It describes patients who have evidence of ongoing volume loss that can be controlled with infusion of crystalloid and/or blood products. It is possible to maintain a certainly level of stability using higher than normal volume infusions. This allows physicians to consider diagnostics or interventions outside of an OR.
    EMS: Ensure adequate IV access and give fluids and/or blood per your local protocols. Transport to a Level I or II trauma center as quickly as possible.
    ED: Activate or upgrade to your highest level of trauma activation. The trauma surgeon needs to be present to help direct diagnostics or interventions. These patients may go to CT, IR or other appropriate areas with nurse and physician accompaniment to diagnose and possibly treat bleeding. If the patient changes to unstable at any point, they must immediately be taken to the OR.