Tag Archives: EMS

General

Scoop and Run or Stay and Play for Trauma Care?

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Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?

For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?

Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%). 

Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!

Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.

Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?

A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.

Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.

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PulseCheck: Hot Topics In EMS Handout

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PulseCheck EMS logo

PulseCheck: Hot Topics in EMS is going on today at the Holiday Inn Select in Bloomington! The program includes TV anchor Don Shelby speaking on the evolution of Primary Service Areas in Minnesota.

I will be giving a presentation on pediatric trauma. This talk was added to the program on short notice, so no handout was available to participants. 

To download a copy of the slides I presented, click here.

General

EMS: Which Field Airways Work The Best?

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Oral endotracheal intubation is the gold standard when a field airway is needed. However, they are not always possible due to protocol, training, patient anatomy or specific injuries. To allow airway support in these situations, a number of techniques and devices have been developed. The problem is, do we really know which one(s) are best?

To try to answer this question, a huge meta-analysis of all the English literature with information on success rates for these techniques was carried out. Over 2000 papers were identified, and they were narrowed down to 35 studies involving over 10,000 patients. 

The success rates that they identified were as follows:

  • King LT airway – 96.5%
  • Esophageal Obturator / Esophageal Gastric Tube Airway – 92.6%
  • Surgical cricothyroidotomy – 90.5%
  • Laryngeal mask airway (LMA) 87.4%
  • Combitube – 85.4%
  • Pharyngeotrachael laryngeal airway (PTLA) – 82.1%
  • Needle cricothyroidotomy – 65.8%

The Bottom Line: The King airway has the highest success rate of the alternative airway devices, although there was less data available and the effectiveness of ventilation has not been worked out yet. The best percutaneous rescue airway was the surgical crich.

Reference: A Meta-Analysis of Prehospital Airway Control Techniques Part II: Alternative Airway Devices and Cricothyrotomy Success Rates. Prehospital Emergency Care 14(4):515-530, Oct-Dec 2010.

General

How Accurate is EMS at Estimating Blood Loss in the Field?

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EMS providers are the trauma professional’s eyes and ears when providing transportation from the scene of an accident. We rely on their assessment of the mechanism of injury and the amount of blood lost. We tend to believe in the accuracy of those assessments.

A study was carried out that tested EMS personnel on their ability to accurately estimate specific amounts of blood that were left at a simulated accident scene. The blood volumes tested were 500cc, 1000cc, 1500cc and 2100cc. A total of 92 professionals participated, and there was an even split into basic EMTs (34%), intermediate/critical care EMTs (33%) and paramedics (31%). Experience levels were as follows: 0-5 years 43%, 6-10 years 30%, >10 years 31%.

The results were as follows:

  • 87% underestimated the quantity of blood
  • 9% overestimated
  • 4% guessed the exact amount
  • Experience or credentialing level did not matter

Only 8% of the subjects were within 20% of the actual volume, and an additional 19% were within 50%. In general, most medics underestimated the amount of blood lost, and their guesses were worse with higher volumes. The median guess for the 2100cc loss group was only 700cc!

EMS Blood Loss Estimates

The bottom line: Visual estimates of blood loss are extremely inaccurate, and are most likely  underestimates. Physicians in the ED should rely on exam and physiology to help determine the amount of blood loss. For safe measure, multiply the reported blood loss of the EMT or paramedic by 2 or 3 to get a realistic number.

Reference: Patton et al. Accuracy of Estimation of External Blood Loss by EMS Personnel. J Trauma 50(5), 914, 2001.

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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

The 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.