# Prehospital Lactate Meters



## Sam Adams (Jun 11, 2012)

Is anyone using lactate meters prehospitally? I'm  looking for sepsis protocols involving them. Actually, any and all first hand accounts. Pros/ cons etc. Thanks in advance


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## DrankTheKoolaid (Jun 11, 2012)

Trying to form one myself for the NorCal region to at least do a trial.  

San Diego has a trial going for POC lactate but it is specific for shock related to trauma.  You can read about it on CaEMSA website.   If and when i get ours up Ill post info here


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## medicsb (Jun 11, 2012)

I believe Pittsburgh EMS measures lactate, possibly as part of a study, though.


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## TransportJockey (Jun 11, 2012)

The service I worked for in the Denver Metro (ActionCare Ambulance) had them in their trucks that ran 911.


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## LondonMedic (Jun 20, 2012)

What would you do with that information?

How would you know that the lactate is from sepsis and not from, say, mesenteric infarction or metformin?


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## Veneficus (Jun 20, 2012)

LondonMedic said:


> What would you do with that information??



I was trying to figure that out myself...


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## Christopher (Jun 20, 2012)

LondonMedic said:


> What would you do with that information?
> 
> How would you know that the lactate is from sepsis and not from, say, mesenteric infarction or metformin?



You use it coupled with the SIRS criteria to perform a Sepsis Alert / Code Sepsis protocol, which would help drive early goal directed therapy. The Denver Alert Protocol saw pretty significant decreases in mortality after its implementation:


Suspected or documented infection
Age > 18 years
Not Pregnant
Two or more of the following: Temp >100.3F or <96.8F, Pulse > 90, RR > 20
Hypoperfusion as indicated by at least one: BP < 90, MAP < 65, *or Lactate >= 4*

Patients with cryptic septic shock may have relatively normal vital signs, except they will have an elevated lactate.


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## JakeEMTP (Jun 20, 2012)

Christopher said:


> [*]Suspected or documented infection
> [*]Age > 18 years
> [*]Not Pregnant
> [*]Two or more of the following: Temp >100.3F or <96.8F, Pulse > 90, RR > 20
> ...



If the patient is symptomatic, aren't you going to initiate treatment anyways for the BP, HR and RR?

If the vital signs are normal, are you going to do a lactate level on everyone over the age of 18 and not pregnant?


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## LondonMedic (Jun 20, 2012)

Christopher said:


> You use it coupled with the SIRS criteria to perform a Sepsis Alert / Code Sepsis protocol, which would help drive early goal directed therapy. The Denver Alert Protocol saw pretty significant decreases in mortality after its implementation:


Why would you not already be resuscitating them?




> Patients with cryptic septic shock may have relatively normal vital signs, except they will have an elevated lactate.


True. But in these patients, would people actually measure lactates (they're well aren't they)? How are you determining that this is sepsis as opposed to anything else?


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## Handsome Robb (Jun 20, 2012)

LondonMedic said:


> Why would you not already be resuscitating them?



No one said we wouldn't be. Some systems call Sepsis alerts much like a STEMI alert to get the ball rolling at the hospital prior to actually arriving there. Get pharmacy, an intensivist, an ICU nurse or two, lab along with others that I'm missing up and at 'em and into the ER waiting rather than playing the "paging" game and waiting for people.


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## LondonMedic (Jun 20, 2012)

NVRob said:


> No one said we wouldn't be. Some systems call Sepsis alerts much like a STEMI alert to get the ball rolling at the hospital prior to actually arriving there. Get pharmacy, an intensivist, an ICU nurse or two, lab along with others that I'm missing up and at 'em and into the ER waiting rather than playing the "paging" game and waiting for people.


How :censored::censored::censored::censored: are your EDs?


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## Christopher (Jun 20, 2012)

LondonMedic said:


> How :censored::censored::censored::censored: are your EDs?



Even high performing PCI centers do poorly on First Medical Contact to Balloon times without prehospital alert systems for STEMI. Sepsis Alert programs provide the same thing for septic patients.

You get the reduction in mortality as the patient has been pre-screened for the ED. All they do now is grab the sepsis-bundle and begins their workup. Follow-thru to the ICU or floor becomes seamless as the system of care is already in place and activate. In a busy healthcare system this keeps patients from falling through the cracks. In any healthcare system it helps to ensure a consistent level of care and QA/QI.


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## JakeEMTP (Jun 20, 2012)

NVRob said:


> No one said we wouldn't be. Some systems call Sepsis alerts much like a STEMI alert to get the ball rolling at the hospital prior to actually arriving there. Get pharmacy, an intensivist, an ICU nurse or two, lab along with others that I'm missing up and at 'em and into the ER waiting rather than playing the "paging" game and waiting for people.



You're kidding?  To initiate treatment on a suspected sepsis patient? Most ERs should have STAT lab capability and alot of ER docs now how to start treatment since the guidelines are posted everywhere and there has been a major push in the hospitals for this over the past 10 years.  That sounds like your ER doctors aren't at par with others if they don't know how to start treating a sepsis patient. Can't they start central lines or intubate without an intensivist?  Why would an ICU nurse need to be there?  The Sepsis Bundle is great and can easily be followed with others brought into but not a big production like what seems to be suggested.


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## Handsome Robb (Jun 20, 2012)

LondonMedic said:


> How :censored::censored::censored::censored: are your EDs?



When you have 4 hospitals serving a population of > 500k with one being a Level II trauma center and one of those hospitals is a band-aid station and another isn't much better things get a bit hectic at times.




JakeEMTP said:


> You're kidding?  To initiate treatment on a suspected sepsis patient? Most ERs should have STAT lab capability and alot of ER docs now how to start treatment since the guidelines are posted everywhere and there has been a major push in the hospitals for this over the past 10 years.  That sounds like your ER doctors aren't at par with others if they don't know how to start treating a sepsis patient. Can't they start central lines or intubate without an intensivist?  Why would an ICU nurse need to be there?  The Sepsis Bundle is great and can easily be followed with others brought into but not a big production like what seems to be suggested.




We don't call sepsis alerts in my system. I was just giving an example. I think it's pretty bold of you to say our ERPs are sub-par without knowing the system I work in or the hospitals that we work with. We have an excellent, more than capable group of Emergency Physicians in our area. Yes they can intubate and start central lines but you know they are going to be looking for a consult not long after that and with busy ICUs  sometimes that can take a while.


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## JakeEMTP (Jun 20, 2012)

NVRob said:


> When you have 4 hospitals serving a population of > 500k with one being a Level II trauma center and one of those hospitals is a band-aid station and another isn't much better things get a bit hectic at times.



We have big hospitals also. Most of our LTC patients we transport either routine or 911 will probably have an elevated lactate level. They get screened and are treated accordingly. I can't imagine calling an alert for every nursing patient which could easily be up to 50 before lunch by your criteria. Many will be treated without any problems.  I can't see having a dozen people running into an ER everytime there is any kind of alert which at a busy place, just trauma, stemi and stroke can be dozens of times a day. Your description of the hospital ER reminds  me of one of those cartoons with the crowd running in and out of door everytime a sign blinks.


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## LondonMedic (Jun 20, 2012)

NVRob said:


> When you have 4 hospitals serving a population of > 500k


Is that high or low?

Here, for example, we have roughly one ED per 250,000 residents.

London has 30 hospitals for a population of 7,000,000 (almost doubling between 9 and 5 Mon-Fri during the summer) of which four are trauma centres).


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## JakeEMTP (Jun 20, 2012)

NVRob said:


> We don't call sepsis alerts in my system. I was just giving an example. I think it's pretty bold of you to say our ERPs are sub-par without knowing the system I work in or the hospitals that we work with. We have an excellent, more than capable group of Emergency Physicians in our area. Yes they can intubate and start central lines but you know they are going to be looking for a consult not long after that and with busy ICUs  sometimes that can take a while.



Your initial description gave a  piss poor view of your ER and its doctors as if they needed the intensivist to get the party started.


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## LondonMedic (Jun 20, 2012)

NVRob said:


> We don't call sepsis alerts in my system. I was just giving an example. I think it's pretty bold of you to say our ERPs are sub-par without knowing the system I work in or the hospitals that we work with. We have an excellent, more than capable group of Emergency Physicians in our area. Yes they can intubate and start central lines but you know they are going to be looking for a consult not long after that and with busy ICUs  sometimes that can take a while.


But you would want them to not do their emergency physician bit and hand over care to intensivists because of a random number generator on your ambulance?

Do they not even get to play with their 'GuessTheLactate' machine?


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## Veneficus (Jun 20, 2012)

LondonMedic said:


> How :censored::censored::censored::censored: are your EDs?



badly, for a number of reasons.


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## Aidey (Jun 20, 2012)

Apparently it is gang up on Rob day today. :glare:

JakeEMTP, your attitude is offensive. Either give us a good explanation for your high and mighty attitude or knock it off. Veneficus has more education than 1/2 of us put together, which gives him the right to have an attitude sometimes. You on the other hand are coming off as a jerk. 

Lactate monitors are meant to be used in conjunction with other assessment findings and patient history to determine likelihood that the pt is septic. This is not hugely different from how we use 12 leads. Given the huge variances between hospital capabilities some of them benefit from being forewarned about a potential sepsis patient. Its great that you think most hospitals have stat lab capability, but until most hospitals do, it doesn't matter what you think. 

There is increasing evidence that the earlier sepsis is caught and fluid resuscitation is initiated the better the pt outcome. Sepsis is assocaited with high morbidity and mortality rates so an effort to decrease those rates is a good thing. As Denver showed, early identification correlated with a decreased mortality. 

The criteria that Christopher posted are not something he just came up with. They are widely accepted criteria for SIRS. If you guys think it is such a horrible idea, feel free to argue that with the hospitals and EMS systems already doing it, and see how far you get. 

Why are CVA, AMI and trauma alerts ok, but sepsis alerts aren't?


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## JakeEMTP (Jun 20, 2012)

Aidey said:


> JakeEMTP, your attitude is offensive. Either give us a good explanation for your high and mighty attitude or knock it off. Veneficus has more education than 1/2 of us put together, which gives him the right to have an attitude sometimes. You on the other hand are coming off as a jerk.



Let him fight his own battles unless you think he isn't able to on his own.  He made statements he needs to back up.  He made his hospital ER sound like its staff was too stupid to initiate a sepsis workup which has been put out there for many years. An ER nurse is not so stupid an ICU nurse has to hold her hand starting an IV, sending labs and getting fluids started. Nor should an ER doctor be incapable of doing some intervention unless an Intensivist is there. 



Aidey said:


> Why are CVA, AMI and trauma alerts ok, but sepsis alerts aren't?



Stroke and AMI  Alerts may need more interventions than what can be done in the ER. A Stroke Alert tells the Radiology department to hold off on that next elective scan. It also can ready the interventional neuro and radiology team.  An AMI can be more than just getting a 12 lead and a few labs. The AMI alerts a cath lab and often the patient will go directly to the cath lab if a stemi.   Many sepsis patients can be handled in the ER for the initiation of treatment and the majority will be admitted to a telemetry unit and not ICU.  If all of the patients who had an elevated lactate level needed an ICU bed and an intensivist there wouldn't be enough ICU beds anywhere and health care would be through the roof with intensivists as consulting for every patient. But, strokes and AMIs should get at least a neurologist or cardiologist if the hospital is rated as providing certified services.


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## FLdoc2011 (Jun 20, 2012)

Been reading through the thread and hoping it hasn't gotten completely out of hand..... but honestly at this point outside of studies/clinical trials, I'm not sure prehospital lactate has a role.   

Even when I'm admitting someone lactate is just one of MANY things I look at and most of the time it doesn't change management that we've already to started or it's used more as marker to help with judging effectiveness of interventions.  

I'm sure some places are calling "sepsis alerts" but is that really changing clinical outcomes?   Like others have said there's really no intervention initially that can't be done in the ER by the ER physician.    Lactate is one of several markers that technically can define "severe" sepsis vs sepsis but that's really not going to change prehospital or initial ED management.  

It seems these sort of things get personal quickly.  I certainly applaud EMS for wanting to advance but like any other area of medicine we need to think before just slapping on another test, especially talking about adding on a test prehospital where the cost/barrier to entry is a lot more than just adding a point of care lactate to an ER that already has the equipment and infrastructure.   

Chances are the ER/hospital is going to run their own lactate anyway right away.   After all, it's not THEIR machine they have calibration records for, and they certainly couldn't bill for it.


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## Veneficus (Jun 20, 2012)

JakeEMTP said:


> He made his hospital ER sound like its staff was too stupid to initiate a sepsis workup which has been put out there for many years.



I didn't interpret it that way.

Anyway, not all hospitals are equal and I don't think it speaks to the quality of the staff when there is a delay in a sepsis workup. 

One reason is if a patient presents as "not really sick" the workup may be delayed until the first set of diagnostics the hospital performs comes in.

In the geriatric population, nonspecific complaints, especially from unreliable patients can also cause delays through no fault of the staff.

I would also like to point out that while sirs/sepsis guidlines have been out for many years, they do change regularly, and doctors and hospitals that have research going on in the topic change much faster than the guidlines. That can make other institutions seem or actually be very far behind. 



JakeEMTP said:


> An ER nurse is not so stupid an ICU nurse has to hold her hand starting an IV, sending labs and getting fluids started. Nor should an ER doctor be incapable of doing some intervention unless an Intensivist is there.



You keep using that stupid word... I am not sure why. 

An ER is not the place for sick people, medical or surgical. There is far more to taking care of sepsis patients that what an ED can provide for. It is not a matter of provider ability, it is a matter of resources. 

Most EDs suffer everytime they have to pull a nurse from staffing to sit on a sick patient. If they don't the patient suffers. 

There is also the issue of things like glycemic control, invasve monitoring, etc etc that is not realistic in an ED. 

I have played both sides of the ED resuscitation argument. But after some learning and experience, have changed my position that ED resuscitation should be no different than EMS, as temporary as possible until the expert assuming long term care can be brought in. With minutes being preferable. 

I also know more than a few ED docs who advocate the same. Perhaps because they are putting aside their ego in order to better serve the patients?



JakeEMTP said:


> Many sepsis patients can be handled in the ER for the initiation of treatment and the majority will be admitted to a telemetry unit and not ICU.



I think this is facility specific. At the academic facility I am at, all suspected SIRS and septic patients go to a respective ICU. I am personally involved in the neonatal sepsis research, and I can attest, there is no place equal or better than a unit, and no service sufficent that is not a unit. As with any pathology, early, specific, intervention is of the best benefit.



JakeEMTP said:


> If all of the patients who had an elevated lactate level needed an ICU bed and an intensivist there wouldn't be enough ICU beds anywhere and health care would be through the roof with intensivists as consulting for every patient.



I think this is an equation of 2 unrelated things. 

As was pointed out by Londonmedic, there are many causes of elevated lactate. While often used, lactate level is not always specific to septic (or for that matter any) shock. Sometimes with sensitivity approaching only 30%. The cause of elevated lactate must be determined. 

As for intensivists, there are not enough now. With a further projected shortage, I have even seen estimates by 2020 only 24% of the positions will be filled.

It has been my observation that anytime an intensivist consults for a patient, there is usually some benefit. In intensive medicine there is a culture of approaching the patient as a whole, not as a single organ or system. A global clinician is much cheaper than a cardio consult, a nephro consult, a neuro consult, etc on the same patient.

It is also better for patients until they can have their individual organs sent to the best respective service and then reassembled prior to discharge. 

It is not to say the intensivist is the answer to everything, but the perspective brought definately doesn't go amiss.

Did you know that outside of the US, it is often orthopods and anesthesia that manages not only the EDs, but EMS as well?


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## Aidey (Jun 20, 2012)

No, you interpreted it as him making his hospital staff sound that way. You make it sound like you work in a very well off privileged system that always has plenty of beds and available staff. A hospital doesn't have to suck in order to need as much heads up as possible. 

It isn't just about who can do what. It is about having enough people available, while not ignoring 1/2 of the other patients in the ED. Same as a code team within a hospital. It is about having continuity of care. A truly sick sepsis patient is not a patient you want to sit on in an ED for very long. Having ICU staff down there means getting the ball rolling on what will need to be done once the patient is transferred, and it means that at least one person will have been with the patient since they arrived. 

An AMI is more than a 12 lead and labs. They may also need fluids, pressors, multiple drips hung and intubation. Hmmm, kind of sounds like what might be done to a sepsis patient doesn't it? 

No one is saying every patient with an elevated lactate needs an ICU bed. What they are saying is that having one more assessment tool allows for a high specificity in diagnosis which means the right patients get the right treatment faster. That is almost exactly what we use a 12 lead for.


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## abckidsmom (Jun 20, 2012)

I hear what you're saying, Aidey, but I really think that the level of prealert necessary for a septic patient is possible just through assessment alone.  

ICU staff are not going to be coming down to the ER to check on a patient with a lactate > 4.  ER staff are going to evaluate the patient, determine their hemodynamic stability, and get them an ICU bed.  

The treatment for sepsis can be rather complex, but in the initial stages, it's easily managed in the ER.  

I do not support spending hundreds of more dollars for yet another new toy that isn't going to change treatment or outcomes for patients.  We water down the "alert mentality" if we have an alert for every random thing.


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## FLdoc2011 (Jun 20, 2012)

Certainly agree with the above two posts.    We routinely get called down to the ED once it's none the patient is going to the ICU.  

At least here in the US the ED is all about moving meat and at least they certainly don't want a critical pt in the ED longer than needs to be.


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## Veneficus (Jun 20, 2012)

abckidsmom said:


> We water down the "alert mentality" if we have an alert for every random thing.



I think the alert mentality came from the need of having to tell EMS providers seemingly obvious things to get them to stop taking patients to the nearest ED all the time.

Take the trauma patient to the trauma facility.

Take the cardiac patient to the cardiac facility.

The same with stroke.

In some states it even had to be put into legislation.


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## usalsfyre (Jun 20, 2012)

FLdoc2011 said:


> Certainly agree with the above two posts.    We routinely get called down to the ED once it's none the patient is going to the ICU.
> 
> At least here in the US the ED is all about moving meat and at least they certainly don't want a critical pt in the ED longer than needs to be.



Quoted for truth. Ask any ED director what their primary concern is. After the Pavlovian "Press Ganey" answer they'll mention throughput.


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## Aidey (Jun 20, 2012)

FLdoc2011 said:


> Been reading through the thread and hoping it hasn't gotten completely out of hand..... but honestly at this point outside of studies/clinical trials, I'm not sure prehospital lactate has a role.
> 
> ...
> 
> I'm sure some places are calling "sepsis alerts" but is that really changing clinical outcomes?   Like others have said there's really no intervention initially that can't be done in the ER by the ER physician.    Lactate is one of several markers that technically can define "severe" sepsis vs sepsis but that's really not going to change prehospital or initial ED management.



The study in Denver did show a reduction in mortality. Hopefully someone here has access to the results and can post them. 

In discussions with other people on this same topic, one of the things that has come up as been the negative impact EMS' impression of the patient has on the speed they are treated in the ED. Basically, EMS views the patients as BS and their report to the ED downplays how sick they potentially are. The ED is biased by this attitude, and thus the patients aren't deemed acute. 

For example. I work in a paramedic/basic system. It is extremely common to be called to a nursing home by for grandma who isn't acting right or some other seemingly dumb reason. These calls are almost always turfed to the basic, who rarely asks very many questions of the nursing home staff. They are babysat on the way to the hospital with minimal assessment, and at the hospital minimal report is given. 

How much faster would the ED staff recognize they have a potentially septic patient on their hands and implement their sepsis protocol if the patient had a full paramedic work up, with lactate?


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## JakeEMTP (Jun 20, 2012)

Veneficus said:


> Did you know that outside of the US, it is often orthopods and anesthesia that manages not only the EDs, but EMS as well?



It is that way in some places in the US also. I believe that is why EMS physicians are trying to get their specialty recognized.

There are national guidelines for sepsis and there are data bases for collection of data. Nothing new there.

Don't want to get into any pissing match with you Vene. That is pointless.  I've read some of your posts on other forums over the past 6 or 7 years. -_-


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## abckidsmom (Jun 20, 2012)

Aidey said:


> The study in Denver did show a reduction in mortality. Hopefully someone here has access to the results and can post them.
> 
> In discussions with other people on this same topic, one of the things that has come up as been the negative impact EMS' impression of the patient has on the speed they are treated in the ED. Basically, EMS views the patients as BS and their report to the ED downplays how sick they potentially are. The ED is biased by this attitude, and thus the patients aren't deemed acute.
> 
> ...



A lot quicker, especially if the paramedics did their jobs.  Even by your language in your post, you realize that the medics are "turfing" the patients they should be caring for.

IMO, in a P/B system, the medic should be doing well over 3/4 of the calls.  It is what it is.  Would you want your mom turfed to the basic and not properly assessed?


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## JakeEMTP (Jun 20, 2012)

Aidey said:


> How much faster would the ED staff recognize they have a potentially septic patient on their hands and implement their sepsis protocol if the patient had a full paramedic work up, with lactate?



Full Paramedic workup? More than what you normally do or an expanded lab set?  Must be nice to have all the time in the world to do a bunch of labs and check all of the medical records. How long do you want to spend on scene? Next to fluids, the patient will need antibiotics which you can not provide.


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## abckidsmom (Jun 20, 2012)

JakeEMTP said:


> Full Paramedic workup? More than what you normally do or an expanded lab set?  Must be nice to have all the time in the world to do a bunch of labs and check all of the medical records. How long do you want to spend on scene? Next to fluids, the patient will need antibiotics which you can not provide.



In my experience:

Full Basic workup:  Name, age, complaint, associated symptoms, vitals, history, transport.  

Full Paramedic workup:  All of the above plus critical thinking based on physiology.  

Just a thought.  I don't do any more workup for my patients than my basic partners, but I apply the most underappreciated tool in the ambulance to every problem I approach: my brain.


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## ah2388 (Jun 20, 2012)

JakeEMTP said:


> Full Paramedic workup? More than what you normally do or an expanded lab set?  Must be nice to have all the time in the world to do a bunch of labs and check all of the medical records. How long do you want to spend on scene? Next to fluids, the patient will need antibiotics which you can not provide.



Why on earth would drawing labs pre-hospital, administering fluids, or obtaining a medical record(keeping in mind the information most patients have), prolong scene times?  I would imagine that these devices, if useful, would be used primarily in rural or semi rural systems with medium to long transport times (20min+?)

Its obviously a concept that deserves continued exploration to see if there is benefit for prehospital providers to be performing this type of POC testing.

As others have said, the value of this device comes from early recognition, which may help to prevent the pt's who present as "stable" from being triaged and "sat on" in the emergency department in favor of other patients.  I do not imagine the delay in care would be >90minutes, so the next question may become whether or not that delay is significant enough to justify the cost.

I may be misinterpreting, but it seems that some in this thread may be hesitant for change.  I think the opposite must be come true in many ways if the current system model is to remain viable long term.


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## JakeEMTP (Jun 20, 2012)

ah2388 said:


> Why on earth would drawing labs pre-hospital, administering fluids, or obtaining a medical record(keeping in mind the information most patients have), prolong scene times?  I would imagine that these devices, if useful, would be used primarily in rural or semi rural systems with medium to long transport times (20min+?)
> 
> Its obviously a concept that deserves continued exploration to see if there is benefit for prehospital providers to be performing this type of POC testing.




Obtaining a medical record or just a brief summary or face sheet doesn't always cut it.

How many cartridges are you going to carry with you POC machine? How will you store them? Will you have them ready for all 911 calls? 

How will it change what you do to treat your patient? Will you be able to do blood cultures on the first stick and will the hospital trust them? Most prefer to draw their own cultures. What about all of the other cultures and lab work that goes with a sepsis diagnosis? Just one or two lab values are only a small part of the story. It is like a pulse ox SpO2. It is just one number and not really adequate to tell how the organs are perfusing.  

Think about all of the factors involved. 

Critical Thinking can  be applied but to be effective you have the education to utilize the data you are gathering from all of the new gadgets.  I think I already said this when another person wanted iSTATs on every EMS truck. What will it change? 

Chances are if you are bringing a sick patient to an ER from a nursing home a long distance, the staff or even physician will have called in some lab values and a report to the ER. 

Alot of places are trying to stop duplication of services which are costly and painful. It is not about more skills on your resume but whether you actually change how you can treat a patient. Doing stuff that will be repeated again and again in the hospital probably isn't the best idea. We already have protocols for BP and HR. If you can't give a more detailed description of your patient to get across the idea the patient is sick, more gadgets isn't going to do you any good.


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## FLdoc2011 (Jun 20, 2012)

Aidey said:


> The study in Denver did show a reduction in mortality. Hopefully someone here has access to the results and can post them.
> 
> In discussions with other people on this same topic, one of the things that has come up as been the negative impact EMS' impression of the patient has on the speed they are treated in the ED. Basically, EMS views the patients as BS and their report to the ED downplays how sick they potentially are. The ED is biased by this attitude, and thus the patients aren't deemed acute.
> 
> ...



Do you have details on that study?  Depending on where it is I may have access to it.


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## Aidey (Jun 20, 2012)

JakeEMTP said:


> How many cartridges are you going to carry with you POC machine? How will you store them? Will you have them ready for all 911 calls?




For the record the Lactate Pro monitor is the most commonly used one. It is ~$400* and as hard to use as a glucometer. Athletes have used them for years for training purposes. It is much more like a glucometer than an I-Stat. 




*This is the price we were quoted when we looked into them.


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## FLdoc2011 (Jun 20, 2012)

I'd have to look into some of these studies to see exactly how they're implementing this, but I just don't see where it's needed, at least for now. 

If it's anything like our POC machines, it's going to take probably close to 10min for a result.   Transport times vary sure, but 10min into a transport you get back a lactate of 5,  what does that change?   Hopefully by that point you're thinking sepsis anyway and have fluids or something going.  

The only reason I could see right now is in specific areas (rural or not) where this is specifically a major issue where certain hospitals don't have the resources or would have to transfer the patient out.   I don't work in an area like that so I can't comment on that, but I would think those would be very limited circumstances that may find a use for specific prehospital diagnostics such as this.... but certainly not for the majority of markets.


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## Aidey (Jun 20, 2012)

The Lactate Pro 1 takes 1 minute, and the Lactate Pro 2 (which isn't yet available in the US) takes 15 seconds. Here is the website for the manufacturer. http://www.fact-canada.com/LactatePro/lactate-pro-portable-analyzer.html

Unfortunately I don't have the information on the study. There are a few people from CO here, hopefully they will.


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## NYMedic828 (Jun 20, 2012)

I don't have anywhere near the experience you folks do only being a medic for a year but here in NYC we usually just notify the hospital ahead of time if we are bringing a more sickly patient in.

Usually give a notification for hypovelemic shock if the signs and symptoms are present but never call it sepsis via radio or paperwork. Can assume its sepsis, can tell the hospital what you think but you can't justify that rule-out in the field.

We get an IV, maybe two, give fluids and drive. 

I like having more toys as much as the next guy, but is it really necessary or should we be focusing on improving upon what we already have first.


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## socalmedic (Jun 20, 2012)

I will try to locate the study I read last year, but it stated that lactate can be affected by as much as 1 mmol/l after the first liter of NaCl. making POC testing prior to admin useful for trending. 

as for accuracy and usability of the POC direct your attention to this study,
http://www.ncbi.nlm.nih.gov/pubmed/11167165
comparing the speed, cost, and accuracy of POC verses central laboratory.


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## ffemt8978 (Jun 20, 2012)

This is for everyone in this thread:

Play nice, or become the focus of my complete and undivided attention.


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## JakeEMTP (Jun 20, 2012)

Some of the studies done in the US and Canada were blind studies. The Paramedics did not treat by the number on the lactate monitor. They treated by their protocols for suspected sepsis. That was what was actually shown to be effective and not the number on the meter. Better assessment skills are the most important and the gadget may just be there to confirm what you have assessed the problems to be.

Also, for Denver EMS, their protocols with a Jan 2012 update has this to say:

Lactate Measurement
At this time there is insufficient evidence to recommend for or against routine point of care measurement of lactate by EMS. Although it shows promise for improved detection of hypoperfusion, lactate measurement is not considered mandatory or standard of care by the Denver Metro EMS Medical Directors. Its use will be governed by individual agency Medical Director policy.

http://www.dmemsmd.org/sites/default/files/Denver Metro Protocols - 12_13_11.pdf

This is found in protocol 4060 Medical Hypotension Shock Protocol. 

Don't forget the 100% facemask at 15 L/Min.


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## ah2388 (Jun 20, 2012)

JakeEMTP said:


> Obtaining a medical record or just a brief summary or face sheet doesn't always cut it.
> 
> How many cartridges are you going to carry with you POC machine? How will you store them? Will you have them ready for all 911 calls?
> 
> ...



I was not advocating for drawing labs, nor was I advocating that a brief Hx was "adequate."  I was simply stating that given the idea that drawing labs is not a difficult thing to teach, and would be simple to do in the field, it could be done without "hanging out on scene" for a prolonged period.  

Regarding blood cultures, I dont see the reason they could not be drawn prehospital, so long as the procedure was performed using accepted guidelines from the various laboratory regulatory agencies.

I would tend to agree with some other posts in this thread advocating that we do better with the tools that we have, specifically in the area of educational requirements etc.

To summarize, I think that a very small population of patients might benefit from paramedics using this tool in a very small percentage of systems.  I base that on nothing more than intuition, which I recognize is a poor indicator.  This concept certainly deserves more exploration, and I would venture to say that exploring concepts which may benefit our patients, especially exploration specific to EMS, is extremely positive.  While there have been some advances, I feel like EMS in some ways dead locked itself into certain ways of thinking, we have to evolve or we will die and exploration is a part of that.


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## JakeEMTP (Jun 20, 2012)

socalmedic said:


> I will try to locate the study I read last year, but it stated that lactate can be affected by as much as 1 mmol/l after the first liter of NaCl. making POC testing prior to admin useful for trending.
> 
> as for accuracy and usability of the POC direct your attention to this study,
> http://www.ncbi.nlm.nih.gov/pubmed/11167165
> comparing the speed, cost, and accuracy of POC verses central laboratory.



For trending how many times you want to stick a patient prehospital is a different matter. You should not use the same line you are infusing the blood in and that was pointed out in the Lactate Pro studies. If you already started fluids, another line or sample puncture at another site will have to be drawn.  How many times you want to open a line in unfavorable situations is another consideration. Hospitals time their lab draws even in closed systems.  In Exercise Phys Masters programs, athletes will have an arterial line for studies of lactate.


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## Veneficus (Jun 21, 2012)

JakeEMTP said:


> Don't want to get into any pissing match with you Vene. That is pointless.  I've read some of your posts on other forums over the past 6 or 7 years. -_-



Am I that old?

I think this is the longest I have been on any forum, and even sometimes here cannot stand the simplicity.


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## NYMedic828 (Jun 21, 2012)

Veneficus said:


> Am I that old?
> 
> I think this is the longest I have been on any forum, and even sometimes here cannot stand the *simplicity*.



Well, in all fairness you are at least a solid 7-10 years of studies ahead of 99% of us. 

The main thing that drew me to and keeps me on this forum is that some people here are in fact so knowledgeable, many being RNs and a few of you being accomplished MDs.

It is refreshing and inspiring to receive help from those who don't forget where they come from rather than just leaving everyone else in the dust.

This thread seems to be getting into a pretty unnecessary battle. We are all here to share experiences and knowledge so that everyone may learn. Not fight with one another over something someone simply proposed as an idea.


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## Christopher (Jun 21, 2012)

ah2388 said:


> Regarding blood cultures, I dont see the reason they could not be drawn prehospital, so long as the procedure was performed using accepted guidelines from the various laboratory regulatory agencies.



We routinely draw labs enroute with every IV start at one of my services (hospital based, mean transport time of 7 minutes or so).


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## NYMedic828 (Jun 21, 2012)

Christopher said:


> We routinely draw labs enroute with every IV start at one of my services (hospital based, mean transport time of 7 minutes or so).



At my volunteer establishment I have the option to draw labs if I feel it would speed anything up and have the time to do it.

In NYC, paramedics are no longer permitted to routinely draw labs. The only time we are required/allowed to do it now is prior to the administration of hydroxocobalamin.

I think the main reason it was removed in NYC was to reduce the occurrence of accidental needle sticks.


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## JakeEMTP (Jun 21, 2012)

Originally Posted by ah2388  
Regarding blood cultures, I dont see the reason they could not be drawn prehospital, so long as the procedure was performed using accepted guidelines from the various laboratory regulatory agencies.



Christopher said:


> We routinely draw labs enroute with every IV start at one of my services (hospital based, mean transport time of 7 minutes or so).



If you are drawing blood cultures, what are you using to clean the site and how long are you allowing it to dry? How many culture specimen bottles are you drawing? Are you labeling with site, time, your name and delivering to the lab yourself?  Where are you storing the specimen bottles in the ambulance and for how long before you throw them away?  These are not the tubes and there is more involved.


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## ffemt8978 (Jun 21, 2012)

Several of the hospitals around here want the rainbow of tubes drawn on any patient with an IV.  We had to get a variance from each hospital because our average transport time made most of them useless before we arrived.


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## JakeEMTP (Jun 21, 2012)

ffemt8978 said:


> Several of the hospitals around here want the rainbow of tubes drawn on any patient with an IV.  We had to get a variance from each hospital because our average transport time made most of them useless before we arrived.



Were any of them the blood culture bottles?  EMS fails in quality control and sometimes just puts doing a skill ahead of should it be done. Tubes aren't stored properly, not mixed properly after the draw,  often mislabled if labeled at all, relying on nurses to label your draws, lack of IV practice with poor technique,  multiple punctures after losing the IV while attempting to draw blood, not knowing anything about the tubes except for rainbow, broken tubes and a whole bunch of reasons. If the lab gets cited for a major medical error coming from one of those blood draws, the burden of your competency will be on them and showing proof of it.  I doubt if many companies can pull up a lab draw education competency. The hospital won't have any defense and the EMS company can just say they were just told to draw these tubes. It would be the hospital's fault entirely for their good faith in the ambulance company or fire department. 

This profession has a tendency to rush in and start doing something before the education. I think that applies to the things like CPAP, ETCO2, 12 leads, pulse oximetry, intubation, RSI,  blood pressures and many of the medications if the posts here are any indication.


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## Christopher (Jun 21, 2012)

JakeEMTP said:


> If you are drawing blood cultures, what are you using to clean the site and how long are you allowing it to dry? How many culture specimen bottles are you drawing? Are you labeling with site, time, your name and delivering to the lab yourself?  Where are you storing the specimen bottles in the ambulance and for how long before you throw them away?  These are not the tubes and there is more involved.



I missed the "cultures" reference. We'll grab extra in 2 10cc syringes on occasion (aseptic w/ chloraprep; our start kits no longer include alcohol or iodine), but otherwise we're just drawing rainbows.


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## Handsome Robb (Jun 21, 2012)

JakeEMTP said:


> If you are drawing blood cultures, what are you using to clean the site and how long are you allowing it to dry? How many culture specimen bottles are you drawing? Are you labeling with site, time, your name and delivering to the lab yourself?  Where are you storing the specimen bottles in the ambulance and for how long before you throw them away?  These are not the tubes and there is more involved.



So you routinely walk all the way to the lab to deliver blood cultures? Sounds efficient. 

The hospitals here use a pneumatic tube system to send labs and meds around the hospital. Even after all my clinical time I have never been to the lab at our Trauma Center.

 We don't draw prehospital labs so I can't comment on that.


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## Veneficus (Jun 21, 2012)

JakeEMTP said:


> This profession has a tendency to rush in and start doing something before the education. I think that applies to the things like CPAP, ETCO2, 12 leads, pulse oximetry, intubation, RSI,  blood pressures and many of the medications if the posts here are any indication.



I think there is validity to this statement. 

It is rooted in the history of EMS though. The idea that minimally trained providers could offer "life saving skills."

I do not like many EMS practices or values. I have given up trying to change the industry. It is what it is. I just try to help advance the individual providers that are interested.

It does require dispelling a fair amount of dogma and propaganda though.

I have read here what is postulated about the Denver protocol. 

I wonder if it is life saving because it helps in a system specific way or in a medical way?

But that will not be decided here. 

But I think it is also important to realize that the shortcomings of US EMS is manifest in the poor pay, relatively few desirable positions, and complete lack of upper mobility.

No matter how good the medic, they will never move past being bound by rather limited protocol. I think that is one of the main reasons the really capable medics often move on from EMS at some point in their career. 

At one point it was something seen as positive, but in the current climate, it seems anybody who betters themself is seen as elitist. 

I know many very capable medics, but there is no denying medics are judged by the company they keep. For every one great one, there are hundreds of poor ones. 

If any person here spent all their time hanging around with criminals of any sort, they would probably be stereotyped a criminal. 

It has been some time since I had to point out that a large portion of the medical community has no respect for what EMS is or does. 

It is up to the providers to change that. But the majority of them choose not to.

Even on this website, one of the most common questions of people resisting advancement and change is: "what is in it for me?" 

I think the simple answer is "What do you put into it?"

Recognizing shortcomings is part of any profession. But it is not easy, particularly in EMS.


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## socalmedic (Jun 21, 2012)

*Update*

here is the study I was talking about a few pages ago.

Decreasing Blood Lactate Levels in EMS Patients
By T. Ryan Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P

Introduction: Research has shown that clearance of blood lactate is associated with better outcomes in patients with severe sepsis and septic shock. One of the primary treatments of these patients is administration of IV fluids. This study looked at blood lactate levels before and after EMS treatment to determine if there was a significant change.
Hypothesis: There will be a change in blood lactate levels between EMS and hospital lactate levels.
Methods: Paramedics were provided with and given training on the Lactate Pro blood lactate meter by Arkray Inc. This meter is FDA-approved and CLIA waived, and has shown a good correlation to hospital lactate tests. Between May 1, 2009, and Sept. 15, 2010, 134 patients with suspected severe sepsis or septic shock underwent blood lactate readings by EMS. Patients with a lactate reading of ≥ 4.0 mg/dL were considered to be in shock regardless of their corresponding blood pressure. Treatment was not dictated by this study and was administered according to EMS protocols.
Results : Of the 134 patients, 120 had hospital lactate levels available for comparison. Overall, hospital lactate levels were lower after EMS treatment. EMS patients were divided into groups that received greater than 1000 mL of fluid between readings (Group A), and patients who received between 250 mL and 1000 mL (Group B). Group A had a median decrease of 2.25 mg/dL (p = 0.0003) while Group B had a decrease of 1.1 mg/dL (p < 0.0001). Analysis used the Wilcoxon-Rank Sum Test.
Conclusions: There was a significant decrease in lactate levels associated with EMS treatment. Further, the group that received greater amounts of IV fluids had an even larger drop in lactate levels. These results illustrate the importance of EMS treatment and how it might impact patient outcomes. Further research and training needs to be done to expand the role of lactate in EMS, as well as reinforcing the importance of fluid administration to these patients.

sorry admin the only source I could find was copy and paste from the link below.

http://millhillavecommand.blogspot.com/2011/09/prehospital-sepsis-new-research.html

here is a link to a jems article about POC lactate.
http://www.emsworld.com/article/10319536/sepsis-alert


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## systemet (Jun 21, 2012)

Can we lay off all the ad hominems, here?  It's not helping us have a useful discussion.  Jake obviously thinks paramedics are undereducated.  If people disagree with that opinion, why not explain why, rather than calling him a troll?

I've used this guy (Accutrend Lactate), and it gives results in 60 seconds.  No idea if it's FDA approved.






I think there was some evidence for a benefit on mortality from a European physician-based system, I'll try and take a look here.

I realise that a lot of people here work in systems where a long triage wait is 20 minutes, and there's a large number of centers with good ICUs. But not everyone does.

While I don't have evidence to support this (unless, I go look up that study that I'm not 100% certain about), I can see how screening for lactate could identify a higher risk subset of patients.  This could be done quite quickly and cheaply in the ambulance, although I imagine you're going to lose some sensitivity and specificity using a cheap hand-held device versus the hospitals lab.  It would be nice if these patients could avoid waiting in triage for a couple of hours, then going to a low acuity bed, and waiting for routine blood work to bring back a high lactate.


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## ffemt8978 (Jun 21, 2012)

Now that everyone has had a chance to come to their senses, and I've removed a lot of posts from this thread I've gone ahead and reopened it.  If I have to get involved again, I will be handing out forum vacations.


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## Handsome Robb (Jun 24, 2012)

Ok. So we all know that multiple things can cause an increase in lactate ranging from intense exercise all the way up to septic shock. 

My question is why is it unreasonable for paramedics to be able to check a lactate level and use it, along with other clinical findings to help rule in/out sepsis and base their treatment off of it? I'm not advocating basing a treatment path off of a single number from a field lactate test. If we can get a POC lactate level prior to prehospital fluid administration, which will lower lactate levels, why not allow it? I know the hospital is going to do their own labs but would it not help the ER if we come in with a patient with suspected sepsis if we can pass on a lactate level prior to prehospital fluid administration? I'm not saying a "Sepsis Alert" is necessary but would us being able to pass on a lab value during our patient handoff that will help the hospital initiate early goal directed therapy and potentially life-saving interventions be a bad thing? Medicine is a team effort involving multiple specialties, including EMS. It's been stated multiple times in this thread: early fluid resuscitation and antibiotic administration reduce the mortality in septic patients, more specifically patients in septic shock. 

We all know that prehospital medicine is not definitive care but isn't that part of our goal? To get the patient the definitive care and early goal directed directed therapy that they need? Does us being able to provide a lab value included in confirming a sepsis diagnosis not help that process? Maybe I'm totally off base here. 

I'll agree that EMS education in the U.S. is severely lacking, there's no question about that but a lactate measurement is no more invasive than a CBG measurement. I'm not saying it's going to change our treatment prehospitally, what I am saying is it can/will aid the hospital in initiating early goal directed therapy while they wait for their own lab results to come back. 

With all of the above said, the system I work in does not utilize prehospital lactate meters and we do not call sepsis alerts.


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## LondonMedic (Jun 24, 2012)

NVRob said:


> My question is why is it unreasonable for paramedics to be able to check a lactate level and use it, along with other clinical findings to help rule in/out sepsis and base their treatment off of it?


Because, as been said at length and as you have just said, it's not a rule in/rule out test.

You've just said, that it won't change your management and it won't change the hospital's management.

You're entire argument for this new kit is that it would tell us something that might be interesting to know.


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## NYMedic828 (Jun 24, 2012)

I'd rather my ambulance had a thermometer before a lactate meter.

A lactate meter is just something I would have to do more work to inspect every tour and keep equipment for. 

It won't change my treatment of giving fluids if the patient needs it so why bother when the hospital is 5 minutes away.

I would think establishinga second IV would be more beneficial to saving time than a lactate check.


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## Melclin (Jun 24, 2012)

NVRob said:


> Ok. So we all know that multiple things can cause an increase in lactate ranging from intense exercise all the way up to septic shock.
> 
> My question is why is it unreasonable for paramedics to be able to check a lactate level and use it, along with other clinical findings to help rule in/out sepsis and base their treatment off of it? I'm not advocating basing a treatment path off of a single number from a field lactate test. If we can get a POC lactate level prior to prehospital fluid administration, which will lower lactate levels, why not allow it? I know the hospital is going to do their own labs but would it not help the ER if we come in with a patient with suspected sepsis if we can pass on a lactate level prior to prehospital fluid administration? I'm not saying a "Sepsis Alert" is necessary but would us being able to pass on a lab value during our patient handoff that will help the hospital initiate early goal directed therapy and potentially life-saving interventions be a bad thing? Medicine is a team effort involving multiple specialties, including EMS. It's been stated multiple times in this thread: early fluid resuscitation and antibiotic administration reduce the mortality in septic patients, more specifically patients in septic shock.
> 
> ...



Because instituting a (NEW TOY) like this is more complex than simply allowing it. Money has to be found in the budget for equipment, initial education, ongoing education, reprinting protocols, oversight of that education and of (NEW TOY)'s use. Consideration has to be given of any risk inherent in its introduction. Given the speed of transport apparent in your systems from the scene time thread, I'm surprised you guys have time to put gloves on. One does have to consider the risk of paramedics skipping other, perhaps more essential bits, in favour of (NEW TOY).



NYMedic828 said:


> I'd rather my ambulance had a thermometer before a lactate meter.
> 
> A lactate meter is just something I would have to do more work to inspect every tour and keep equipment for.
> 
> ...



I can honestly say that a temp informs or even changes a clinical decision in my practice about once every 2 weeks. I can count on one hand the number of times a monitor has changed anything in 1.5 yrs. I'm glad we have both, but if I had to chose, I'd be hard pressed to get rid of a thermometer. I can't fathom why your bosses would spend ALOT of money on something like NIBP, or big brand/expensive head blocks or whatever and then no give you a thermometer.


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## NYMedic828 (Jun 24, 2012)

Yea I realize people make the argument that a thermometer doesn't truly change treatment, but it seems silly that we can't have a tool that is so simple, gives a definitive result and cost less than some of our disposable equipment. 

But that's for another thread I guess.


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## Melclin (Jun 24, 2012)

NYMedic828 said:


> Yea I realize people make the argument that a thermometer doesn't truly change treatment, but it seems silly that we can't have a tool that is so simple, gives a definitive result and cost less than some of our disposable equipment.
> 
> But that's for another thread I guess.



Maybe I'm just an idiot but I think it often changes treatment. Perhaps sepsis or infection isn't far off your radar, but I've had a few times where I was sitting there thinking...hmmm welll....hmm... and took a temp and everything was clear.


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