# iStat



## luke_31 (Mar 28, 2017)

Anybody using iStats in the field?  We are getting them to run chem 8s on the off chance that our patient is hyponatremic.  Curious to see how durable the device is in the back of the ambulance and if anyone has had problems with getting them to work while bouncing down the road.


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## dutemplar (Mar 28, 2017)

Uhm, I've used some elsewhere but not here.  Designed for field use, so it wasn't bad but if you're off-roading insanely it can probably be an issue.  My use for them was USAR and also prolonged field care in very forward deployed positions.

You're using a $11,000 machine and $25 test to check everyone on the offhance that someone is hyponatremic?


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## TransportJockey (Mar 28, 2017)

Used it in WesternTexas. We didn't ever have any issues with it. We carried chem 8, lactate, and troponin cartridges

Sent from my SM-N920P using Tapatalk


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## Summit (Mar 28, 2017)

Why look for random hyponatremia? What are you going to do about it?


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## EpiEMS (Mar 28, 2017)

Summit said:


> Why look for random hyponatremia? What are you going to do about it?



If it's acute, can't hypertonic saline be administered? Not sure if anybody carries it, though.


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## MonkeyArrow (Mar 28, 2017)

Summit said:


> Why look for random hyponatremia? What are you going to do about it?


Push sodium bicarb, although that would have to be a gutsy protocol.


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## luke_31 (Mar 28, 2017)

We are going to be carrying hypertonic saline.  We've had hyponatremic patients and the thought process above us is to try and identify it faster, as some of our transports can be twenty to thirty minutes, so they want the treatment started ASAP once identified.  We have some pretty roagh terrain that we ride on and use improvised roads to get to patients.  I think it's a little bit overboard but it's not our call to be doing this, so we have no choice but to go along with it.


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## luke_31 (Mar 28, 2017)

MonkeyArrow said:


> Push sodium bicarb, although that would have to be a gusty protocol.


Our medical director is actually considering that instead of hypertonic saline after one of our paramedics brought it up.


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## E tank (Mar 28, 2017)

luke_31 said:


> Our medical director is actually considering that instead of hypertonic saline after one of our paramedics brought it up.



NaHCO3 works pretty well, is fast and really convenient.

 As to the iStat, the lab lady tells us that once the cartridge is placed and the start button pressed, the whole unit shouldn't be touched at all because motion artifact can somehow cause an error. I think I've seen that once or twice where I have to start all over (don't get rid of the blood you draw). Set it down, start it and don't touch it. The smoother the ride the better, stopped is best, IME


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## luke_31 (Mar 28, 2017)

E tank said:


> NaHCO3 works pretty well, is fast and really convenient.
> 
> As to the iStat, the lab lady tells us that once the cartridge is placed and the start button pressed, the whole unit shouldn't be touched at all because motion artifact can somehow cause an error. I think I've seen that once or twice where I have to start all over (don't get rid of the blood you draw). Set it down, start it and don't touch it. The smoother the ride the better, stopped is best, IME


Thanks, good advice on keeping the blood draw. We already have the blood tubes in the trucks and are doing the in-service with the manufacturer and the hospital this week.  They are looking to get us in the field with them in the next week or two.  The no movement issue will be fun though, we have a protocol for heat injuries that involves getting the patient to the hospital in ten minutes, sort of like trauma patients, but it's not all that realistic as some locations are much further away. Guess starting the iStat before transport will probably be a good thing to do.


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## VFlutter (Mar 28, 2017)

Unless they are actively seizing I do not really see a point in treating hyponatremia in the field.


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## luke_31 (Mar 28, 2017)

Chase said:


> Unless they are actively seizing I do not really see a point in treating hyponatremia in the field.


Very true, our protocol will be to call for orders before treating the hyponatremia. I think in the end this will end up being more for our ER benefit, rather then us treating, as it's more then likely we will be at the ER before he test finishes.


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## hometownmedic5 (Mar 28, 2017)

So they spent the money to write a protocol, buy the gear and train the people; and they made it a mother may I protocol?

:smh:


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## luke_31 (Mar 28, 2017)

hometownmedic5 said:


> So they spent the money to write a protocol, buy the gear and train the people; and they made it a mother may I protocol?
> 
> :smh:


Yup, one of the few drugs that we need to call for orders on.  Except they made us use our budget to purchase the devices and now we are over budget for the year and only half way through the budget cycle.   95% of our calls all we do is notify the ER of what we are bringing them.  We have pretty liberal protocols and if we want to use one of the drugs outside of protocol all we do is contact the ER doc for permission which is rarely denied.


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## E tank (Mar 28, 2017)

luke_31 said:


> Very true, our protocol will be to call for orders before treating the hyponatremia. I think in the end this will end up being more for our ER benefit, rather then us treating, as it's more then likely we will be at the ER before he test finishes.



And if its really out of whack, they'll just repeat it.


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## luke_31 (Mar 28, 2017)

E tank said:


> And if its really out of whack, they'll just repeat it.


Maybe, they have the same iStat machine in the ER.


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## Summit (Mar 28, 2017)

Hyponatremia should make you ask "WHY" and "HOW LONG" not react with "OMG FIX A LAB VALUE" unless:



Chase said:


> Unless they are actively seizing I do not really see a point in treating hyponatremia in the field.


EXACTLY


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## VentMonkey (Mar 28, 2017)

Chase said:


> Unless they are actively seizing I do not really see a point in treating hyponatremia in the field.





Summit said:


> EXACTLY


Right, but most ground paramedics won't/ don't carry HNS, so again, how will they _stop_ the sz?


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## luke_31 (Mar 28, 2017)

Summit said:


> Hyponatremia should make you ask "WHY" and "HOW LONG" not react with "OMG FIX A LAB VALUE" unless:
> 
> 
> EXACTLY


Our protocol to test sodium levels doesn't go into effect unless they are altered and there is no other identifying cause. We had a real bad hyponatermic patient that ended up dying and this is one of the solutions to try and avoid the situation again. The possibility of this happening again is likely as we are dealing with a very healthy athletic population that can overdue the fluid intake without having enough sodium in the diet to counter all the water they intake.


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## Summit (Mar 28, 2017)

iStats have purpose in the field... randomly screening for hyponatremia is NOT one of them. I think they are useful in long rural transport times... like 45mins... maybe driving a transport decision... or identifying the cause of a code... or terminating a code on K+... or on a CC IFT...

Hyponatremia? Was this something someone thought up to get a grant to buy these devices?

Honestly, I wouldn't trust lab values from an iStat that ran in a moving ambulance. Your receiving facility won't.



VentMonkey said:


> Right, but most ground paramedics won't/ don't carry HNS, so again, how will they _stop_ the sz?


Apart from your other tools to stop muscle activity, give NS unless contraindicated. It will raise SerumNa. Your receiving facility might anyways. Bicarb.

Think about the various etiologies behind hyponatremia... is this SIADH? Post op? CHF? Cirrhosis? Overhydration?

We don't want to raise Na very fast unless we know it was acute. Who can name the complication we are worried about here?


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## VentMonkey (Mar 28, 2017)

@luke_31 are you guys going to be carrying HNS at your service as well? That's interesting that it's a priority demographic in your region.

Keep us posted on the results.


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## VFlutter (Mar 28, 2017)

I guess the unfortunate answer is there is nothing they can do about it. You can stop the motor activity but nothing will likely touch the actual EEG activity until sodium levels are increased. So some sodium bicarbonate may help in that situation were nothing else is avaible and it is a long transport. 

Just like everything in medicine it is risk vs benefit. IMO the risk of over-correcting sodium outweighs the benefit in most situations excluding status seizures. Having seen a true case of CPM, it's something I wouldn't wish on anyone. And seeing as many physicians have a hard time correctly replacing sodium in the acute setting I do not think it is something that should be messed with prehospital.


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## VentMonkey (Mar 28, 2017)

@Summit admittedly I had to google-fu CPM, so thanks for sharing.

Also, as far as DI, and SIADH how often are you all ICU's nurses seeing this in-hospital? Are there any major pointers aside from an acute perception of the patients medical history to tip prehospital folks off?

I find endocrine disorders remarkably fascinating and can't help but wonder how often they're missed by us out-of-hospital folks.

And just 'cuz it's fun to say...pheocromocytoma anyone?


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## Summit (Mar 28, 2017)

Admitted an SIADH the other s/p TBI... although usually that's with more severe head injuries. DI is not a rare inpatient


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## VentMonkey (Mar 28, 2017)

Summit said:


> *Admitted an SIADH the other s/p TBI*... although usually that's with more severe head injuries. DI is not a rare inpatient


Talk about complex medical cases. This is what I refer to when I say oftentimes the "critical trauma" Mongo brags about bringing in ends up way sicker from the physiological cascade of no-goodness that unfolds in-hospital more often than not; it's sad, really.

Keep bragging, Mongo, keep bragging, anyhoo...

Also, for any paramedics who want to learn, and/ or enjoy a good puzzler I would recommend looking these patient-types up; you may realize you've ran one.


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## Summit (Mar 28, 2017)

This patient wasn't that sick... that is what made it unusual. They went home... then developed SIADH... and back they came!


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## VFlutter (Mar 28, 2017)

VentMonkey said:


> @Summit
> And just 'cuz it's fun to say...pheocromocytoma anyone?



Pretty rare but I have seen a few. Awesome pathophysiology.


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## Eden (Mar 28, 2017)

VentMonkey said:


> @Summit admittedly I had to google-fu CPM, so thanks for sharing.
> 
> Also, as far as DI, and SIADH how often are you all ICU's nurses seeing this in-hospital? Are there any major pointers aside from an acute perception of the patients medical history to tip prehospital folks off?
> 
> ...


My fav contraindication.


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## luke_31 (Mar 28, 2017)

Summit said:


> iStats have purpose in the field... randomly screening for hyponatremia is NOT one of them. I think they are useful in long rural transport times... like 45mins... maybe driving a transport decision... or identifying the cause of a code... or terminating a code on K+... or on a CC IFT...
> 
> Hyponatremia? Was this something someone thought up to get a grant to buy these devices?
> 
> ...


No grant money, we are a federal agency so it just comes out of the overall budget for supplies.


VentMonkey said:


> @luke_31 are you guys going to be carrying HNS at your service as well? That's interesting that it's a priority demographic in your region.
> 
> Keep us posted on the results.


We currently are planning on carrying 3% saline, but it may change to Sodium Bicarbonate instead in the protocol.  We have a unique demographic for most of our patient population being military and on a training installation.  We see some things that most others don't see on a regular basis, but the reverse is true too.  Most common complaints like chest pain and true SOB calls are less likely for us.  We also do a lot of rectal temp monitoring for our heat patients and have chilled saline and iced sheets to cool patients.  Will definitely update once we start the protocol and how the iStat machines handle in the field.  Some of the "roads" we go down are nothing more than dirt between trees, so we get rocked around in the ambulances a lot.


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## luke_31 (Mar 28, 2017)

E tank said:


> And if its really out of whack, they'll just repeat it.


Maybe, since we are directly attached to the ER at our hospital it would be the same machines and they are used to treating patients that we bring in directly on what information we gather in the field.


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## medichopeful (Mar 29, 2017)

Chase said:


> Unless they are actively seizing I do not really see a point in treating hyponatremia in the field.



This.

I'm jealous of services that have the iStat, and I personally think it would be awesome to have the EC8+ cartridge.  Basic electrolytes and VBG/ABGs (though not complete), along with H+H.


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## FiremanMike (Mar 29, 2017)

luke_31 said:


> Anybody using iStats in the field?  We are getting them to run chem 8s on the off chance that our patient is hyponatremic.  Curious to see how durable the device is in the back of the ambulance and if anyone has had problems with getting them to work while bouncing down the road.



Our community paramedic will be getting one at some point, but I don't see a current need for it for EMS use.


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## luke_31 (Mar 29, 2017)

FiremanMike said:


> Our community paramedic will be getting one at some point, but I don't see a current need for it for EMS use.


Neither do we, but we don't have a say on this


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## Tigger (Mar 30, 2017)

FiremanMike said:


> Our community paramedic will be getting one at some point, but I don't see a current need for it for EMS use.


We have one for our MIH program. In order to bring patients directly to psych facilities we have to run a Chem 8 on them. We don't do it while moving, but it's held up pretty well especially since it's in an big pelican case. Also, it does not like cold. At all.


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## E tank (Mar 30, 2017)

Chase said:


> I guess the unfortunate answer is there is nothing they can do about it. You can stop the motor activity but nothing will likely touch the actual EEG activity until sodium levels are increased. So some sodium bicarbonate may help in that situation were nothing else is avaible and it is a long transport.
> .



 Roughly, 2 ml/kg  8.4 % NaHCO3 raises serum sodium about 2-3 points.


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## EpiEMS (Mar 30, 2017)

Tigger said:


> In order to bring patients directly to psych facilities we have to run a Chem 8 on them.



Is the MIH medic interpreting the results, or just comparing them to a threshold?


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## Tigger (Mar 30, 2017)

EpiEMS said:


> Is the MIH medic interpreting the results, or just comparing them to a threshold?


Depends what you mean by that. We don't have a CLIA waiver that would allow us to make destination decisions based on labwork alone. However, we nonetheless developed a checksheet for admission of mental health patients and one of them is "lab values within normal ranges." There is still wiggle room if the provider does not think they lab value is concerning (ie BGL of 180).


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## EpiEMS (Mar 31, 2017)

@Tigger, I didn't realize this - so you would need a specific CLIA waiver if you're using a CLIA-waived test for treatment and/or destination decisions?


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## Tigger (Apr 5, 2017)

EpiEMS said:


> @Tigger, I didn't realize this - so you would need a specific CLIA waiver if you're using a CLIA-waived test for treatment and/or destination decisions?


Apparently we require something called a moderately complex waiver. That's about the end of my knowledge of it, our community paramedic guy knows these things (or at least I think he does).


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## luke_31 (Apr 20, 2017)

Well we are now running with the iStats in the ambulance, so far it's not had any problems beyond some provider issues with not being totally comfortable using it yet. Handles really well going down the rough roads, when we start the test before moving. No hyponatremic patients yet, but they still haven't gotten the stock of hypertonic saline from the pharmacy yet. So I guess it's a good thing since we can't treat the hyponatremia yet.


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