# Central Lines Prehospitally



## Handsome Robb (Apr 27, 2013)

What's the benefits? What's the risks? If you're system is placing them, when and why are you doing it? What criteria/protocols do you have for them? Where are you placing them, only IJs or are you using other sites? Are you rural, suburban or urban?

From recent posts it seems like they're placed in cardiac arrests or "anyone who needs one" in a certain system. With that said, what's the preferred route of medication administration in cardiac arrests? It's peripheral IV not central line. They don't even use them in the hospital during arrests. Are they being placed. In criticsl trauma patients? If so, why? What's the point? That person doesn't need a paramedic who can place a central line, they need a trauma surgeon, their team and a hospital. How long are transports being delayed while a central line is laced on scene? 

Are there any studies out there supporting their placement in the field in regards to morbidity/mortality? I googled it briefly at work but we were slammed and I didn't have time to find anything of any value.

Are you using the to monitor CVPs? If so, what's the benefit and is it going to change your treatment? 

Do the hospitals leave them in place or pull them? If they're immediately pulling them what's the point of even placing them and exposing the patient to the risk of infection? Not only have you created a much larger infection risk for the patient but you've also used a site that the hospital could have used for a line that was placed in a proper sterile field that can be utilized for an extended period of time.

I'm not trying to start a fight, I'm truly curious . I don't know a ton about them or the benefits vs risk in the emergency setting. What makes them so much better than a peripheral IV (including EJs, yes they're peripheral) and IOs? 

Like I said, I just want to know. We are allowed to access them if a patient is in extremis but even then we are still looking for other points of access then switch to using that as soon as we get one. 

Ready, set, go!


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## Ecgg (Apr 27, 2013)

The following landmark study "An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU" was conducted in ICUs in Michigan. They were losing money heavily and had to find a solution.

This accompanied Appendix  list the dangers if proper procedures are not followed.

Appendix A
Catheter-Related Blood Stream Infections
(CR-BSI) FACT SHEET​
Bottom line
1. CR-BSIs are associated with increased morbidity, mortality and costs of care.
2. CR-BSIs are a preventable complication that causes as many as 11 deaths every day in the
U.S.
3. The following interventions decrease the risk for CR-BSIs:
• Appropriate hand hygiene,
• Use of chlorhexidine for skin preparation,
• Use of full-barrier precautions during central venous catheter insertion,
• Subclavian vein placement as the preferred site, and
• Removing unnecessary central venous catheters.


Wash your hands before inserting a central venous catheter
Bottom Line: Proper hand hygiene is required before and after palpating catheter insertion sites, as well
as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. In
addition, the use of gloves does not obviate the need for hand hygiene. Category IA
Since 1977, at least 7 prospective studies have shown that improvement in hand hygiene significantly
decreases a variety of infectious complications. Proper hand-hygiene procedures can be achieved through
the use of either a waterless, alcohol-based product (1) or an antibacterial soap and water with adequate
rinsing (2). Compared with peripheral venous catheters, CVCs carry a substantially greater risk for
infection; therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs
should be more stringent than proper hand hygiene alone.
Ref:
1. Pittet D et al. Lancet 2000;356:1307–9 2. Larson EL et al. Am J Infect Control 1995;23:251–69

USE OF FULL-BARRIER PRECAUTIONS DURING CVC INSERTION
Bottom Line: Maintain aseptic technique for the insertion of intravascular catheters. Category IA
Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape)
during the insertion of CVCs substantially reduces the incidence of CRBSI compared with standard
precautions (e.g., sterile gloves and small drapes). (5,6)

You can read the rest in the said Appendix.


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## JPINFV (Apr 27, 2013)

Considering it's hard enough getting hospital based personnel to observe proper sterile technique for central lines... having EMS put one is while gloving, gowning, preping, draping, and doing it under truly sterile technique would be... interesting.


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## VFlutter (Apr 27, 2013)

*http://www.emtlife.com/newreply.php?do=newreply&noquote=1&p=477262*

You can probably guess my stance on the topic from previous threads but I am absolutely against prehospitally placed central lines. In my opinion there is just no benefit and there are just as effective alternatives with less risks. Central lines are extremely useful in certain situations when properly placed and utilized however not every cardiac arrest or trauma patient need one. Actually relatively few do. 

The ambulance is no environment to be placing central lines. Ideally CVCs should be placed with ultrasound guidance with full sterile precautions. There used to be a time when we would throw femoral CVCs in all cardiac arrest patients in the hospital. Even during a code they would still do a thorough betadine cleanse and use basic sterile precautions (gloves/mask). If the patient was resuscitated they would place a subclavian or IJ CVC the proper way and immediately pull the femoral. Now we just use IOs and peripherals. 

*Disclamer: I am going off what I saw in a certain video. My assumptions could be wrong but I think it was pretty clear* Placing a central line in a "dirty" ambulance using non sterile gloves, no mask, no sterile gown or drapes and no betadine prep is absolutely inappropriate. 

Any central line that is placed in an unsterile fashion will pulled as soon as possible. Most likely in the ER before the patient ever gets to the unit. So is it worth placing a central line that will only be used for a few hours? Especially with the effort needed to place them and the relative risks. Someone can try to convince me otherwise but I can not think of any situation where it would be necessary. 

Risk vs Benefit: CVC are great because you have reliable access to central venous circulation. You can infuse large volumes of fluid and medications which will quickly be distributed. You can easily give medications (Chemo, Potassium, Pressors) that are caustic to peripheral veins. You can use a CVC for TPN, dialysis, or plasmaphersis. You can monitor CVP which is helpful however I do not think you would be able to get accurate readings in an ambulance due to movement artifact.

The major risks are infection, thrombus, arrhythmia, pneumothorax. CLABSI and sepsis is a major complication. To keep it short I won't go I won't go into all the statistics but there is a ton of data out there, especially from the Surviving Sepsis Campaign. Pneumos occasionally occur and happen more commonly with blind insertion without use of ultrasound. Thrombus either from the lines itself or DVT from the vein where the line originates is somewhat common if not anticoagualted. Ventricular arrhythmias are common but usually transient and resolve when the guidewire is removed.   

Alternatives. IO's are much quicker, have less risks, and are pretty much as effective in a prehospital environment. Or just a large bore IJ would be comparable.   

Bottom line: I do not see any reason to place a central line prehospitally. The risk does not outweigh the benefit and there are better alternatives. And as mentioned before the line will be pulled in the ER. 

But it is a super cool exciting invasive procedure that you can brag about


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## FLdoc2011 (Apr 27, 2013)

I agree in that I don't see a need for prehospital central lines when an IO can fill the role of an emergency line much quicker and safer than placing a line in that environment.  

I place them routinely in the hospital and the standard of care now is full body drape under sterile technique using ultrasound guidance (most for IJs).   So right there that's not practically feasible prehospital.   

Besides infections,  I've seen pneumothoracies (even from experienced operators),  arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications.   Are you prepared to deal with those in a prehospital environment?


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## Summit (Apr 27, 2013)

Echoing what others have stated above:
The benefits of a prehospital CVC over an IO are essentially nonexistant while the risks of a prehospital CVC over an IO are HUGE. 

We don't even use CVCs for in-hospital codes except in the most extreme situation: blew two sternal IOs so anesthesia went gown/betadine/sterile glove/drape and did a femoral... the systemic solution was to switch the entire system to EZIO, so no more code CVC starts. If we have an in-hospital code and don't have existing access, we start an EZIO and we don't even bother with starting a peripheral .


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## Ecgg (Apr 27, 2013)

FLdoc2011 said:


> I agree in that I don't see a need for prehospital central lines when an IO can fill the role of an emergency line much quicker and safer than placing a line in that environment.
> 
> I place them routinely in the hospital and the standard of care now is full body drape under sterile technique using ultrasound guidance (most for IJs).   So right there that's not practically feasible prehospital.
> 
> Besides infections,  I've seen pneumothoracies (even from experienced operators),  arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications.   Are you prepared to deal with those in a prehospital environment?



Pneumothorax? No problem. Needle thoracentesis, 2 invasive procedures back to back. It's all about hitting those numbers annually baby!


I have seen the above scenario play out often post resuscitation in the ER when residents were placing central lines via subclavian route with no ultrasound guidance. You can hear the needle lung puncture and the nurse going straight to get the chest tube kit.


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## JPINFV (Apr 27, 2013)

FLdoc2011 said:


> Besides infections,  I've seen pneumothoracies (even from experienced operators),  arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications.   Are you prepared to deal with those in a prehospital environment?



Also, in my limited observational experience as a med student, have seen atrial placements where the only "indication" that it was atrial in a severely hypotensive patient was provider gestalt followed by blood gas confirmation after they had already pulled it.


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## Akulahawk (Apr 27, 2013)

Before the IO in adults came into more wide-spread use, I was a bit of an advocate for the prehospital placement of central lines. I'm not anywhere near as much an advocate for this as I was. Mostly I'm an advocate for being able to start a line in a vein that won't collapse, even in low-flow situations. The IO now fills that void (so to speak). Would it be nice to be able to place a central line? Sure. However, in the prehospital environment, such a start should be covered by ABX as soon as the patient gets to the ED. In _my_ view, field IV lines should end up being done in this manner: peripheral → IO → Central Line (Like IJ or Subclavian). The whole thing should stop at the IO because most of the time, that's going to be successfully placed. 

What do I want? Simple. Medication and fluid access. Nothing more, nothing less. Where I'm at, I would completely expect to never place a CL in the field because of the benefits of IO and risks of CL placement AND the proximity of hospitals. However, I feel that should a patient already have a central line in place, Paramedics should be allowed to access the line _if_ IV access is needed.


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## NomadicMedic (Apr 27, 2013)

When I worked in Washington, I was taught to place a subclavian CL. My protocols allowed placement of a CL. I never used it because I had access to an EZ-IO device. I'm of the belief that field placement of central lines should go the way of the PASG. There are easier, safer alternatives.


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## Handsome Robb (Apr 27, 2013)

Seems like my train of thought is similar to the rest of everyone who has posted. Thanks for the responses.

Before the EZIO or even IOs in general I could see how a CVC would be useful and potentially have benefits that outweigh the risks. With that said, since the IO has pretty much wandered into nearly all EMS systems I don't see any reason to be placing them...a properly place and flushed IO will flow just fine, I've seen it with my own two eyes. Generally we will infuse a liter of NS in the first 10-15 minutes of an arrest with moderate pressure in the pressure bag. Crank the pressure up the flow rate goes up, to a point.


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## Akulahawk (Apr 27, 2013)

DEmedic said:


> When I worked in Washington, I was taught to place a subclavian CL. My protocols allowed placement of a CL. I never used it because I had access to an EZ-IO device. I'm of the belief that filed placement of central lines should go the way of the PASG. There are easier, safer alternatives.


I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.


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## VFlutter (Apr 27, 2013)

Akulahawk said:


> I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.



In that situation I think a large gauge EJ/IJ would be sufficient without placing a central line.


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## Aidey (Apr 27, 2013)

Akulahawk said:


> I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.



I think it should depend on the system. I can understand it being used in a CCT/Flight situation working under an expanded scope.* With the EZ IO and the right needles you've got 6 sites to choose from. If your patient has none of those sites available, you've got bigger issues than venous access. At some point you have to realistically evaluate if it is necessary to spend so much time on venous access. 




*As in an actual CCT environment. Not a flight agency with a couple add on meds.


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## jwk (Apr 27, 2013)

Chase said:


> In that situation I think a large gauge EJ/IJ would be sufficient without placing a central line.



An EJ is generally considered a peripheral IV, although it can be advanced into the central circulation with a long enough catheter.

An IJ by definition is always a central line.


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## medicsb (Apr 27, 2013)

Akulahawk said:


> I don't necessarily think that prehospital CL placement should go the way of the PASG... but it should be available in the event that you blow/are unsuccessful in peripheral line placement and your IO placement was similarly unsuccessful.



Considering how rare this situation would be, I don't think you could ever justify the procedure due to infrequent practice.  In my experience, plenty of medics forget that an EJ is peripheral and jump to an IO when they don't _really_ need to.


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## jwk (Apr 27, 2013)

FLdoc2011 said:


> I place them routinely in the hospital and the standard of care now is full body drape under sterile technique using ultrasound guidance (most for IJs).   So right there that's not practically feasible prehospital.
> 
> Besides infections,  I've seen pneumothoracies (even from experienced operators),  arterial cannulations, and airway compromise from neck hematomas following central lines to name a few complications.   Are you prepared to deal with those in a prehospital environment?



Full sterile barrier precautions is definitely the standard of care now, and US guidance is heading that way, although I still do my IJ's the old fashioned way.  As with sticking an ETT in the wrong pipe, it's not a sin to hit the carotid with a finder needle or even the 18 ga needle/catheter used to place the guidewire, which I've done more than once.  However, putting that 8-9FR introducer in big red will buy you nothing but pain and heartache.  I've seen it twice, not by me thankfully, and it is quite impressive to see the resulting airway-compromising neck hematoma.  (if by some chance you see someone do that, DO NOT pull out the catheter - call a surgeon).  Pneumothorax from an IJ should be an exceedingly rare event, and in many studies, the incidence was 0%.  Not the same with subclavians, where even successful placement in the SCV is associated with a fairly significant incidence of pneumo.

With all the restrictions and guidelines being placed on CVL use in-hospital, I can't see that it has a pre-hospital use any longer.


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## FLdoc2011 (Apr 27, 2013)

Even in hospital setting we have EZIO if needed for emergency access.  Most of the time everyone already has at least a periph site but during a code or other urgent situation if that's not working we'll usually drill in an IO real quick.   

Sometimes may do a quick femoral line but those are becoming more and more frowned on.  

Really if prehospital providers are looking at a possible emergency access site for during codes then a femoral would make more sense since you can easily throw one in without interrupting compressions.   

If you have time to properly do an IJ or subclavian then I doubt it's that urgently needed where an IO wouldn't suffice.


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## 46Young (Apr 27, 2013)

This thread is interesting. We discuss, ad nauseum at times, the desire to increase educational standards, with a reward of increased scope of practice. But here, we're scrutinizing the use of central lines in the pre-hospital environment. I've said, several times, that pre-hospital EMS has an upper limit on what is practical regarding education and scope. How far do we want to go? How much of an increased scope is appropriate when our real goal is treating the signs and symptoms of the patient's condition, ensuring their hemodynamic stability, and transporting to the definitive care of the ER? Where do we hit the ceiling, so to speak? Some agencies refer to their ambulances as "mobile intensive care units." I feel that this is going a little too far. In certain cases, we do similar work to what a patient will experience in an ER, but that does not mean that we should be able to do anything and everything that an ER can do initially. EMS does have its limits.

Based on this thread (I agree with the OP), central lines seem to be past that ceiling of reasonable pre-hospital interventions by paramedics. I feel that central lines in the field (when EJ's and IO's are an option) are relegated to a "gee whiz" status in pre-hospital care.

At some point, generally speaking, additional interventions become inappropriate in the pre-hospital environment when definitive care is readily accessible, and doing these interventions in the field has no positive effect on patient outcomes.

One more thing - this thread was motivated by the use of central lines by KCM1. If KCM1 were the average in pre-hospital care, EMS as a profession would have but a small fraction of the issues it currently has. We should applaud the relatively few quality EMS agencies, not pick them apart to the last minor detail. I ask all of you, if your employer put forth a recruitment video, which showed a few significant calls and testimonials from field crews and management, how would your department compare to KCM1? Not too favorably, for sure, in nearly all cases. 

Try these videos on for size. The first one was made in 2004 or 2005, when I was working there as an EMT and in medic school. The second one is about NS-LIJ working in contract with Rockville Centre. Supervisor DeGeorge came in one class after me - great medic and great guy. What do you think about these videos?

http://www.northshorelij.com/hospitals/location/cems-videos













I've said


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## JPINFV (Apr 27, 2013)

46Young said:


> This thread is interesting. We discuss, ad nauseum at times, the desire to increase educational standards, with a reward of increased scope of practice. But here, we're scrutinizing the use of central lines in the pre-hospital environment. I've said, several times, that pre-hospital EMS has an upper limit on what is practical regarding education and scope. How far do we want to go? How much of an increased scope is appropriate when our real goal is treating the signs and symptoms of the patient's condition, ensuring their hemodynamic stability, and transporting to the definitive care of the ER? Where do we hit the ceiling, so to speak? Some agencies refer to their ambulances as "mobile intensive care units." I feel that this is going a little too far. In certain cases, we do similar work to what a patient will experience in an ER, but that does not mean that we should be able to do anything and everything that an ER can do initially. EMS does have its limits.
> 
> Based on this thread (I agree with the OP), central lines seem to be past that ceiling of reasonable pre-hospital interventions by paramedics. I feel that central lines in the field (when EJ's and IO's are an option) are relegated to a "gee whiz" status in pre-hospital care.
> 
> At some point, generally speaking, additional interventions become inappropriate in the pre-hospital environment when definitive care is readily accessible, and doing these interventions in the field has no positive effect on patient outcomes.



To quote a famous SCOTUS opinion in Jacobellis v Ohio, "I know it when I see it." No one is going to argue that EMS should be doing exploratory laparotomies in the back of the ambulance. However the line is always moving back and forth. In my mind, deciding on scope of practice is a two part test. First, given the time frame involved in the vast majority of cases, does this intervention improve some sort of outcome (decreased mortality/morbidity, decreased pain, increased provider safety, etc)? Second, given the skill of the average paramedic in the system, can it be performed safely? Probably the best example is RSI. Yes, I think an argument can be made that RSI is beneficial in some circumstances. Are all systems skilled and educated enough to implement it? Absolutely not. 

Central lines, in my opinion, fails question number one when it comes to placing them in the field. 



> Try these videos on for size. The first one was made in 2004 or 2005, when I was working there as an EMT and in medic school. The second one is about NS-LIJ working in contract with Rockville Centre. Supervisor DeGeorge came in one class after me - great medic and great guy. What do you think about these videos?
> 
> http://www.northshorelij.com/hospitals/location/cems-videos




...Roll With It...


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## Akulahawk (Apr 28, 2013)

I'm truly glad for really sparking off a good discussion on the matter. I've never worked in an area where we could do a CL, and the chances of that being approved any time soon are about slim and none... and slim just died... 

It's just another tool in the tool bag, and if your area has need for it, make sure your providers know how to use it. If there's no real need for it... why have it there? I would much rather spend time educating Paramedics how to access pre-existing central lines safely/correctly and be able to use it on a routine basis (instead of requiring OLMC for access OK) than spending that time doing CL placement education.


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## Ecgg (Apr 28, 2013)

46Young said:


> This thread is interesting. We discuss, ad nauseum at times, the desire to increase educational standards, with a reward of increased scope of practice. But here, we're scrutinizing the use of central lines in the pre-hospital environment. I've said, several times, that pre-hospital EMS has an upper limit on what is practical regarding education and scope. How far do we want to go? How much of an increased scope is appropriate when our real goal is treating the signs and symptoms of the patient's condition, ensuring their hemodynamic stability, and transporting to the definitive care of the ER? Where do we hit the ceiling, so to speak? Some agencies refer to their ambulances as "mobile intensive care units." I feel that this is going a little too far. In certain cases, we do similar work to what a patient will experience in an ER, but that does not mean that we should be able to do anything and everything that an ER can do initially. EMS does have its limits.
> 
> Based on this thread (I agree with the OP), central lines seem to be past that ceiling of reasonable pre-hospital interventions by paramedics. I feel that central lines in the field (when EJ's and IO's are an option) are relegated to a "gee whiz" status in pre-hospital care.
> 
> ...


I am all for increasing educational standards and there should be no ceiling when it comes to education. I don’t care what letters follow your name there is no such a thing as too much education. 

The problem here is not that we are hitting the celling. Perhaps a better way to look at it, is what is our ultimate goal or what are we ultimately trying to accomplish?

 I venture most would agree we want the patient to get discharged from the hospital with the least amount of complications that he/she incurred from EMS interventions. If we are first on scene we make the decisions what prehospital interventions we are going to administer or withhold. This is where real education (not a 50 hours of CME) comes into play to reel in your outlaw biker cowboyitis and give the patient best possible outcome. 
Does the benefit of my intervention outweigh the negative side effects?
In case of prehospital central lines I will make the case it probably will not.
If we take cardiac arrest for example 






Quality compressions, recoil, AED, Airway control would be all much higher class interventions. AHA States Amiodarone is recommended after defibrillation and epinephrine in cardiac arrest with persistent VT or VF (Class IIb).

So for a cardiac arrest in prehopsital environment which in itself not conducive to proper sterility procedures, we will subject the patient to possibility of sepsis (leading cause of ICU mortality) while giving them class 2 b medications which “may be considered”. 
If I say I will go ahead and do this anyway because I am all about hitting my annual numbers and doctors told me god speed and gave me their blessings in 50 hour annual CME. Are you really helping this patient?

On the other hand the doctors decided to give you point of care testing meter and a thermometer (this is way above the ceiling; paramedics reading labs?). You are now able to read the blood chemistry and notify for SIRS/Sepsis, Toxicology Overdose or Abuse, Cardiac markers, Abnormal Coags, Blood gases  etc.  Rapid notification and transport to the proper facility. Here the benefits outweigh the risks of the procedure.


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## Handsome Robb (Apr 28, 2013)

This wasn't meant to nitpick at any specific system, I know with the recent thread it could be misconstrued that way. CVCs were brought up and it sparked my interest.

KCM1 does a lot of things very well, I'd love to go to the medic school up there but it's not somewhere I'd want to live or a system I'd want to work in, just my opinion but that's not what this thread is about.

Are there any other ground 911 systems in the U.S. or internationally for that matter? I know our flight service RNs can, I'm not sure of the parameters behind when and why though or if they do it very often. I'm more interested in 911 services.

I don't claim to be an expert on central lines, quite to the contrary. I haven't been in the field that long, about 18 months but in that time I've seen a LOT of patients and I've always been able to get a line whether it be in an arm, leg, EJ or an IO. Drilled one live IO, the rest have been arrests. Honestly there are very few times I would even have time to place one. In the cases where we really needed an IV and couldn't get one, after a few attempts in the arm and maybe an EJ we're at the ER.

What medications would be better administered through central lines in the prehospital field? The only ones that come to mind are adenosine and pressors. Sure you can give big fluid boluses through them but without being able to administer blood products this doesn't really matter unless your goal is to replace their entire volume with saline. 

Thank you for all the input I'm interested to see where this goes.


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## VFlutter (Apr 28, 2013)

Robb said:


> I know our flight service RNs can, I'm not sure of the parameters behind when and why though or if they do it very often. I'm more interested in 911 services.



From my understanding flight RNs are primarily trained to place central lines in the hospital setting. For situations like if they pick up a critical patient at rural hospital who may not be competent or willing to place one themselves. I would think it is extremely rare that they place them on scene calls. But I could be wrong.




Robb said:


> What medications would be better administered through central lines in the prehospital field? The only ones that come to mind are adenosine and pressors. Sure you can give big fluid boluses through them but without being able to administer blood products this doesn't really matter unless your goal is to replace their entire volume with saline.



Pressors/inotropes are really the only ones I can think of. Sure Adenosine would be much more effective through a central line but it shouldn't be used as justification for placing a central line.


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## ExpatMedic0 (Apr 28, 2013)

I really have no idea why EMS would need to do central lines, especially since the introduction of things like the EZ IO. Does anyone have 1 good reason?


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## medicsb (Apr 28, 2013)

I can't think of a reason why a flight/CC team should be allowed to place CVCs, either, unless they're well experienced in doing so.  The only non physicians I've heard of placing CVCs in hospital are NPs and PAs whom rarely make up a flight crew or CCT team.  

To me, its about training and ongoing experience with the procedure.  Doing it once or twice a year is not sufficient experience.


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## Aidey (Apr 28, 2013)

medicsb said:


> I can't think of a reason why a flight/CC team should be allowed to place CVCs, either, unless they're well experienced in doing so.  The only non physicians I've heard of placing CVCs in hospital are NPs and PAs whom rarely make up a flight crew or CCT team.
> 
> To me, its about training and ongoing experience with the procedure.  Doing it once or twice a year is not sufficient experience.



I can see it, depending on the area. There are some places in the US where the "ED" is legally 2 beds in the local clinic and is staffed by a PA and the MD comes by on Tuesdays and Thursdays for 6 hours each day. For CCT crews operating in those areas, I think it makes a lot more sense. For a crew that spends their time going between level II and I hospitals...not so much.


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## medicsb (Apr 28, 2013)

Aidey said:


> I can see it, depending on the area. There are some places in the US where the "ED" is legally 2 beds in the local clinic and is staffed by a PA and the MD comes by on Tuesdays and Thursdays for 6 hours each day. For CCT crews operating in those areas, I think it makes a lot more sense. For a crew that spends their time going between level II and I hospitals...not so much.



Those "EDs" are very remote and of very low volume that, again, contact with them is going to be fairly rare and lack of adequate vascular access, rarer.  

But, regardless, I'm not necessarily anti-CVC in all prehospital or inter-facility situations.  I just think that whoever is doing it should be well trained and well experienced with the procedure (and the complications).  I'd bet that >99% would not be able to adequately train nurses or medics for prehospital or IFT CVC placement.


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## Aidey (Apr 28, 2013)

medicsb said:


> Those "EDs" are very remote and of very low volume that, again, contact with them is going to be fairly rare and lack of adequate vascular access, rarer.



To clarify, I was referring to CCT services that cover areas with multiple hospitals like that. There are still a number of areas in the US and Canada that have a large hub city, and then a ton of small rural communities around it. In an area like that the flight agency may have several calls a week those "EDs". In that case the flight crew would actually be performing the high risk skills more often than the ED staff.


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## usalsfyre (Apr 28, 2013)

medicsb said:


> contact with them is going to be fairly rare


I found it was several times a week. 



medicsb said:


> and lack of adequate vascular access, rarer.


I would say it was the rule rather than the exception. Finding multiple pressors piggybacked into a crappy peripheral was not at all unusual.    



medicsb said:


> But, regardless, I'm not necessarily anti-CVC in all prehospital or inter-facility situations.  I just think that whoever is doing it should be well trained and well experienced with the procedure (and the complications).  I'd bet that >99% would not be able to adequately train nurses or medics for prehospital or IFT CVC placement.


I agree with this. The majority of community based services can't provide the training opportunities.


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## Bieber (Apr 28, 2013)

I think it's perfectly feasible for paramedics to place central lines in a sterile manner, even in the back of an ambulance... I just don't see a great need for it.


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## Carlos Danger (Apr 28, 2013)

Bieber said:


> I think it's perfectly feasible for paramedics to place central lines in a sterile manner, even in the back of an ambulance... I just don't see a great need for it.



Have you ever tried it?

It is not feasible. Trust me.


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## Carlos Danger (Apr 28, 2013)

medicsb said:


> *I can't think of a reason why a flight/CC team should be allowed to place CVCs, either*, unless they're well experienced in doing so.  The only non physicians I've heard of placing CVCs in hospital are NPs and PAs whom rarely make up a flight crew or CCT team.
> 
> To me, its about training and ongoing experience with the procedure.  Doing it once or twice a year is not sufficient experience.



You really can't think of a reason why a critically ill patient might benefit from central access during transport?

Proper training and experience is a given - _no one_ should be performing _any_ intervention without the proper training, physicians included.


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## chaz90 (Apr 28, 2013)

Bieber said:


> I think it's perfectly feasible for paramedics to place central lines in a sterile manner, even in the back of an ambulance... I just don't see a great need for it.



I've seen enough sterility problems in ERs with CVC placement that I wouldn't ever want to see one in a dingy, bouncing metal cube.


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## medicsb (Apr 28, 2013)

Halothane said:


> You really can't think of a reason why a critically ill patient might benefit from central access during transport?
> 
> Proper training and experience is a given - _no one_ should be performing _any_ intervention without the proper training, physicians included.



It's not so much a matter of indications for CVC access, but the nurse or medic having enough experience and training to do it.


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## Bieber (Apr 29, 2013)

Halothane said:


> Have you ever tried it?
> 
> It is not feasible. Trust me.


Can you tell me in what way you find it unfeasible? I'm not saying it isn't impractical, or that it isn't less than ideal, only that it's not physically impossible to accomplish it adequately with the proper tools, time, and training.

Thanks.


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## VFlutter (Apr 29, 2013)

Bieber said:


> Can you tell me in what way you find it unfeasible? I'm not saying it isn't impractical, or that it isn't less than ideal, only that it's not physically impossible to accomplish it adequately with the proper tools, time, and training.
> 
> Thanks.



To argue semantics when I hear* feasible* I think of the definition as "_Possible to do easily or conveniently". _I do not think he was arguing that it was physically impossible however it is not easy, convenient, nor practical. But that is just the way I took it.


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## Bieber (Apr 29, 2013)

Chase said:


> To argue semantics when I hear* feasible* I think of the definition as "_Possible to do easily or conveniently". _I do not think he was arguing that it was physically impossible however it is not easy, convenient, nor practical. But that is just the way I took it.


I must have misunderstood what he meant by "feasible"; I would agree with your definition.


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## Carlos Danger (Apr 29, 2013)

Bieber said:


> Can you tell me in what way you find it unfeasible? I'm not saying it isn't impractical, or that it isn't less than ideal, only that it's not physically impossible to accomplish it adequately with the proper tools, time, and training.
> 
> Thanks.



No, it is not physically impossible to accomplish. But that is not the same thing as being practical (feasible = practical).

Picture the process of donning sterile gloves, gown, and mask, opening a sterile CVC line kit, cleansing the site, prepping the line, placing the line, flushing all 3 ports of the line, and placing a sterile dressing, all without breaking sterility. Remember, if at any point, anything that should be sterile touches something that is not-sterile, you start over. That means no touching anything at any point during the process, including the patient. And this is all done at the scene, because there is definitely no doing this while moving towards the hospital.

Now think about the time involved here. Even if everything goes well, you are looking at a minimum of 5-10 minutes of prep time alone. In the hospital, the process of placing one of these can easily take 30 minutes or more. And that is by people who do them all the time and have a lot more room and help than you have in the ambulance.

The places where I've done these (and I would guess, most other places that do these prehospital), we simply didn't bother with all that. You open the kit and prep your equipment, put on some sterile gloves, clean the site, and make the stick. You can justify this occasionally with the fact that in some patients in some situations, the need for central access outweighs the risk of infection. But I think you are talking about a really, really small population here, and in most cases we are just exposing the patients unnecessarily to the risk of a difficult procedure in the field and introducing pathogens directly into the central circulation. Not good.

The other thing is indication. Why do you need a central line, anyway? The most common indication for them in the hospital is in patients who are getting multiple infusions (pressors, abx, etc) or caustic meds (chemo, etc) that irritate peripheral veins. 

Lastly, CVC's are quite often not easy, even in the best circumstances. US definitely makes them easier and safer, but now you are talking about adding another significant expense and training burden just to do an occasional CVC?


For a program that does a lot of transports of really sick patients, AND has more experienced than average clinicians, AND has a good way to train on them regularly, I think it may make sense to have CVC's in their skills repertoire. But you are mostly just talking about helicopter and some ground CCT programs.  

Bu generally speaking, CVC's are just impractical to do in EMS, and very rarely necessary. Especially with the advent of the IO devices we have now.


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## Clipper1 (Apr 29, 2013)

First: Why do you want to take time to do a central line?  Especially in a code.

This has already been done in the past and was even in the Paramedic curriculum in the 70s and 80s. But, like many things in medicine, advancements are made. Less time consuming techniques are developed or the need to have one immediately is no longer necessary. PA (Swanz) catheters were also placed in every ICU patient at one time and most were not needed.  CVLs are great but often in the hospital another form of central line called a PICC can also suffice for those patients which are difficult sticks and who need long term therapy.  

Do you just want the skill to say you have it because it is "advanced"? There is nothing advanced when you are going backwards when it comes providing efficient and quick effective therapy. If it is only for bragging rights, the only ones to impress would possibly be reading a forum like this.  Others who work with central lines daily in the hospital which are placed under more ideal situations are rarely impressed.

Why not the IO or EJ (peripheral)?  Even in Washington (Seattle) the question of why central lines are still being placed when IOs could be done.  Those who say "because that's how it has always be done" are not really giving a reason as to "why".   Why stop CPR to place a central line?  Why have to deal with the potential serious complications of a central line which most of the time you can not? Do you want to do the central line because you are inadequate at placing a PIV or you think the IO is too simple and not as cool as saying you "do central lines"?


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## Aidey (Apr 29, 2013)

For the record, I don't think there is a single person here saying they want central lines to be added to their protocols, so it is unclear who you are addressing in your post.


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## truetiger (Apr 29, 2013)

I think they have a place in EMS, I couldn't tell you how many times I've wanted to start one on a transfer patient because the sending facility is running a pressor dose of dopamine on a septic patient through a peripheral site...they simply won't place central lines even in patient's that are in bad need of one. I think its leasable, with proper training, to allow central lines in transfer situations in which the ED is improperly treating the patient. In fact, there's quite a few air and ground cct services that do this, that is respond to the po dunk facility and fix the $&@# up before leaving.

Do they have a place on a scene call or in an ambulance? No way. If your patient is sick enough you think they warrant a central line, then why not drill them? IO = central access.


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## Rialaigh (Apr 29, 2013)

truetiger said:


> I think they have a place in EMS, I couldn't tell you how many times I've wanted to start one on a transfer patient because the sending facility is running a pressor dose of dopamine on a septic patient through a peripheral site...they simply won't place central lines even in patient's that are in bad need of one. I think its leasable, with proper training, to allow central lines in transfer situations in which the ED is improperly treating the patient. In fact, there's quite a few air and ground cct services that do this, that is respond to the po dunk facility and fix the $&@# up before leaving.
> 
> Do they have a place on a scene call or in an ambulance? No way. If your patient is sick enough you think they warrant a central line, then why not drill them? IO = central access.



I could see this warranted. CC interfacility transport gets on scene and the patient is about to bite the dust, your looking at an hour or an hour and a half transport time. I could completely agree with allowing these medics to start a central line, confirm correct tube size and placement, correct drip dosage, etc etc over 30 minutes to an hour to stabilize the patient in the ER prior to transporting, maybe even call the receiving doc to see what meds should be started prior to going en route to increase survival chances of the patient...

this is about the only application I see it even remotely beneficial


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## Clipper1 (Apr 29, 2013)

Aidey said:


> For the record, I don't think there is a single person here saying they want central lines to be added to their protocols, so it is unclear who you are addressing in your post.



Am I supposed to single out someone?  I don't feel that is necessary for the content of this discussion.  Is there a reason you feel I should single out someone?

My post was just asking some of the things to consider.  Our Paramedics do insert central lines and these are the same questions are being asked. I also know of a few other agencies which insert central lines. If you can not come up with an adequate reason for the insertion of central lines in the field then maybe it is time to consider moving on to what is more acceptable in this age where getting back to time sparing techniques to allow for effective compressions or minimally invasive procedures are being advocated.


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## Clipper1 (Apr 29, 2013)

truetiger said:


> I think they have a place in EMS, I couldn't tell you how many times I've wanted to start one on a transfer patient because the sending facility is running a pressor dose of dopamine on a septic patient through a peripheral site...they simply won't place central lines even in patient's that are in bad need of one. I think its leasable, with proper training, to allow central lines in transfer situations in which the ED is improperly treating the patient. In fact, there's quite a few air and ground cct services that do this, that is respond to the po dunk facility and fix the $&@# up before leaving.
> 
> Do they have a place on a scene call or in an ambulance? No way. If your patient is sick enough you think they warrant a central line, then why not drill them? IO = central access.





Rialaigh said:


> I could see this warranted. CC interfacility transport gets on scene and the patient is about to bite the dust, your looking at an hour or an hour and a half transport time. I could completely agree with allowing these medics to start a central line, confirm correct tube size and placement, correct drip dosage, etc etc over 30 minutes to an hour to stabilize the patient in the ER prior to transporting, maybe even call the receiving doc to see what meds should be started prior to going en route to increase survival chances of the patient...
> 
> this is about the only application I see it even remotely beneficial





If this is the situation to where you believe the patient is too unstable to transport without more lines or a central line, you call your medical director and allow an MD to MD discussion to take place.  Is the patient crashing when you pick them up?  Not every septic patient gets a central line. If they do it is to monitor CVP. If you are not monitoring CVP during transport and the patient is stable otherwise there might not be a need to put the patient at further risk with a central line until in the other facility. 

And, the alterative in transport or prior could also be an EJ. But, if the patient is crashing the IO is also a good alternative. 

You also should know that many times the kits for prehospital central access are short lines or catheters. They are not the standard central lines used in the hospitals.  You would not need an xray to confirm placement. This means they will not be used for monitoring CVP and they must be removed to another line to be placed.

Placement of a regular central line can be tedious and must have an xray.  Once in, you are not going to have much room for error and you don't just push it in if you don't feel you got it right.


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## truetiger (Apr 29, 2013)

Hmm central line only to monitor CVP? What about pressors? The local hospitals we frequent like to use dopamine as their pressor of choice for anything. Why make a septic patient tachycardic and irritate the heart? Sepsis isn't a pump problem, so you'll need to adequately fluid resuscitate them and take care of the pipe problem (decreased SVR). Levophed is a popular choice, and needs a central line for administration. 

Short catheters? Are you referring to a cordis? I don't know of any "short" central line catheter. A triple lumen can be administered through the cords.


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## Bieber (Apr 29, 2013)

Halothane said:


> No, it is not physically impossible to accomplish. But that is not the same thing as being practical (feasible = practical).
> 
> Picture the process of donning sterile gloves, gown, and mask, opening a sterile CVC line kit, cleansing the site, prepping the line, placing the line, flushing all 3 ports of the line, and placing a sterile dressing, all without breaking sterility. Remember, if at any point, anything that should be sterile touches something that is not-sterile, you start over. That means no touching anything at any point during the process, including the patient. And this is all done at the scene, because there is definitely no doing this while moving towards the hospital.
> 
> ...


Like I said, I agree that they are not practical for EMS, nor does there seem to be a tremendous need for them in our setting. The challenges to actually performing them, and performing them correctly, however, seem to have more to do with us than anything else.


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## Rialaigh (Apr 29, 2013)

Clipper1 said:


> If this is the situation to where you believe the patient is too unstable to transport without more lines or a central line, you call your medical director and allow an MD to MD discussion to take place.  Is the patient crashing when you pick them up?  Not every septic patient gets a central line. If they do it is to monitor CVP. If you are not monitoring CVP during transport and the patient is stable otherwise there might not be a need to put the patient at further risk with a central line until in the other facility.
> 
> And, the alterative in transport or prior could also be an EJ. But, if the patient is crashing the IO is also a good alternative.
> 
> ...




I know a lot of critical transport occurs between tiny outlying facilities and large level 1 centers. The facility that I do clinical work at and frequent often has a 9 bed ER, one doc in the whole hospital between 6p-6a, a 20 bed med surge and a 6 bed critical care neither of which are ever full. I know when we get a bad patient and call for a chopper to take them (or ground transport on cloudy, windy, rainy, full moon, or any other reason days...) if the patient is in real bad shape the ER doc wants them out as soon as possible and generally says "just get them the %#$ out of here. When the critical care transport team shows up its their show, our ER doc wants nothing to do with the patient, if you want blood we will get if for you, if you want meds we will pull them for you, its your show, you tell me what you want and we get it for you and then you get them the hell out. Any MD to MD communication would go like this "my team tells me the patient is XYZ and has ABC and needs EFG, what about HIJ" and the ER doc at our tiny facility would say "do whatever you want just get them out of here". 


I feel comfortable with the critical care transport near us, they are excellently trained, well equipped, calm, and ready to do anything. I would be perfectly okay with them placing a central line, getting their drips in order, starting blood, and then moving the patient out. I would feel much better with them starting a central line then our ER doc saying "call the CRNA in (45 minutes minimum) and have them place the line" most of our ER docs wont place central lines, some of them hate intubating and will call in the CRNA at night to do that...


There are plenty of small facilities where this is a reality, I am comfortable with the critical care transport near us doing ANYTHING that they want, they are well trained...


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## chaz90 (Apr 29, 2013)

I think an ED Doc that won't place a central line or intubate needs to reevaluate their career choice. The country does need more family practice physicians, few of which are ever called on to do either of those procedures.


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## truetiger (Apr 29, 2013)

See that's the problem. These docs are not ER docs. They are family practice physicians either moonlighting or by some turn in their career ended up in the ER. It's pretty bad when most of the medics and nurses have a better idea than they do.


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## Rialaigh (Apr 29, 2013)

chaz90 said:


> I think an ED Doc that won't place a central line or intubate needs to reevaluate their career choice. The country does need more family practice physicians, few of which are ever called on to do either of those procedures.



I agree but this isn't isolated to near me. Many many small town hospitals that get all the trauma and unstable cardiac patients first in to "stabilize" have these types of docs. The critical care teams that have the ability to act in part as a physician greatly increase the chances of these patients making it alive to an appropriate facility whether it be straight to an ICU or straight to surgery.


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## usalsfyre (Apr 29, 2013)

chaz90 said:


> I think an ED Doc that won't place a central line or intubate needs to reevaluate their career choice. The country does need more family practice physicians, few of which are ever called on to do either of those procedures.



The problem is most of these guys are FM docs or moonlighting residents.


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## VFlutter (Apr 29, 2013)

Just to clarify I think the original intent of the thread was 911 EMS medics (Non CCT) placing central lines in the field. Although CCT/Flight medics or RNs placing central lines in the hospital setting is a related topic it is really a totally different argument. 

In my opinion critical patients can be placed into 3 categories in relation to central lines...
A) Absolutely need a CVC for early goal directed therapy 
B) May be beneficial; not necessary, but would be convenient
C) Not indicated 

I think we have a bias towards thinking our patients are in group A when in reality the vast majority are in group B or even C. For many of the scenarios people have purposed it sounds like a central line would be been beneficial but not absolutely necessary. Then you again have to weigh the risk vs benefit. 

Up until just recently a central line with CVP monitoring was the standard of care for all septic patients. We are starting to move away from that and towards non-invasive measures. Some MDs won't place invasive lines until they get a few doses of antibiotics and have a therapeutic draw.

When a MD is refusing to place a central line do you just assume that they are incompetent to do so? Or do you have a conversation as to the reason behind why they are refusing? Is it possible they have a better understanding of the situation then you do? I have no doubt that some MDs in rural ERs may be unwilling due to competence, and rightfully so. Central line placement is not a benign procedure that you should be doing if you have not done one since your residency years ago.

A Cordis usually refers to a single lumen large diameter (8-9fr) central line. They not really used much anymore outside of trauma and CT surg. You can float a TLC, PAC, or TVP wire down them.


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## Rialaigh (Apr 29, 2013)

Chase said:


> Just to clarify I think the original intent of the thread was 911 EMS medics (Non CCT) placing central lines in the field. Although CCT/Flight medics or RNs placing central lines in the hospital setting is a related topic it is really a totally different argument.
> 
> In my opinion critical patients can be placed into 3 categories in relation to central lines...
> A) Absolutely need a CVC for early goal directed therapy
> ...




If your transport time is under an hour or an hour and a half (even longer likely) then I see 0 9-1-1 patients that fall into category A.

 There is absolutely no early goal directed therapy requiring a central line prior to the patient being evaluated by a physician, If we are talking strictly 9-1-1 response I see no reason to ever place one without having a critical care mobile team there taking control of the patient for an extended transport time.


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## Clipper1 (Apr 29, 2013)

truetiger said:


> Hmm central line only to monitor CVP? What about pressors? The local hospitals we frequent like to use dopamine as their pressor of choice for anything. Why make a septic patient tachycardic and irritate the heart? Sepsis isn't a pump problem, so you'll need to adequately fluid resuscitate them and take care of the pipe problem (decreased SVR). Levophed is a popular choice, and needs a central line for administration.
> 
> Short catheters? Are you referring to a cordis? I don't know of any "short" central line catheter. A triple lumen can be administered through the cords.



Cordis (brand name) could be used but not all that useful. It is also a single lumen.

You are not going to be placing multi lumen central catheters in the field. The EMS agencies which do place central catheters in the field will just use a longer large bore catheter which can be a 10 - 14g. 

Yes central lines (multi lumen) are used to monitor CVP. If you are not going to monitor CVP during transport, many times a PIV will give adequate flood. A second PIV is always advisable for transport which can administer meds. 

If a physician writes for norepinephrine then he or she should know it should be given via central line.  

Raileigh


> I feel comfortable with the critical care transport near us, they are excellently trained, well equipped, calm, and ready to do anything. I would be perfectly okay with them placing a central line, getting their drips in order, starting blood, and then moving the patient out.



If the team is well trained and has the time to do a real central line and wait for x-rays, reposition and suture, then great. Since many CCTs don't have the ability to carry blood, the formalities of the hospital would be to get the appropriate labs first. Hopefully the physician has already done that. 

Some EMS teams get annoyed when they transport flight or specialty teams such as pedi or neo because these teams are well trained and might spend 1 - 4 hours inserting lines and stabilizing before transport back.  They usually drop off and will be called back later. Few stick around to watch the teams.   But, these teams also spend hours training and continuing their education perfecting their skills in the hospital and must do x amount of CL insertions per quarter.  This would probably be difficult for many perhospital EMS based CCTs where getting enough intubations is a challenge. 

One of the reasons ER doctors want the patients out is bed availablity. If the patient is not transferred to a larger facility quickly they could lose the ICU bed. If the patient gets admitted to the small town hospital's ICU, transferring out is a :censored::censored::censored::censored::censored: due to getting someone to accept the patient. The exception is usually children since there is a standing agreement for them.

Which teams are you talking about? North Carolina? A few of their teams are very impressive but the ones I am familar with are a mix of different health care providers and are hospital based.


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## Clipper1 (Apr 29, 2013)

Rialaigh said:


> I agree but this isn't isolated to near me. Many many small town hospitals that get all the trauma and unstable cardiac patients first in to "stabilize" have these types of docs. The critical care teams that have the ability to act in part as a physician greatly increase the chances of these patients making it alive to an appropriate facility whether it be straight to an ICU or straight to surgery.



No they do not "act as a physician".

Everything they do can be within their scope of practice and they act under the protocols of their medical director (physician) and the directors (more physicians) of a specific unit. 

This applies to whoever and whatever title they have behind their name on the transport teams.  

But, their whole knowledge base and experience will be larger. One or two impressive skills alone does not save the patient.  If you insert a central line (not just a single lumen catheter) you should have the ability to use CVP monitoring and titrate all medications effectively.


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## usalsfyre (Apr 29, 2013)

Clipper1 said:


> If this is the situation to where you believe the patient is too unstable to transport without more lines or a central line, you call your medical director and allow an MD to MD discussion to take place.


And say what exactly? Order him to place a central when he's obviously not comfortable with the procedure? Or we leave the pt in a place where he's sure to die vs possibly dying in transport? Good way to be a pt advocate...



Clipper1 said:


> Is the patient crashing when you pick them up?  Not every septic patient gets a central line. If they do it is to monitor CVP. If you are not monitoring CVP during transport and the patient is stable otherwise there might not be a need to put the patient at further risk with a central line until in the other facility.


Pressors are a pretty good reason for a central line. Especially when you talk about taking the show on the road where peripherals can get pulled all too easy. Not to mention CVP is not an accurate target for fluid resus (citations to follow when I get home)


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## VFlutter (Apr 29, 2013)

Clipper1 said:


> Cordis (brand name) could be used but not all that useful. It is also a single lumen.
> 
> You are not going to be placing multi lumen central catheters in the field. The EMS agencies which do place central catheters in the field will just use a longer large bore catheter which can be a 10 - 14g.
> 
> Yes central lines (multi lumen) are used to monitor CVP. If you are not going to monitor CVP during transport, many times a PIV will give adequate flood. A second PIV is always advisable for transport which can administer meds.



http://www.youtube.com/watch?v=6KHM-IVF5Ek
Here is a video showing the 3 most common types of central lines: Triple lumen, cordis (introducer), and trauma. 

I believe the one you are referring to is the trauma line, most commonly made my Arrow. It is a short, wide, single lumen catheter similar to a Cordis but shorter and does not have the ability to accept other lines. The Arrow Trauma Central Line kit is what KCM1 uses.


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## Rialaigh (Apr 29, 2013)

Clipper1 said:


> *No they do not "act as a physician".*
> 
> Everything they do can be within their scope of practice and they act under the protocols of their medical director (physician) and the directors (more physicians) of a specific unit.
> 
> ...



What I meant by this is outside of life saving traumatic complex surgical procedures a lot of well trained critical care transport teams can and will do about anything a ER physician does. They will place chest tubes, they will place central lines, they do surgical assisted intubation and some do trach's. 

They pretty much function as a physician under another physicians license, their scope of practice and what they can do is so much higher then a regular paramedic or nurse that they fall much more in line with what ER physicians will do.




Clipper1 said:


> Which teams are you talking about? North Carolina? A few of their teams are very impressive but the ones I am familar with are a mix of different health care providers and are hospital based.



All of my experience (working at several area hospitals and then flying patients out from scene) is with Med Center air through CMC in Charlotte, NC. Every team they have ever sent (especially pediatric specialty teams or perfusion teams) seem to have been excellently trained, well equipped, ready to do anything, and have good communication and working relationships with their doctors and ours. When they show up our docs generally turn all care over to them, if they want to extubate the patient, change every drip, and do a surgical airway our doc steps out of the way and says "your patient, I trust you, take care of them and get them on out of here".


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## Clipper1 (Apr 29, 2013)

usalsfyre said:


> And say what exactly? Order him to place a central when he's obviously not comfortable with the procedure? Or we leave the pt in a place where he's sure to die vs possibly dying in transport? Good way to be a pt advocate...



Two physicians should come up with a viable alternative.  Hopefully your MD knows your scope of practice and the meds you carry.  Having contact between the two higher levels of care for a discussion about YOUR concerns is much better than you just running off with an unstable patient.  There might actually be a decent alternative for meds. Not all meds are just used the way your current protocols read.  Don't assume all doctors at these smaller hospitals are incompetent. Sometimes if they are reminded of things to do by another physician, they get it together quickly.


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## Clipper1 (Apr 29, 2013)

Rialaigh said:


> All of my experience (working at several area hospitals and then flying patients out from scene) is with Med Center air through CMC in Charlotte, NC. Every team they have ever sent (especially pediatric specialty teams or perfusion teams) seem to have been excellently trained, well equipped, ready to do anything, and have good communication and working relationships with their doctors and ours. When they show up our docs generally turn all care over to them, if they want to extubate the patient, change every drip, and do a surgical airway our doc steps out of the way and says "your patient, I trust you, take care of them and get them on out of here".



Those teams are well trained. It may take several years of ICU experience to get on those teams. Many of the team members are RNs and RTs who have an extensive scope of practice with high standards for maintaining their skills and must answer to their medical directors for all competencies. 

In most states, RNs have a very expansive scope of practice. So do RTs. Few will ever utilize what they are actually allowed to do. But, at no time do they consider themselves doctors. Skills can be taught easily. The additional knowledge is what sets them apart. But, the members of these teams will have additional training but they are still not doctors. 

The sending physician has also had a direct conversation with the rec'g physican and will usually maintain that contact until the team arrives.  The transport team will also contact the rec'g physician and a member(s) of the ICU staff to give a full report before departing. 

If EMS was to get central lines, would the oversight be as much? Look at the stats for intubation or even PIVs at some services.


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## usalsfyre (Apr 29, 2013)

Clipper1 said:


> Two physicians should come up with a viable alternative.


We've now injected a third physician into a transfer situation. I don't see how this will go well. 



Clipper1 said:


> Hopefully your MD knows your scope of practice and the meds you carry.  Having contact between the two higher levels of care for a discussion about YOUR concerns is much better than you just running off with an unstable patient.


If they're "stable" then why again are we transferring to a higher level of care? Most people who have performed CCT transfers realize there's an inherent level of instability. You should manage it as best you can, but there's always the chance of decompensation. If you haven't done CCT though you might not realize this. 



Clipper1 said:


> There might actually be a decent alternative for meds. Not all meds are just used the way your current protocols read.


I'm pretty  studied on pressors. I'm not aware of any that aren't ideally delivered through a central.



Clipper1 said:


> Don't assume all doctors at these smaller hospitals are incompetent. Sometimes if they are reminded of things to do by another physician, they get it together quickly.


I never said all. But many of them are out of there depth in a resuscitation. Not to say they aren't wonderful physicians in other areas.


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## jwk (Apr 30, 2013)

I agree that vaso-active drips ideally should be given through a central line BUT that is far from a given, even in the better facilities, and it's definitely not a uniform standard of care.  I think anyone on vaso-active drips should also have an arterial line, but that doesn't happen either.


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## Merck (Apr 30, 2013)

Perhaps it's a little location-dependent.  Only dopamine will be run peripherally here, and centrally if available.  I'll give phenylephrine IVP if necessary but not an infusion.  I think it's just good form.  In the off-chance there is extravasation the dopamine, with less profound alpha effects won't cause as much harm as others.


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## Carlos Danger (Apr 30, 2013)

Merck said:


> Perhaps it's a little location-dependent.  Only dopamine will be run peripherally here, and centrally if available.  I'll give phenylephrine IVP if necessary but not an infusion.  I think it's just good form.  In the off-chance there is extravasation the dopamine, with less profound alpha effects won't cause as much harm as others.



I agree it's good form, my point was just that it could be done (and often is) when a central line isn't available.


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## Clipper1 (May 1, 2013)

usalsfyre said:


> We've now injected a third physician into a transfer situation. I don't see how this will go well.



Do you really see no point in discussing a patient you believe to be unstable with physicians? 



usalsfyre said:


> If they're "stable" then why again are we transferring to a higher level of care? Most people who have performed CCT transfers realize there's an inherent level of instability. You should manage it as best you can, but there's always the chance of decompensation. If you haven't done CCT though you might not realize this.



Stable is a broad term. You can be critical and yet also be stable if adequate perfusion with decent vital signs are maintained.  A lot of patients are stabilized before transport. A higher level of care could mean a hospital specializing in strokes, trauma or cardiac issues in an attempt to improve outcomes. An MI does not have to go to cath lab but getting a patient to one can improve outcomes. 




usalsfyre said:


> I'm pretty  studied on pressors. I'm not aware of any that aren't ideally delivered through a central.



Does that mean you do not carry any on the ambulance?


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## Aidey (May 1, 2013)

Ok people, lets keep this on topic. I just moved 25 posts about ventilators to their own thread. The next person that posts about ventilators in this thread will get my undivided attention.


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## Clipper1 (May 1, 2013)

Aidey said:


> Ok people, lets keep this on topic. I just moved 25 posts about ventilators to their own thread. The next person that posts about ventilators in this thread will get my undivided attention.



Why do you remove posts which are also discussing something concerning critical care? Sometimes central lines and ventilators are associated. You may need a central line or one is warranted if the patient is on a ventilator and requiring pressors to achieve the settings necessary. Also, if you don't have a central line and are limited by the meds you can give, ventilator modes is definitely a related topic.  Just focusing on a skill without justifying its purpose through a critical care discussion of related topics is a little short sighted especially if you are trying to enhance not only scope but also a knowledge base. Even is there is not an overall agreement here, some may start to think about looking up the information themselves and seeking more education on different topics.


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## JPINFV (May 1, 2013)

Clipper1 said:


> Why do you remove posts which are also discussing something concerning critical care?


Because hijacking threads isn't good for the flow of discussions. They also weren't removed, they were moved.
http://www.emtlife.com/showthread.php?t=35336


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## FLdoc2011 (May 1, 2013)

usalsfyre said:


> We've now injected a third physician into a transfer situation. I don't see how this will go well.
> 
> 
> If they're "stable" then why again are we transferring to a higher level of care? Most people who have performed CCT transfers realize there's an inherent level of instability. You should manage it as best you can, but there's always the chance of decompensation. If you haven't done CCT though you might not realize this.



We get intracranial hemorrhages sent to us all the time that are relatively "stable" in that they aren't acutely decompensating, but needed to be transferred to a place with the appropriate level of care in case they do decompensate.   Not all these patients end up getting brain surgery but they at least should be at a facility with neurosurgery and/or interventional neuro-radiology available.


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## Carlos Danger (May 1, 2013)

Some of the most critical and complex patients I've transported were quite stable.


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