Does anyone carry a thermometer on their bus?

[Hellsbells]

Originally Posted by zmedic
Pediatric fever- In most places medics can't give tylenol or Motrin

Yep we give tylenol to peds in Canada too

Otherwise it is just increasing cost and distracting from other core tasks (repeat vital signs, finishing paperwork in a timely fashion, gathering additional history.)

Yes, of course the 5-10 seconds it takes to get a temp is a great distraction to pt care, and in no way could be considered part of a competent assesment or related to their history.

 

[usalsfyre]

Again I think those temps should rectal, which I'm not sure is so fesible in the field. Also I'd like to see some data that a prehospital temp is going to reduce time to antibiotic administration. I think in most cases there should be signs of sepsis like tachycardia or altered mental status that would clue one in to the possible diagnosis. Also I wonder if people will be falsely reassure by a prehospital temp.

Now there may be a role for it in the field, but I want to see some good data before I'd recommend if for widespread usage.

I believe it's being looked at here.

 

[zmedic]

Like I said in my post, I was talking about in the US. We don't leave people at home unless they refuse. Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital? And if the kid doesn't need to be transported, the parents should have tylenol or motrin at home. If they don't, well what does one dose really do? They would need to come in for a script and a parenting lesson.

You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.

The cost is a big thing. Especially if you are advocating putting an electronic thermometer on every ambulance in america. Which the medical device companies would love. I can think of all kinds of things that would be cool to have on the ambulance. I'm sure that I could come up with arguments about how they could maybe help, but I think we need to get to the point where evidence comes first, then widespread implementation. How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)

 

[medic417]

How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)

Done and done. Yes every ambulance should have them.

 

[ffemt8978]

You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.

The cost is a big thing. Especially if you are advocating putting an electronic thermometer on every ambulance in america. Which the medical device companies would love. I can think of all kinds of things that would be cool to have on the ambulance. I'm sure that I could come up with arguments about how they could maybe help, but I think we need to get to the point where evidence comes first, then widespread implementation. How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)

What about the rural services with hour long transport times? While I agree that having a temp won't change my treatment plan, I still think the trend of patient's vital signs (including temp) is important information to give to the hospital. We usually end up delivering a patient to the ER with at least six sets of VS taken during transport.

 

[Aidey]

I still maintain that if sepsis alerts get implemented thermometers would be beneficial. I do agree there there is not an overwhelming amount of evidence to support their use now.

If I get started on my peak flow rant we'll never get back on track. I've never understood why we don't use them.

 

[Hellsbells]

Like I said in my post, I was talking about in the US. We don't leave people at home unless they refuse. Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital? And if the kid doesn't need to be transported, the parents should have tylenol or motrin at home. If they don't, well what does one dose really do? They would need to come in for a script and a parenting lesson.

I don't really understand why you are against having thermometers in ambulances, honestly, the cost would be quite negligable to have them in every ambulance in the US. If giving antipyretics doesn't result in improved outcomes, as you say, then why even give it to children in the emerg dept? My way of thinking, is that if you begin drug admin enroute, it decreases the workload on staff at the hospital. Furthermore, we can give a dose of tylenol at home, and direct the parents to buy OTC childrens tylenol, and prevent an unessesary trip to the ER.

You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.

I can, and will, because it doesn't. This is a procedure that takes literally seconds, this argument is bizarre to me quite frankly.

 

[usalsfyre]

Like I said in my post, I was talking about in the US. We don't leave people at home unless they refuse. Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital? And if the kid doesn't need to be transported, the parents should have tylenol or motrin at home. If they don't, well what does one dose really do? They would need to come in for a script and a parenting lesson.

You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.

The cost is a big thing. Especially if you are advocating putting an electronic thermometer on every ambulance in america. Which the medical device companies would love. I can think of all kinds of things that would be cool to have on the ambulance. I'm sure that I could come up with arguments about how they could maybe help, but I think we need to get to the point where evidence comes first, then widespread implementation. How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)

I had a snarky response, typed up, but thought the better of it. Suffice to say this, unless you are intimately familiar with the specifics of how a chart shows up on your doorstep (including how if the software interface makes any sense and the technology factors involved in moving the chart there) then it's a bit inappropriate to tell EMS to have their charts finished at your convenience. It would be similar to me saying "quit doing anything else until you finish the chart I need to transfer this patient out".

I've noticed a "just get the patient here so I can work my magic" theme in many of your post. Field implementation of certain things makes sense. If you don't trust your providers to appropriately manage patients, perhaps you should work on improving that aspect. I pointed you to ongoing research about sepsis protocols in the US. I'm told by physicians familiar, if not directly involved with, that research that that research they are seeing significant reductions in time to antibiotic administration and appropriate resuscitation. Granted these are surrogate measures and final data remains to be seen.

 

[abckidsmom]

What about the rural services with hour long transport times? While I agree that having a temp won't change my treatment plan, I still think the trend of patient's vital signs (including temp) is important information to give to the hospital. We usually end up delivering a patient to the ER with at least six sets of VS taken during transport.

Us too. And when a febrile patient decides (wink wink nudge nudge) to take tylenol on the scene, our vitals show a break in the fever with antipyretic.

Still working on getting a fever/sepsis protocol so I don't have to feel nervous at all.

 

[medic417]

I don't really understand why you are against having thermometers in ambulances, honestly, the cost would be quite negligable to have them in every ambulance in the US. If giving antipyretics doesn't result in improved outcomes, as you say, then why even give it to children in the emerg dept? My way of thinking, is that if you begin drug admin enroute, it decreases the workload on staff at the hospital. Furthermore, we can give a dose of tylenol at home, and direct the parents to buy OTC childrens tylenol, and prevent an unessesary trip to the ER.



I can, and will, because it doesn't. This is a procedure that takes literally seconds, this argument is bizarre to me quite frankly.

I am really questioning whether he is a doctor even. If so seems has not been exposed to much besides his local area.

 

[R99]

I am really questioning whether he is a doctor even..

he's probably a house surgeon or something lol

and you can't leave people at home wtf so u transport everybody?

 

[zmedic]

Wow. Getting personal.

I'm not going to go into my personal experience, because why would you believe it anyway. I think you should ask yourself "would this guy be hanging out on an EMS forum if he wasn't interested in EMS." And if you don't think I'm an MD, look at my other posts and decide if I know what I'm talking about or not. To address some of your points.

1. Research. I trust it when it's done and shows good results. I don't really care about studies that are under way, or analysis done partway through a study. I'll read a study when it is completed and the data is in. Don't care what people are planning to prove.

2. Again. I'm writing from the perspective of the US. What medics do in England/NZ/Australia has nothing to do with what I'm saying. In other countries where you can leave the patients at home is a different story. Or if you are starting antibiotics enroute. Doesn't apply to US medics with a different level of training and different protocols.

3: Trending temps. We don't even do that in the ER. Are you really advocating checking temps multiple times during a transport?

4: Prehospital ultrasound is another rant. Just don't have the energy to deal with it.

5. Directing parents to get over the counter tylenol. I work in an area where people come to the ER to get prescriptions for Motrin so medicaid will pay for it. And giving them tylenol so their fever breaks doesn't improve the outcome, so don't see how there should be any push to giving it earlier. I think giving people things from the ambulance they should be buying over the counter just encourages them to call 911 for crap. Furthermore, there is some evidence that you have a fever so that your immune system works better. Kids the advantage to giving tylenol is that they are less cranky, not life and death.

6. I'm certainly not a "get them to the ER so I can work my magic person." I'm a "only do things in the field that will make the patient feel better or improve outcomes" person. There are plenty of things that seemed logical, but were removed from protocol because they didn't work. MAST pants anyone?

7: Charting. Yes I understand other things come first. Like patient care. But EMS makes a big deal of "we're gathering all this data for the hospital." If that data doesn't get transmitted to the docs and nurses in a timely fashion, it's as if it was never really collected. Now you can argue "anything important is communicated verbally," but having the run form helps. Sure, taking a temp doesn't take that much time. But you add 30 seconds here to a call, 30 seconds there, and it adds up. Like starting an IV in trauma. Every medic tells me that they aren't the ones who are delaying transport in trauma. That they can intubate in seconds without stopping compressions during CPR. Yet the data says it adds time.

 

[zmedic]

he's probably a house surgeon or something lol

and you can't leave people at home wtf so u transport everybody?

Murphy's law in the US. You tell someone they don't need to go to the hospital you get sued. The best you can do in the vast majority of places here is say "we are happy to take you to the hospital, which we recommend. Now if you want to stay at home and call your doctor that's fine just sign this refusal that says you can die if we leave you here."

Does it makes sense? No. But if someone calls 911 and says they want to go to the hospital we take them. God help the medic that doesn't.

 

[ffemt8978]

Wow. Getting personal.

Agreed, and suffice to say it has not escaped my attention.

 

[BandageBrigade]

Please dont take offense

But...
Zmedic you are not and cannot be writing from a perspective of every system in the US. You obviously have no idea how many systems are run. We carry both temporal and rectal thermometers in all of our ambulances. Temperature is a good aide/indicator for many therapies, such as active rewarming techniques (like using a bear hugger, which we carry). Ever hear of paramedic initiated refusals? Treat and release? We do them, as do many other services in the US, including several of the services that members of this forum are on. We draw labs (including cultures) on many of our patients. My report is not done for or at your convenience. We have a policy of when they must be completed by. If there is any information you need about care I provided, you can ask when I give report. Otherwise all ERs have my work number.

 

[zmedic]

I agree that I don't speak for everyone in the US. But I've worked in several states and give my perspective based on that.

From the research I've seen at conferences it seemed that when studied paramedic initiated refusal lead to about 10% of refusals that should have been transported to the ER, and my understanding is that not many places were still doing that.

I understand that many places use thermometers on the ambulances. I'm asking if it's needed. I'm happy to be convinced that it is. Haven't been so far. The example that you gave of active rewarming. Are these patients that you had no idea were cold until they had a subnormal temp? Ie if they are awake they should be able to tell you they are cold. If they are altered and are found in just about any temp bellow 68 degrees they probably would benefit from some level of warming. Homeless patient outside in November? Needs warming. Again, I'm willing to be convinced. If data is out there that prehospital temperatures lead to early identification of sepsis and therefore earlier fluid administration and better outcomes I'd say let's do it. But I want to know if there are other effects. Are people going lights and siren to the hospital because they get a temp of 100.2 in an otherwise stable patient? Are there people who are being falsely reassured that the patient with a temp of 98.9 and a HR of 102 isn't septic? Does BLS need to be taking temps if they aren't going to be giving fluids to these sepsis patients? What is the false alarm rate of the sepsis notification policy?

Speaking of costs, do we need a Bear hugger on every ambulance? I'm sure the company that makes those heaters and those disposible blankets think so. But it's a lot of money compared to turning up the heat in the ambulance and putting on 5 blankets.

To the forms. Yeah, I understand that it can't always be done by the time that you hit the door. But when I'm riding and I've done my assessment, done my treatment, done that second set of vitals, I'm writing so as much of the form is done as possible when I get there. At the big ERs like where I work now and where I've dropped off patients on the bus, the MD isn't sitting in the room listening to the report unless it's a critical patient or trauma. The RN gets the report. Sure I should be there for every patient that gets dropped off, but the truth is I tend to have 5-6 other patients I'm working on at the same time.

And it's great you work in a small enough area that the ER has your number. But you want to know what it takes to get in touch with one of the FDNY units? Especially when the nurse doesn't write down their unit number? I'm just saying EMS collects a lot of info that nobody actually reads because it doesn't get matched up to the patient's chart until most of the diagnosis and treatment has already happened.

 

[zmedic]

Speaking of costs, do we need a Bear hugger on every ambulance? I'm sure the company that makes those heaters and those disposible blankets think so. But it's a lot of money compared to turning up the heat in the ambulance and putting on 5 blankets. There are how many ambulances in the US?
http://www.the-aaa.org/media/ambulance_facts.html
they say about 48,000. So something like a bear hugger is about $500 used for the OR style ones (I'm sure the portable ones are cheaper but lets say $100? That's some big bucks to put on every ambulance. I know thermometers are cheap compared to a lot of medical equipment. I'm seeing about $15 online. So $720,000 to put one on every ambulance. If it helps outcomes, great. But a few dollars here, a few dollars there really add up to healthcare costs.

That was one of the big advantages to hospitals. They brought a lot of equipment that docs needed in one place and that saved money. So instead of every doctor needed a x-ray machine, and a lab etc there was a common one to use. Putting hospital type equipment out in the field goes in the other direction. If it helps by providing needed care earlier wonderful. But if not, don't do it. (I know I said I wouldn't go into ultrasound, but you want to figure out what it costs to put a $12000 ultrasound on every ALS ambulance in America?)

 

[BandageBrigade]

There is very little you just posted that I can or want to refute. Regarding temps and active rewarming, we do step increments in active rewarming, so as not to rewarm to fast or to warm, therefore temps are obtained. Did I know these patients were cold and needed rearmed? Absolutly. Would blankets and the heater get the job done? Eventually, sure, but not as efficient as I'd like it to be. Any patient that is RSI'd gets temps recorded, preferably repeat ones. Would you be able to catch malignant hyperthermia with temps? You'd better, but it's nice to have. Can you tell your patient is having difficulty breathing without a pulse ox? Yes, but its still nice to have. Regarding the cost of a bear hugger, well we participate in lots of studies and trials for rural medicine and receive lots of grants through it.

Every treat and release or paramedic initiated refusal is reviewed by the medical director and our QA/QI supervisor does a follow up with each of these patients.

We use Med-Media EmStat 5 for charting, unfortunitly the way it is setup it must be logged in and connect to our system to close out the report. It is very unfortunate that you cannot easily contact field staff, especially for patient care questions. We are provided a work cell phone specifically for this (down side is you have no reason not to answer when work calls you in).

 

[BandageBrigade]

Also - I can't believe that your nurses don't write down a unit number or name. The nurse always takes my name, and I hers, as well as the doctors name who is taking the patient. It is considered standard practise here.

 

[systemet]

Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital?

* Seems like a nice thing for the child. Reduces their discomfort and suffering.

* May prevent recurrence of a febrile seizure in a child with previous seizures.

* May prevent a child without a history of febrile seizures having their first?

Please correct me if any of these points are incorrect. There's a lot I don't know, especially about peds, and I'm happy to be educated. Wouldn't an antipyretic also be of benefit if there's a more serious underlying pathology, like meningococcemia? Just wondering?

You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.

Why does it matter if it add time to patient care if the patient isn't critical and time-dependent? And why should paperwork be prioritised over patient care?

How about ultrasound on every ambulance?

Here I think we need to show that it's useful. That it allows us to identify a subgroup of patients who might otherwise wait in a triage area but that need emergent surgery.

It seems like it's useful in the ED, in more skilled hands. I think we need to evaluate whether paramedics can use US effectively, and whether it improves outcomes. I think people are currently doing this.

You mentioned in another post that you have strong opinions about this. I'd like to hear them, it could be an interesting conversation.

Peak flow meters for asthma? (Whole other discussions)

This would be great, although now pretty much everyone who looks half sick gets dexamethasone or prednisone. It might help us avoid doing this unnecessarily.