# Subarachnoid bleed and hyperventilation



## Simusid (Mar 25, 2012)

This has been bugging me since the call a few days ago.   We arrived on scene to an elderly female unresponsive following an unwitnessed fall.  My parter very quickly said "head bleed" and off we went to the hospital.  Within a very short time the ED confirmed a pretty severe subarachnoid hem and the next decision was either medflight to boston or IFT to Providence RI.   The family wanted her to go to RI but the problem was that it's hard to get IFT quickly after 11 PM.  We happened to still be there doing paperwork and cleaning up and the Dr. asked if we could do the IFT even though we're a 911 truck.  We said of course (still have coverage in town) and off we go with a nurse and respiratory therapist.

That's all backstory.  Here's my question.  During the 15 minute transport I watched the RT bag this patient at a rate of no slower than once every two seconds and on average probably closer to once per second.  Several times it was better than once per second as I was silently thinking "ONE Missi...".   It has essentially been beaten into my head that it is bad to hyperventilate a patient by bagging too often, but for me that has always been in the context of a cardiac arrest patient (Note:  my service is participating in a CCR study so we don't tube or bag any more during arrests) 

BUT, I just read this http://emedicine.medscape.com/article/1164341-treatment which states "Patients with signs of increased ICP or herniation should be intubated and hyperventilated. "    I have no idea how to assess ICP or herniation other than to look for posturing.   She had no signs of posturing.  

So the question is was the RT bagging too fast?  I've asked several medics about this and their consensus is yes.  One labeled the RT a "respiratory terrorist."   But I don't want to second guess the RT in this situation.   Is there more to the story here?    This is my first head bleed case.


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## RESQGUY (Mar 25, 2012)

Well, here in San Diego our protocol is the following:

Neurological Trauma ( head and spine injuries)
Ensure adequate oxygenation without hyperventilating PT.
Goal 6-8 ventilations/min


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## Veneficus (Mar 25, 2012)

*From one of my favorite sources:*

"Hyperventilation. 

The use of hypocapnia has been reviewed in detail in the section on management of Paco2. Hyperventilation has long been a component of the management of TBI patients, and the effectiveness of acute hypocapnia in reducing ICP is well confirmed.[10] There is substantial evidence, however, that hyperventilation is potentially deleterious[23,24,29-31,283] and should not be overused. The evidence suggests that hyperventilation and the concomitant vasoconstriction can result in ischemia,[21,29-32] especially when baseline CBF is low,[32] as is likely to be the case in the first 48 to 72 hours after head injury.[23,33,38,39] The expert panel convened by the Brain Trauma Foundation specified that prophylactic hyperventilation is “not recommended,” and that “hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced.”[59] The available information argues that hyperventilation should be used selectively rather than routinely in the management of TBI patients. Maintaining ICP less than 20 mm Hg, preventing or reversing herniation, minimizing retractor pressure, and facilitating surgical access are still important objectives in the management of TBI patients and to the extent that hyperventilation contributes to these objectives, it is still appropriate. The anesthesiologist should agree on management parameters with the surgical team at the outset of a procedure."

Miller's Anesthesia exerpt from chapter 63


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## NYMedic828 (Mar 25, 2012)

Veneficus said:


> "Hyperventilation.
> 
> The use of hypocapnia has been reviewed in detail in the section on management of Paco2. Hyperventilation has long been a component of the management of TBI patients, and the effectiveness of acute hypocapnia in reducing ICP is well confirmed.[10] There is substantial evidence, however, that hyperventilation is potentially deleterious[23,24,29-31,283] and should not be overused. The evidence suggests that hyperventilation and the concomitant vasoconstriction can result in ischemia,[21,29-32] especially when baseline CBF is low,[32] as is likely to be the case in the first 48 to 72 hours after head injury.[23,33,38,39] The expert panel convened by the Brain Trauma Foundation specified that prophylactic hyperventilation is “not recommended,” and that “hyperventilation should be avoided during the first 24 hours after injury when CBF is often critically reduced.”[59] The available information argues that hyperventilation should be used selectively rather than routinely in the management of TBI patients. Maintaining ICP less than 20 mm Hg, preventing or reversing herniation, minimizing retractor pressure, and facilitating surgical access are still important objectives in the management of TBI patients and to the extent that hyperventilation contributes to these objectives, it is still appropriate. The anesthesiologist should agree on management parameters with the surgical team at the outset of a procedure."
> 
> Miller's Anesthesia exerpt from chapter 63



:unsure: Confuzzling read.  Informative non the less after decyfering it lol.

in NYC we are required to intubate and hyperventilate patients with 

Fixed or asymmetric pupils
Abnormal flexion or extension (neurological posturing)
Hypertension and bradycardia (Cushing’s Reflex)
Intermittent apnea (periodic breathing)
Further decrease in GCS score of 2 or more points (neurological deterioration)

to maintain an ETCo2 of 30-35mmHg.

If ETCo2 monitoring is not possible, BVM at one breath every 3-5s.



It seems in EMS we are always behind the 8ball with what current medical practices are. Its unfortunate. The fact that will still board and collar half our patients is a prime example.


What caused you guys to immediately rule out a bleed anyway? (other presenting s/s)


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## MSDeltaFlt (Mar 25, 2012)

Simusid said:


> This has been bugging me since the call a few days ago.   We arrived on scene to an elderly female unresponsive following an unwitnessed fall.  My parter very quickly said "head bleed" and off we went to the hospital.  Within a very short time the ED confirmed a pretty severe subarachnoid hem and the next decision was either medflight to boston or IFT to Providence RI.   The family wanted her to go to RI but the problem was that it's hard to get IFT quickly after 11 PM.  We happened to still be there doing paperwork and cleaning up and the Dr. asked if we could do the IFT even though we're a 911 truck.  We said of course (still have coverage in town) and off we go with a nurse and respiratory therapist.
> 
> That's all backstory.  Here's my question.  During the 15 minute transport I watched the RT bag this patient at a rate of no slower than once every two seconds and on average probably closer to once per second.  Several times it was better than once per second as I was silently thinking "ONE Missi...".   It has essentially been beaten into my head that it is bad to hyperventilate a patient by bagging too often, but for me that has always been in the context of a cardiac arrest patient (Note:  my service is participating in a CCR study so we don't tube or bag any more during arrests)
> 
> ...



Here's the deal. Though hyperventilation is appropriate at times in CVA/TBI pts, you don't really know what the effects are on your ICP's as you increase respirations unless you have a probe actively measuring ICP's.  So, with that being said, one only has left to go on what's normal.  Therefore, breathe for them normally.  If you have the ability of ventilator, set it up to get PaCO2 to low side of normal - 35-40 torr.  If you don't have that availability, just bag them as normal as possible.


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## usalsfyre (Mar 25, 2012)

Not trying to be insulting, but this type of situation is why CCT is a separate discipline and shouldn't really be attempted by those not familiar with the transport environment.


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## Simusid (Mar 25, 2012)

usalsfyre said:


> Not trying to be insulting, but this type of situation is why CCT is a separate discipline and shouldn't really be attempted by those not familiar with the transport environment.



I'm not positive, but I think if it had been a CCT truck, the same nurse and RT would have gone with the patient in which case the same quality of bagging would have taken place and I'd still have the same question.

If you're saying I had no business being on that transport, I guess I don't disagree with you except that it would have taken an hour or more to find a suitable CCT truck and the doctor didn't want to wait.


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## 18G (Mar 25, 2012)

Bagging at 40-60min is way too fast. Unless the pt. had obvious signs of >ICP, ventilations should have been given while using EtCO2 as the guide and maintaining on the low end of normal 35-37mmHg. Even with >ICP 40-60min is way too fast. 

I've bagged a SAH patient literally for 2hrs on an IFT and used EtCO2 as the guide. The trauma doc was surprised that the ABG's were as good as they were with the patient not being on a vent and being bagged for 2hrs.


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## AnthonyM83 (Mar 25, 2012)

While most RT's I've seen bagging patients in the emergency setting seem to have been hyperventilating inappropriately, I can't say specifically for your situation. Did the doctor order hyperventilation? Were they trying to keep capnography within a certain range? Were they just going off signs/symptoms, such as Cushing's Triad / other signs of herniation? Did they have some kind of imaging done confirming herniation? Was the RT simply excited or nervous or believed it didn't matter either way? Couldn't tell ya specifically in your case...


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## Simusid (Mar 25, 2012)

AnthonyM83 said:


> While most RT's I've seen bagging patients in the emergency setting seem to have been hyperventilating inappropriately, I can't say specifically for your situation. Did the doctor order hyperventilation? Were they trying to keep capnography within a certain range? Were they just going off signs/symptoms, such as Cushing's Triad / other signs of herniation? Did they have some kind of imaging done confirming herniation? Was the RT simply excited or nervous or believed it didn't matter either way? Couldn't tell ya specifically in your case...



Her pulse was in the low 70's and got as low as 65.   Her BP was 116/67, 110/65, 131/96 over the transport.  Nobody said anything about herniation.  She was not posturing.   RT definitely did not seem nervous at all, more bored if anything.   Transport time was about 25 minutes with no change in pt status throughout.   I'm trying to keep my questions general and not about this specific patient and I think what I'm hearing is that bagging every 2 seconds or less is probably not indicated.


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## usalsfyre (Mar 25, 2012)

Simusid said:


> I'm not positive, but I think if it had been a CCT truck, the same nurse and RT would have gone with the patient in which case the same quality of bagging would have taken place and I'd still have the same question.
> 
> If you're saying I had no business being on that transport, I guess I don't disagree with you except that it would have taken an hour or more to find a suitable CCT truck and the doctor didn't want to wait.



I'd you'd had a CCT truck the patient would've been on a vent eliminating the human factor all together .

The "hurry up and get them outta here" mentality is a huge problem. It's part of the reason for the explosion of HEMS and inappropriate transports.


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## Dwindlin (Mar 25, 2012)

I don't know about everyone else but in the hospitals I frequent I see this often from the RTs.  They all hyperventilate the patients.  I can't recall the number of times bringing post-op patients to the ICU and I'm accompanying bagging the patient at 10-12/min, soon the as the RT takes over its a breath every 2 seconds.  

Anyone else notice this from RTs, or is it just here?


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## MS Medic (Mar 25, 2012)

I would suspect the "problem" your seeing is due to incongruity between EMS and hospital setting treatment methods. I'm not saying your calling it wrong but I've noticed things like that in the past when I brought a pt in. I would later ask the hospital staff why they did the issue in question. I would then get a honest answer from them that seemed to make perfect sense to everyone else in the room but left me walking out scratching my head thinking WTF.


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## FLdoc2011 (Mar 25, 2012)

Even in hospital setting I routinely see our RTs bagging way to fast during codes either because of adrenaline going or they just aren't paying attention.  

But we do regularly use hyperventilation with goal pCO2 of ~28-32 on our bleeds when there is evidence of acute change and increased ICP.   We don't do trauma so I can't comment specifically there, but we do a lot Non-traumatic bleeds.  From what I've read it's a temporary measure usually only useful for less than 24hrs and can possibly even lower cerebral perfusion pressure so certainly some thought required before just routinely hyperventilating everyone.   

In any case it sounds like they were bagging way to fast.   On the vent we usually have rate around 22-26 which works well.


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## Handsome Robb (Mar 25, 2012)

The only time we "mildly hyperventilate" is if we have signs of posturing or cushing's reflex. 

Either way, like someone else said, 40-60 bpm is way too fast.


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## Veneficus (Mar 26, 2012)

AnthonyM83 said:


> Did they have some kind of imaging done confirming herniation?



Imaging in a head injury patient with clinical signs of head injury in a facility that doesn't have neurosurgery is a disservice to the patient. 

The only thing that would do is waste time by delaying transport to a facility that can care for him. 

Upon arrival at the definitive facility, imaging would have to be done anyway.

I don't understand why EMS providers seem to think that having some kind of image of badness somehow makes everything all better.

My questions would be: 

Why did this lady go to a facility without neurosurg to begin with?

Was some treatment done at the original facility that would improve this patients condition?

or did it just waste time and generate a needless bill while the ED went through its "suspected head injury protocol," on a patient it knew it couldn't help?


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## FLdoc2011 (Mar 26, 2012)

Veneficus said:


> Imaging in a head injury patient with clinical signs of head injury in a facility that doesn't have neurosurgery is a disservice to the patient.
> 
> The only thing that would do is waste time by delaying transport to a facility that can care for him.
> 
> ...



A receiving facility is required at the very least to do screening exam per EMTALA and if there's suspected head injury you bet they're going to scan the patient.   We accept brain bleeds all the time from outside facilities and there is no way our neurosurgeons or neurointerventionalist would accept without knowing what the underlying pathology is.  And we may or not rescan them depending on if we have the film and on the pt's clinical condition. 

Even at a facility without neurosurg there is still stuff that they could do there in the meantime.... manage comorbidities, non invasive management of ICP, or even emergent burr hole if needed.  

We don't admit peds but the ER will see peds and they can't just transfer a ped pt out before some sort of workup and stabilization.


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## Veneficus (Mar 26, 2012)

FLdoc2011 said:


> A receiving facility is required at the very least to do screening exam per EMTALA and if there's suspected head injury you bet they're going to scan the patient.



Going to, yes, of significant benefit, I have my doubts.



FLdoc2011 said:


> We accept brain bleeds all the time from outside facilities and there is no way our neurosurgeons or neurointerventionalist would accept without knowing what the underlying pathology is..



Why?

"I'm sorry, but until you diagnose the brain pathology I am afraid our neuro facility is not willing to help your suspected head injury patient."

That sounds sort of off kilter to me.

That would assume the facility has a working/available CT at all hours. I know of smaller hospitals in major US cities that shut down their CT at 9pm, with nobody on staff to run it in the building.

Not every ED is set up to dx and manage critical patients. I have seen multiple smaller hospitals in the US that do not even have CTs.  



FLdoc2011 said:


> And we may or not rescan them depending on if we have the film and on the pt's clinical condition. .



Or if the image quality or rendering is not acceptable to the receiving facility.

I could not possibly recount all the times I have seen rescans because of questionable or outright poor quality from community facilities.



FLdoc2011 said:


> Even at a facility without neurosurg there is still stuff that they could do there in the meantime.... manage comorbidities, non invasive management of ICP,..



That is why I asked. 



FLdoc2011 said:


> or even emergent burr hole if needed..



Forgive me, but from what I have seen, most outlying facilities and providers in any nation, even if they do have the equipment in the back room somewhere, would never consider such a procedure if they do not perform it regularly.

But I will put it to an informal poll to all of the EMs on my FB page just to get some more feedback on it.  



FLdoc2011 said:


> We don't admit peds but the ER will see peds and they can't just transfer a ped pt out before some sort of workup and stabilization.



Do you think it is medically beneficial to a patient to receive a workup if they cannot be helped or is it just an administrative thing?

Stabilization is a rather tricky term. What does it mean to you?


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## Handsome Robb (Mar 26, 2012)

Veneficus said:


> Not every ED is set up to dx and manage critical patients. I have seen multiple smaller hospitals in the US that do not even have CTs.



The hospital where I grew up didn't and still doesn't have a CT scanner. I have fond and not so fond memories of that hospital but honestly they are equipped to handle a runny nose or a flu bug and that's about it. More like an urgent care that can work a code and do emergent airways if needed but I'd be willing to bet the Paramedics would have done it before they got there or would be high on the list of candidates considered for the job if they were still at the hospital for the simple fact that many if not all of them have more recent experience with airways of that nature.


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## AnthonyM83 (Mar 26, 2012)

Veneficus said:


> Imaging in a head injury patient with clinical signs of head injury in a facility that doesn't have neurosurgery is a disservice to the patient.
> 
> The only thing that would do is waste time by delaying transport to a facility that can care for him.
> 
> ...



Imaging was the most unlikely of the explanations when I brainstormed ideas on things that could have influenced their judgment. The reply also wasn't very scenario specific.


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## FLdoc2011 (Mar 26, 2012)

Veneficus said:


> Why?
> 
> "I'm sorry, but until you diagnose the brain pathology I am afraid our neuro facility is not willing to help your suspected head injury patient."
> 
> ...



Well, knowing what the actual injury is can impact what type of care or even where the patient is transferred to.  It may be something where after review our Neurosurgeons may decide that the pt needs to go to a different facility with a specific/specialized treatment available or the patient may need Neurointerventional radiology and our guy is off that night, etc...   

But with EMTALA in order to transfer from one hospital to another it has be for a higher or different level of care not available at the first facility... so if you're going to transfer a patient for neurosurgical evaluation then you need to do if there's a neurosurgical problem.  

If there's no CT available that's a different issue, but then again a transfer is warranted since you are transferring for a higher level of care in order to obtain a CT.   In my example a facility is not going to transfer just to get a CT when they can do it there.   




> Forgive me, but from what I have seen, most outlying facilities and providers in any nation, even if they do have the equipment in the back room somewhere, would never consider such a procedure if they do not perform it regularly.
> 
> But I will put it to an informal poll to all of the EMs on my FB page just to get some more feedback on it.



Yea, I'm sure it's highly location/physician dependent on whether they are able to or have had the training.  A good number of ED docs have done ED residency and most likely at a trauma center and may have some experience.  Granted I'm sure it's a pretty rare thing for an ED doc to do, just like thoracotomy and emergent trach but certainly within their skill set if absolutely needed.





> Do you think it is medically beneficial to a patient to receive a workup if they cannot be helped or is it just an administrative thing?
> 
> Stabilization is a rather tricky term. What does it mean to you?



I don't know about beneficial, but it's required.  EMTALA mandates that a pt presenting to an ED has a screening medical exam to evaluate for any emergency conditions.   Again, we don't do Peds or OB/Gyn but we still occassionally get really sick kids and preggos in the ED and we can't transfer them out without some idea of what's going on and some sort of workup while making sure they are stable enough for transport.   When we call another facility and find an accepting doctor we have to have a reason to transfer them for additional care.


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## Veneficus (Mar 26, 2012)

FLdoc2011 said:


> But with EMTALA in order to transfer from one hospital to another it has be for a higher or different level of care not available at the first facility... so if you're going to transfer a patient for neurosurgical evaluation then you need to do if there's a neurosurgical problem..



I think this can be accomplished with a good neuro exam, not specifically requiring a CT. Even if you have something like a subdural bleed, it doesn't mean it will require surgery. But that is a decision for neuro at whatever facility they are at.   



FLdoc2011 said:


> If there's no CT available that's a different issue, but then again a transfer is warranted since you are transferring for a higher level of care in order to obtain a CT.   In my example a facility is not going to transfer just to get a CT when they can do it there..



The last patient I referred to to a different facility for a CT presented with neuro deficits (and a very convincing story of mechanisms). Most patients I have seen, particularly in trauma centers present with neuro deficit.    

In both my education and experience a CT is not what soley determines if there is a reason to refer to a facility for nero consult.



FLdoc2011 said:


> Yea, I'm sure it's highly location/physician dependent on whether they are able to or have had the training.  A good number of ED docs have done ED residency and most likely at a trauma center and may have some experience.  Granted I'm sure it's a pretty rare thing for an ED doc to do, just like thoracotomy and emergent trach but certainly within their skill set if absolutely needed...



As fate would have it, I know emergency physicians all over the world, both US residency trained as well as other specialties who work in emergency. 

I posed the question: "If you were in a community hospital and suspected a patient had herniation from a TBI, would you be inclined to place a burr hole or other surgical intervention. It is being forwarded right now, but the first EM to answer stipulated he would only in the most grevious of circumstances. An ortho surgeon said yes he would. 



FLdoc2011 said:


> I don't know about beneficial, but it's required.  EMTALA mandates that a pt presenting to an ED has a screening medical exam to evaluate for any emergency conditions..



I do not dispute this, I just dispute if a CT at a facility that can do nothing with it but transfer the patient is required to do that as part of the screening exam.

Actually, I think I picked that up in my last ATLS class. Right along with "If you can't close a chest, don't open it." 



FLdoc2011 said:


> Again, we don't do Peds or OB/Gyn but we still occassionally get really sick kids and preggos in the ED and we can't transfer them out without some idea of what's going on and some sort of workup while making sure they are stable enough for transport.   When we call another facility and find an accepting doctor we have to have a reason to transfer them for additional care.



Cleveland Clinic?


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## FLdoc2011 (Mar 26, 2012)

Veneficus said:


> I think this can be accomplished with a good neuro exam, not specifically requiring a CT. Even if you have something like a subdural bleed, it doesn't mean it will require surgery. But that is a decision for neuro at whatever facility they are at.
> 
> The last patient I referred to to a different facility for a CT presented with neuro deficits (and a very convincing story of mechanisms). Most patients I have seen, particularly in trauma centers present with neuro deficit.
> 
> ...



No, just a community hospital on Florida's west coast.  

Can also ask your ED friends if they would or even could transfer a suspected head bleed for neurosurg eval (hypothetically if they didnt have the capability in house) without imaging/CT.   Outside of blatant obvious trauma.

We get plenty that don't have any specific neuro defects.  

Ultimately the reason to transfer to to another facility is to obtain a level of care not available at the current place.  Outside of blatant obvious trauma how would you know it's a bleed that needs neurosurg vs say an ischemic stroke possibly requiring TPA that you could keep and treat in house?   Or even a massive tumor that you may want to give steroids to.

I would be hung up on and/or laughed at if I called another doc/hospital asking to transfer a patient for neurosurg eval without actually knowing if there's a neurosurg issue even present.  Not having CT capability is completed different.

There's also medical legal issue....  A lawyer would have a field day with this.
"So doctor, you suspected an intracranial hemorrhage based on clinical findings.
"Yes"
"What did you do to verify this before sending the pt out?"
"um... Nothing"
"so you don't actually know that's what was going on, how bad it was, if there was edema/shift/impending herniation/aneurysm/ischemic stroke/abscess/mass..... Which would require varying treatments that you have the ability to start at your facility."

If you really suspect a bleed then you have to follow standard of care or have your lawyer on speed dial.


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## Veneficus (Mar 26, 2012)

FLdoc2011 said:


> Which would require varying treatments that you have the ability to start at your facility."



I think this is the key to the whole argument.



FLdoc2011 said:


> If you really suspect a bleed then you have to follow standard of care or have your lawyer on speed dial.



So if your CT delays a patient from definitive treatment, you would go to court with the defense:

"Lady's and gentlemen of the jury, despite my expert, professional, clinical judgement and a deteriorating patient, I sought to satisfy an interpretation on EMTLA and attempt a definitive diagnosis which I knew I might not be able to help, subsequently delaying the patient from a doctor that could have helped."?

I am sure a decent lawyer will follow that up with:

"So my client's mom might be alive if she would have arrived at a specialty center sooner?"

Really, if "follow this plan no matter what the patient presents with" is suppoosed to stop one from getting sued, I'll risk the court with:

"I judged the patient was beyond my capability and the capability of my facility and spared no effort or expense to give her every opportunity to get the help she desperately needed from an expert and a more capable center."

and my attorney could follow it up with:

"So you ignored a set of guidlines meant to protect you from a lawsuit in order to put the interest of your patient first?"

I also have no doubt both parties could present a chain of experts to back their position.

Ultimately if you are going to court you need to tell a really good story to 12 of the most ignorant people you can imagine, who may decide the merits of the case on the best story and the perception of the doctor's ego.

Perhaps we could consider this from a different angle?

If a patient presented with crushing substernal chest pain radiating to the arm and jaw, with EKG changes and elevated troponin and you didn't have a PCI lab but did have angio CT, would you perform the angio prior to transfer?

How is that any different from diagnosing a nonspecific brain injury on clinical symptoms of a neuro exam?

Because somebody suggested a picture?


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## 18G (Mar 26, 2012)

Not sure if I should comment in between you two guys but I agree that a head CT should be done. It is specific and tells a bigger picture of what resources or facility may be needed to handle the problem. If you don't do a head CT how is the receiving hospital to be prepared for what's coming in?

Isn't it kinda like having a patient with chest pain that is looking kinda bad and we want to quickly send them to the cath lab without doing a 12-lead and blood work? And the doc at the cath lab has no clue what he is getting or what's even causing the chest pain for sure? All he know's is he is getting a patient with chest pain that "could" require PCI. 

It's great we get em out the door fast, but don't we also need to triage them to the appropriate facility and physician staff too?


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## FLdoc2011 (Mar 26, 2012)

Veneficus said:


> So if your CT delays a patient from definitive treatment, you would go to court with the defense:
> 
> "Lady's and gentlemen of the jury, despite my expert, professional, clinical judgement and a deteriorating patient, I sought to satisfy an interpretation on EMTLA and attempt a definitive diagnosis which I knew I might not be able to help, subsequently delaying the patient from a doctor that could have helped."?
> 
> ...



Sounds good and all but not how it works.  I'm not an ER doc, but it's not beyond the capability of an ER doc to diagnosis a brain bleed.  He would be held to a certain standard of care, which would include a CT to look for bleed if clinically indicated.  

Ultimately, they're going to be sued no matter what, so that's not really an argument.  But they certainly WILL be sued if they rushed to get rid of the pt and missed something else on a CT, even if that mean the pt left a couple minutes sooner (the actual scan takes seconds). 

It's a completely different story if it's beyond the capability of the facility.  Totally different story and of course you have to transfer so that they can get the scan that is required. 



> If a patient presented with crushing substernal chest pain radiating to the arm and jaw, with EKG changes and elevated troponin and you didn't have a PCI lab but did have angio CT, would you perform the angio prior to transfer?
> 
> How is that any different from diagnosing a nonspecific brain injury on clinical symptoms of a neuro exam?



This is a little different.  In the CP scenario you already have a diagnosis and diagnostic/test evidence confirming it.   If it was clinically indicated then yes you may get the angio first (tearing sensation to the back, UE/LE BP discrepancies, widened mediastinum on Chest XR, etc....).  But if you've already diagnosed STEMI then standard of care is PCI within 90min.

If you're diagnosing a nonspecific brain injury, then it's just that a "non-specific" brain injury.  Sure, neuro exam is required and will probably give you the a pretty good idea but no one I know is going to stake their career/lives on just that.  We're held to a different standard and in this day and age of technology exam alone is not standard of care.  

What if in my good intentions of trying to get the pt out as soon as possible, I skip the scan and it turns out the pt actually has bacterial meningitis, and I've delayed them getting antibiotics in the goal time period and they die?  There is no defense of that.   I'm certainly NOT going to bet my license and career on having patients present with classic symptoms of whatever disease they have.


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## FLdoc2011 (Mar 26, 2012)

18G said:


> Isn't it kinda like having a patient with chest pain that is looking kinda bad and we want to quickly send them to the cath lab without doing a 12-lead and blood work? And the doc at the cath lab has no clue what he is getting or what's even causing the chest pain for sure? All he know's is he is getting a patient with chest pain that "could" require PCI.



Actually a good example I didn't think about.  

As a physician part of my job is to diagnose and treat, and I'm held to the standard of care involved in diagnosing and using the modalities I have available to diagnose.  In the case of suspected bleed I need the scan.   I can't treat or transfer what I haven't diagnosed.


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## Veneficus (Mar 26, 2012)

FLdoc2011 said:


> Sounds good and all but not how it works.  I'm not an ER doc, but it's not beyond the capability of an ER doc to diagnosis a brain bleed.  He would be held to a certain standard of care, which would include a CT to look for bleed if clinically indicated.



I attempted to find this standard of care. 

In a quick google search, I found several different ones, mostly depending on the country and patient populations, adult, ped, GCS, clinical manifestations, etc. 

All of the ones I found suggest that either:

A: neuro consult is available in house

or

B: There is deterioration or gross clinical signs. (including one that states transfer should be initiated even if the CT is clear but patient complains of persistent headache or vomiting)

As such, no universal guidline or standard of care exists, it is region dependant.

I even went as far as to look up the EMTLA law in regards to that section of the argument.

I could find nothing that states any specific part of an evaluation be performed, only that no part of the evaluation can be skipped because of the ability to pay. 



FLdoc2011 said:


> Ultimately, they're going to be sued no matter what, so that's not really an argument.  But they certainly WILL be sued if they rushed to get rid of the pt and missed something else on a CT, even if that mean the pt left a couple minutes sooner (the actual scan takes seconds)..



The scan takes seconds. If the table is open. After the patient has been transfered to it. After the appropriate scanning parameters are entered and the patient positioned. On average I have seen, 5-10 minutes.

Which doesn't sound like much. But if your initial exam and workup takes 15 minutes, you are now running into 20-30. 

I have seen many patients code in a CT scan. I have read about many more. Particularly when surgical intervention was delayed for the scan. 



FLdoc2011 said:


> If you're diagnosing a nonspecific brain injury, then it's just that a "non-specific" brain injury.  Sure, neuro exam is required and will probably give you the a pretty good idea but no one I know is going to stake their career/lives on just that.  We're held to a different standard and in this day and age of technology exam alone is not standard of care. .



Only in the US and I eagerly wait to see how many more years that is financially sustainable. 



FLdoc2011 said:


> What if in my good intentions of trying to get the pt out as soon as possible, I skip the scan and it turns out the pt actually has bacterial meningitis, and I've delayed them getting antibiotics in the goal time period and they die?  There is no defense of that.   I'm certainly NOT going to bet my license and career on having patients present with classic symptoms of whatever disease they have.



All of the guidlines that I have found on antimicrobial therapy in meningitis suggest starting on clinical suspicion prior to CT. With a decline in prognosis after a delay of 3 hours(that is a rather long time), with a goal of 1 hour of arrival at the hospital.


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## Veneficus (Mar 26, 2012)

18G said:


> Not sure if I should comment in between you two guys?



Why not?

This argument is really a difference of medical philosophy. 

Technology dependence vs. clinical accumen. 

It really could be about any pathology. 

Being European trained, I advocate what I learned, which is more subjective than many US physicians. (physical exam and liberal use of ultrasound)

The US loves its expensive technology. And deemphasizes provider ability.

Neither of us doubt that a CT should be done. Neither think the patient shouldn't be treated by the place most capable. There is a argument about order of operation, that's all. No different that arguing ERC vs. AHA guidlines.


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## FLdoc2011 (Mar 26, 2012)

Not sure where you are looking but go to reputable source such as UpToDate or the specific practice guidelines for medical specialties. 

CT head is the test of choice to diagnosis cerebral hemorrhage and important to distinguish between ischemic stroke and other stroke mimics.   

When statements like that are made in peer reviewed medical publications then it's standard of care and it's going to get done. 

I just now see the bit about Europe,  and that plays a huge role.  Honestly, the medical legal environment is completely different there and it may be feasible or accepted to transfer without the scan.  At least in the US that's not the case. 

And it's not really about clinical acumen.  You're held to a different standard with your training and the diagnostic tools available.  On one level it certainly is a philosophical argument and I don't disagree, there are a LOT clinical situations where I wish we could go back to relying on clinical judgement but that's not reality and there is standard of care that I must follow.   And honestly,  no matter how good of clinician I become stuff still gets by and I would be foolish to completely rely on it if I didn't have to.


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## Veneficus (Mar 26, 2012)

FLdoc2011 said:


> Not sure where you are looking but go to reputable source such as UpToDate or the specific practice guidelines for medical specialties.



Went to various national position papers in UK, France, and Australia.

Did a google search for the US, but every site wanted money and I wasn't willing to pay.



FLdoc2011 said:


> CT head is the test of choice to diagnosis cerebral hemorrhage and important to distinguish between ischemic stroke and other stroke mimics.



Like I said, we do not disagree on this. 

But when not in a specialty facility with one available, it is really just a question of when. 



FLdoc2011 said:


> I just now see the bit about Europe,  and that plays a huge role.  Honestly, the medical legal environment is completely different there and it may be feasible or accepted to transfer without the scan.  At least in the US that's not the case.



But I am willing to have an academic argument on it anyway. 



FLdoc2011 said:


> And it's not really about clinical acumen.



I think if you got to see the clinical skills of European physicians, you would find them very impressive. 

I grew up in the States andworked in EMS there, but when I saw a European physician dx SVT listening to heart tones and another dx not only an ischemic stroke vs hemorrhagic but the exact artery in the brain which was later verified by CT, I was sold.

More so when I was told I could not pass neuroscience if I could not do the same thing.  



FLdoc2011 said:


> You're held to a different standard with your training and the diagnostic tools available.  On one level it certainly is a philosophical argument and I don't disagree, there are a LOT clinical situations where I wish we could go back to relying on clinical judgement but that's not reality and there is standard of care that I must follow.   And honestly,  no matter how good of clinician I become stuff still gets by and I would be foolish to completely rely on it if I didn't have to.



Stuff always gets by. It is the nature of medicine. Whether you have technology or not.


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## FLdoc2011 (Mar 26, 2012)

At least in the US even when at a facility without neurosurg it's going to get done. They need the diagnosis before transfer and to rule out other intracranial pathology.  

In UK it's probably different.  EMTALA is a US thing and the legal environment here is different. 

I have seen terrific clinicians, that's not the point.  Even the best clinician isn't going to have near the sensitivity/specificity of a specific test like CT when it comes to something like hemorrhage.    Anecdotal evidence of seeing great clinicans make great calls is not evidence based medicine and does not hold up in legal circles.  

Found this: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_081059.pdf

Thats UK's national stroke strategy.   On page 29 refers to urgent brain scan needed to differentiate between ischemic and hemorrhagic stroke and that scanning should be in next immediate scan slot or within 60mins if "out-of-hours" (?after hours I guess).


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## Veneficus (Mar 27, 2012)

Veneficus said:


> Neither of us doubt that a CT should be done



Not sure why you think there is an issue with that?

Next scan or within the hour if a CT is not immediately available is generally practiced everywhere except the US military. (been there seen that)

But I still doubt the utility of a scan in a facility that is not going to treat what it finds.

The "what if" game is not really impressive. "What if you have no changes on a scan but still symptoms?" Would you deny that patient a transfer for expert consultation?
(see I can play "what if" too ) 

But could I just inquire?

If you use CT as a replacement for physical exam instead of as an adjunct to it, what do you need a doctor for?

Everytime I try to debate the merits of a practice, particularly here, it always seems to degrade to the threat of legal action.

Adopting a "defensive medicine" strategy is not evidence based, good judgement, or good medicine. It is simply outrageously expensive and for the benefit of the provider not the patient.

I also am very entertained by the envoking of EBM. Especially since most often it is just a poor attempt to justify expense. 

Could I ask you?

With all of the EBM "supporting" current US emergency practice, why are costs and extensive diagnositcs such a problem?

Why bother practicing in a place where medicine is based on fear?

With all the places around the globe looking for doctors, why not just skip the life of fear and take the show on the road?

I am sure if the US lost a significant percentage of its physician pool some serious effort would be made to control the legal problems?

Either that or it would train more mid-level providers at a lower cost and they could just follow the protocol anyway.

I get it, you will perform the scan before transfer because that is what you do. But your argument as to why it is a good practice comes down to fear of legal action.

Does that automatically make it good patient care?

Why bother having stroke centers if it is not the destination of choice prior to a CT scan?


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## FLdoc2011 (Mar 27, 2012)

Veneficus said:


> Next scan or within the hour if a CT is not immediately available is generally practiced everywhere except the US military. (been there seen that)
> 
> But I still doubt the utility of a scan in a facility that is not going to treat what it finds.



Again, because even though they might not be able to surgically treat a bleed, they might be able start medical therapy (mannitol, 3%NS, hyperventilation, etc..) AND they need to know what they are treating.   A doc is not to give one of those therapies without knowing what is actually going on or based purely on exam if they don't have to. 

And again, another example is that we don't do OB, so a young female preggo walks in with pelvic pain she's getting that ultrasound even though we're may not be able to treat what we find.  But the OB facility down the street is not going to take her unless there's a reason for them to.    



> The "what if" game is not really impressive. "What if you have no changes on a scan but still symptoms?" Would you deny that patient a transfer for expert consultation?
> (see I can play "what if" too )



No changes on scan but still symptoms?  Well then my differential and management change.  See, I get the CT (early/immediate CT scan is recommended in the guidelines as above) because it changes my management of the patient.  That's the general rule in medicine in regards to any test.  If it made no difference then why get it.   So a neg scan and still highly suspect a bleed then I would do an LP or change my differential to include some other mimics of stroke and change my workup accordingly.    

If there's no neurosurgical issue then yes, I would not transfer.  I mean you'd still probably get Neurology to see them and if I have neurology available in house then I can NOT transfer the pt just to receive the same level of care.  And if I called another receiving facility asking to transfer they are going to ask why do you want neurosurg if your scan is negative and the LP is negative......  At that point I have ruled out a bleed.   



> But could I just inquire?
> 
> If you use CT as a replacement for physical exam instead of as an adjunct to it, what do you need a doctor for?



I never said a replacement for physical exam.   When physical exam or a simpler test comes close to the sensitivity/specificity to CT for detecting a bleed then I'll reconsider and I'm sure recommendations will change at that point.  In medicine we go by evidence and what test is going to give me the highest yield and change how I manage this patient.    I'm certainly not forgetting about physical exam, it's just that I have a relatively cheap, quick, and relatively safe test that I can perform that will give me the answer.    



> Everytime I try to debate the merits of a practice, particularly here, it always seems to degrade to the threat of legal action.
> 
> Adopting a "defensive medicine" strategy is not evidence based, good judgement, or good medicine. It is simply outrageously expensive and for the benefit of the provider not the patient.



CT scan is not "outrageously" expensive, in fact I would argue it compares well if it take into account the money/time/use of resources involved in transferring someone who didn't need to be transferred, especially if you end of flying them somewhere.   

You can't practice medicine without considering the legal  aspect.  In this case it isn't ordering a low yield test as a CYA defensive move (which happens a lot with other things), because this is the standard of care.  If I DON'T get the scan I am not practicing standard care medicine and then I'm certainly open to legal issues.      

This isn't defensive medicine,  it's the standard of care as we've already pointed out in the guidelines (UK's own stroke initiative as well).   



> Could I ask you?
> 
> With all of the EBM "supporting" current US emergency practice, why are costs and extensive diagnositcs such a problem?



Well, some would argue a huge part again is the legal environment and EMTALA, which mandates that a pt needs to have a medical screen for emergent conditions.  So someone comes in with Chest Pain they are going to be worked up and admitted if necessary because you bet that if they discharged saying it was just GERD, and have an MI when they get home they are going to sue.   
So clinically you may not suspect an MI, but are you willing to bet your career/financial stability on that call and that it's not just an atypical presentation?  
That's why we risk stratify pts and use that as a guide for certain workups.  

In our case with the bleed if there's high suspicion or pt is at high risk of one then the CT is going to be the next step.  



> Why bother practicing in a place where medicine is based on fear?
> 
> With all the places around the globe looking for doctors, why not just skip the life of fear and take the show on the road?
> 
> I am sure if the US lost a significant percentage of its physician pool some serious effort would be made to control the legal problems?



Unfortunately that may happen.  The US is still an attractive place to practice, not everyone wants to jump overseas quite yet. 



> I get it, you will perform the scan before transfer because that is what you do. But your argument as to why it is a good practice comes down to fear of legal action.
> 
> Does that automatically make it good patient care?



My argument again is not that it's due to fear in this specific instance, the argument is that it's the current standard of practice and the test of choice.   So when I order the test of choice needed to potentially diagnosis a life threatening condition and decide on treatment/disposition THAT is good patient care.  

Again,  ask your EM colleagues which imaging test they immediately get if a pt presented with symptoms concerning for a head bleed....   AND also ask what their differential diagnosis is and what other conditions they are trying to rule out with that imaging test.    

Why bother having stroke centers if it is not the destination of choice prior to a CT scan?[/QUOTE]


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## Veneficus (Mar 27, 2012)

FLdoc2011 said:


> Again, because even though they might not be able to surgically treat a bleed, they might be able start medical therapy (mannitol, 3%NS, hyperventilation, etc..) AND they need to know what they are treating.   *A doc *is not to give one of those therapies without knowing what is actually going on or based purely on exam if they don't have to.



Funny that, I have seen it during clinically apparent injuries. On both sides of the pond. In a level I trauma center. At the direction of a neurosurgeon. Prior to a CT so it would be working while in CT.

Perhaps he was not practicing to the standard of care? 



FLdoc2011 said:


> And again, another example is that we don't do OB, so a young female preggo walks in with pelvic pain she's getting that ultrasound even though we're may not be able to treat what we find.  But the OB facility down the street is not going to take her unless there's a reason for them to..



You mean being pregnant with pelvic pain and not at an OB center is not enough?

That sounds like you are just trying to gouge money from somebody.    



FLdoc2011 said:


> CT scan is not "outrageously" expensive, in fact I would argue it compares well if it take into account the money/time/use of resources involved in transferring someone who didn't need to be transferred, especially if you end of flying them somewhere.



I think you should really reconsider what you call expensive. 

I must say, you have an interesting arguing style, I have seen it here before. Do I know you?  



FLdoc2011 said:


> You can't practice medicine without considering the legal  aspect.  In this case it isn't ordering a low yield test as a CYA defensive move (which happens a lot with other things), because this is the standard of care.  If I DON'T get the scan I am not practicing standard care medicine and then I'm certainly open to legal issues.



This is another rather interesting statement. Most, if not all of the physicians I know generally work with doing the right thing and legal issues second. 

You seem to have a preoccupation with this and EMTLA, with a rather interesting interpretation of it compared to what I have read.     



FLdoc2011 said:


> This isn't defensive medicine,  it's the standard of care as we've already pointed out in the guidelines (UK's own stroke initiative as well).



Nobody disputed that a CT was in order. If I recall correctly the original argument, we were talking about a patient with a suspected bleed? No wild zebra pathology.    



FLdoc2011 said:


> Well, some would argue a huge part again is the legal environment and EMTALA, which mandates that a pt needs to have a medical screen for emergent conditions.  So someone comes in with Chest Pain they are going to be worked up and admitted if necessary because you bet that if they discharged saying it was just GERD, and have an MI when they get home they are going to sue.
> So clinically you may not suspect an MI, but are you willing to bet your career/financial stability on that call and that it's not just an atypical presentation?



Do we admit every person complaining of chest pain for OBS?

Do we not admit people to GI anymore?

This is a strange exampe and argument to me. Not everyone who complains of chest pain gets admitted. 

Are you a medical doctor?



FLdoc2011 said:


> Unfortunately that may happen.  The US is still an attractive place to practice, not everyone wants to jump overseas quite yet.



:rofl:

Yea, because everyone knows that the pay is not proportional to results or effectiveness. 



FLdoc2011 said:


> Again,  ask your EM colleagues which imaging test they immediately get if a pt presented with symptoms concerning for a head bleed....   AND also ask what their differential diagnosis is and what other conditions they are trying to rule out with that imaging test.



Why? 

I have a fair idea of what they are myself. I have also many times that a CT was in order. 

I again state, that in a suspected head bleed, like any other surgical emergency that was not potentially treatable where I was, I would start to move that patient prior to getting bogged down in diagnostics. Based soley on clinical findings and suspicion.

That is the whole point of escalating care. It is why people like ACS put out classes on not fooling around trying to treat something you are not capable of. 

It is why a level III trauma center will send a patient to a level I. It is why a non cardiac facility will send a patient to a cardiac facility.

I have to ask. Exactly what kind of medicine do you practice where you must provide definitive and undisputed evidence the patient is over your head before you send them to somebody better capable?     

"Yep the patient is dead now, maybe pathology will tell us if it was the bleed we suspected or not, we probably should have sent them out a bit earlier..."

Seems like a rather depressing conversation.

Rather than keep replying to this now nonsense, arguing about whether or not a CT is the standard of care in a patient with a suspected head bleed, without addressing the merits of early transfer except with zebras and legal interpretation, I am going to ask one more question...

Is this a reincarnation of ventmedic?


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## 18G (Mar 27, 2012)

So what happens when you suspect a head bleed (without a CT) and transfer the patient 2hrs down the road to a receiving facility that does a CT and comes to find out you were wrong and that it is not a head bleed? And the patient should have went to facility XYZ an hour closer or could have stayed where they were?

Is it possible to be 100% sure of a head bleed without a CT? A CT scan doesn't take that long and is more definitive than a physical exam is it not? So at the earliest suspicion of a head bleed, why not send the patient to CT?

If you're going to transfer a patient out shouldn't you be as sure as possible what the diagnosis is by using all the available tools at your disposal? 

You don't get a prize for using physical exam alone do you? Or is it more of a "chest out, I'm that good" mentality that makes you argue against CT prior to transfer?

I can remember when I hurt my leg in elementary school and the doctor in the ED was dead set based on his exam that my leg wasn't broken. My mother was very insistent on an x-ray and the doc even got kinda smart with her. But he ordered the x-ray and guess what, I was in a cast for six weeks. 

Technology is a great thing...  why not use it and let it paint the picture of what the problem is?


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## MS Medic (Mar 27, 2012)

18G said:


> You don't get a prize for using physical exam alone do you? Or is it more of a "chest out, I'm that good" mentality that makes you argue against CT prior to transfer?



This is a hit the nail on the head moment. Why would someone with MD training spend so much time on an EMS forum telling everyone why they are wrong rather than on a forum with peers where there can be higher level discussions.


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## Pavehawk (Mar 27, 2012)

Veneficus said:


> "Yep the patient is dead now, maybe pathology will tell us if it was the bleed we suspected or not, we probably should have sent them out a bit earlier..."
> 
> Seems like a rather depressing conversation.



Unless you're the pathologist... My cousin (a pathologist) likes to call it job security.

Remember, an internist knows everything and does nothing... A surgeon knows nothing and does everything... a pathologist knows it all and does it all... three days too late :rofl:


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## Veneficus (Mar 27, 2012)

MS Medic said:


> This is a hit the nail on the head moment. Why would someone with MD training spend so much time on an EMS forum telling everyone why they are wrong rather than on a forum with peers where there can be higher level discussions.



I don't see it as a chest out kind of thing, I see it as a "how much evidence do you need and how much fooling around are you planning on doing sort of thing."

As the "what if's" get more complex, individual judgement comes into play.

Would you withold a CT for a patient going far away? That depends on whether or not it would delay transport.

I see it as a similar situation as a abd bleed. Would you delay transport to confirm your suspicion with a ct, ultrasound, perform a DPL if you have clinical evidence of a bleed?

For some reason I don't think so. 

Why would you treat any other surgical emergency any different?

If you have to wait 30 minutes for a transport, why not CT?

If you suspect herniation based on physical findings, would a ct really change anything?

Again I don't think so. At that point you probably need definitive action.

But at the same time, why would you sit on a patient when doagnositcs could take equal or longer than a transport and if you find something on your CT but can't help, what is the point of that? 

Puff out your chest and say " I knew it now I can show the world?"

If you go way back to the original post, one of the questions I asked was, why go to a local facility to transport again.

I reiterated that position with several similar situations.

The answers I got was:

Because of an interpretation of a law

Because we CT everyone no matter what

What if X,Y,Z that had nothing to do with the scenario at hand.

Along with an almost OCD argument boardering on schitzophrenic features constantly going back to something I agreed with several times.

Why do I hang out here?

Stress relief mostly. I spend all day in high level discussion, usually involving patients where convential treatment is not working or has already failed.

When I am not doing that I am finding new solutions to rather old an complex problems.

It is nice to spend some time hanging out with EMS people. 

I'd like to think I can give something back or offer a different perspective.

I am not without my passions though and do enjoy a spirited argument.

If it is that disruptive, I am sure I could go spend some time with a videogame just as easily.


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## MS Medic (Mar 27, 2012)

The discussion between you FL Doc turned into something completely off topic from the OP. Seeing how we don't have CTs in the ambulance, I don't have any interest in that discussion but I'm still going to call it like I see it and you and I will have to agree  to disagree.


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## 18G (Mar 27, 2012)

But isn't the point this... one way or another a CT scan is gong to be performed. No matter if it's performed at the originating facility or at the destination, someone is going to be ordering a CT scan.

Would a neurosurgeon really open up someones skull without a CT scan?


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## Veneficus (Mar 27, 2012)

18G said:


> But isn't the point this... one way or another a CT scan is gong to be performed. No matter if it's performed at the originating facility or at the destination, someone is going to be ordering a CT scan.



I am not disagreeing with that, I am just disagreeing with the timeing.




18G said:


> Would a neurosurgeon really open up someones skull without a CT scan?



depends on how bad the patient looked and in what circumstances.


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## Veneficus (Mar 27, 2012)

MS Medic said:


> The discussion between you FL Doc turned into something completely off topic from the OP. Seeing how we don't have CTs in the ambulance, I don't have any interest in that discussion but I'm still going to call it like I see it and you and I will have to agree  to disagree.



I am curious to hear why somebody who doesn't have a ct would be willing to discount clinical findings and go to a local center that may have to transfer a patient out as opposed to bypassing the local center to go to a more capable one.

Is that not one of the most important things EMS providers can do?


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## FLdoc2011 (Mar 27, 2012)

I'll have to reply to the above points when I'm home and have time.   But yes, I am a physician and no, I'm not some reincarnate of a previous poster.   Only here because I have an interest in some EMS topics and this topics is one I have experience in. 

Are you a physician? 

I never said "everyone" gets a CT.  But in the case of suspected bleed then yes they are getting a scan, even before transfer because, even as I've already pointed out (AND linked to printed guidelines) we need to rule out certain other issues.  

And to be clear, I am not talking about blatant obvious trauma or how medicine is practiced in other countries.  There are always exceptions and that neurosurgeon giving tx before the scan is an exemption in dire circumstances.  

If someone is actively herniating in front of me then they probably aren't stable enough for a scan anyway and there are other immediate issues that need to be addresses such as airway.   And in that case they aren't stable enough for transport at that time either.   

I'm not really sure how else I can be more clear.  It's not about defensive medicine, or legal fear.  It IS the test of choice and what is going to be done.   

In the example of the preggo with pelvic pain,  I get the ultrasound not to drain their wallet but to make sure there's not something life threatening going on.   If not then there's no reason to transfer them to an OB facility.    I'm actually SAVING healthcare dollars by doing that instead of transferring and spending more time and money on the transfer.  And even then another facility is not going to accept my pt if I don't have a reason for them to, they're going to say get the ultrasound and then we'll talk of there's still reason to.


I see your above post and that's a different issue all together.... If you suspect head bleed then just like ischemic stroke you need to transport them to a facility that can receive those pts.... JUST like what we do here with chest pain centers and stroke centers.     

I would argue that on clinical findings alone you're not going to be as reliable as you think you might be in differentiating a bleed from something like an ischemic stroke.   If at all possible of course you wouldn't transfer to a facility that doesn't have CT,  unless the patient was also absolutely crashing and you had to get them the nearest place no matter what.    Ex:  we don't admit peds but we, fortunately rarely, get critically I'll kids brought in by EMS if we are the absolute closest hospital and the kid is crashing.


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## Veneficus (Mar 27, 2012)

FLdoc2011 said:


> I see your above post and that's a different issue all together.... *If you suspect head bleed *then just like ischemic stroke you need to transport them to a facility that can receive those pts.... JUST like what we do here with chest pain centers and stroke centers. .



That is the whole point to my argument over all of these pages.




FLdoc2011 said:


> If at all possible of course you wouldn't transfer to a facility that doesn't have CT,  unless the patient was also absolutely crashing and you had to get them the nearest place no matter what.    Ex:  we don't admit peds but we, fortunately rarely, get critically I'll kids brought in by EMS if we are the absolute closest hospital and the kid is crashing.



and in your experience, how much does transporting a crashing patient to the closest facilty actually help?


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## FLdoc2011 (Mar 27, 2012)

Veneficus said:


> I am curious to hear why somebody who doesn't have a ct would be willing to discount clinical findings and go to a local center that may have to transfer a patient out as opposed to bypassing the local center to go to a more capable one.
> 
> Is that not one of the most important things EMS providers can do?



I think this clears up your stance a little more.  You're point is you pick up a pt with suspected bleed, and you have two choices to transport to,   Hosp A 15min away with CT but no neuro surg, and Hosp B 30min away with CT AND neurosurg.    Is that what you're getting at?

In that instance I would assume EMS protocols vary.    Here, outside of trauma, you would go to the nearest stroke center, even if no neurosurg.  Clinical exam alone not enough to differentiate ischemic from hemorrhagic. 

But if highly suspicious and within protocol I would certainly say reasonable to bypass and go to Hosp B,  IF the extra time require for transport wouldn't put you outside window for something like TPA that could've been given at the closer facility


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## Veneficus (Mar 27, 2012)

FLdoc2011 said:


> I think this clears up your stance a little more.  You're point is you pick up a pt with suspected bleed, and you have two choices to transport to,   Hosp A 15min away with CT but no neuro surg, and Hosp B 30min away with CT AND neurosurg.    Is that what you're getting at?
> 
> In that instance I would assume EMS protocols vary.    Here, outside of trauma, you would go to the nearest stroke center, even if no neurosurg.  Clinical exam alone not enough to differentiate ischemic from hemorrhagic.
> 
> But if highly suspicious and within protocol I would certainly say reasonable to bypass and go to Hosp B,  IF the extra time require for transport wouldn't put you outside window for something like TPA that could've been given at the closer facility



That is exactly what I was trying to say.

I apologize again for mistaking you for somebody else.


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## FLdoc2011 (Mar 27, 2012)

Veneficus said:


> and in your experience, how much does transporting a crashing patient to the closest facilty actually help?



If they are truly that bad and crashing then they are already way down on the survivability scale and its already come to heroic measures for the most part, but we can still do things in the ED for that pt that can't be done by EMS, especially if there would be a longer delay in certain interventions from a longer EMS transport.


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## FLdoc2011 (Mar 27, 2012)

Veneficus said:


> That is exactly what I was trying to say.
> 
> I apologize again for mistaking you for somebody else.



I'm ready for a cigar and beer.  :rofl:


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## systemet (Mar 27, 2012)

I wrote an angry response, then decided to tone it down.  My apologies to MS Medic who didn't deserve what I posted.



MS Medic said:


> This is a hit the nail on the head moment. Why would someone with MD training spend so much time on an EMS forum telling everyone why they are wrong rather than on a forum with peers where there can be higher level discussions.



Why does it matter?  Shouldn't we be happy that two highly educated individuals are discussing the inhospital treatment of a common prehospital presentation.





> MS Medic 	The discussion between you FL Doc turned into something completely off topic from the OP. Seeing how we don't have CTs in the ambulance, I don't have any interest in that discussion but I'm still going to call it like I see it and you and I will have to agree to disagree.



I found it interesting.  I don't think our discussion on this site should be limited to discussing only diagnostic techniques that are available prehospitally.  Many of us doing interfacility transports, some emergent, in why CT may play a role.


----------



## Veneficus (Mar 27, 2012)

FLdoc2011 said:


> I'm ready for a cigar and beer.  :rofl:



Can we agree on Guiness or do we have to argue again.


----------



## FLdoc2011 (Mar 27, 2012)

Veneficus said:


> Can we agree on Guiness or do we have to argue again.



That'll do just fine.... Ha!


----------



## Mex EMT-I (May 24, 2012)

Hi,

Well i think the subject here (After that very good exchange of system views) is the ETCO2 right? Most of the EMS services around the globe are taking that into account when it is time to treat the patient, and more importantly the TBI and stroke patient.

Does anyone knows of a study relating ICP, ETCO2 and Ventilator parameters (frecuency and volume), or if thats too in the high only ICP and ETCO2?


And by the way, one every 2 seconds is way TOO high. Almost sure (if not contradicted by the study i just asked for) the RT was not doing a good job there.


----------



## JakeEMTP (May 24, 2012)

When you get into critical care transport and ICUs it is a whole different ballgame. They may go by minute volume and will give a higher rate with smaller tidal volumes with each squeeze to protect the lungs and still get the CO2 they want. You might  see their vents set at a rate of 30 -40 with the low side for tidal volume setting. Also unless we know what other factors like ph or if the pt was acidotic for some other reason or if they aspirated with lung problems, it is hard to tell what a good rate is for this pt.  

Too little information given to form a conclusion if the rate was too fast or even too slow.


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## EnviroMed (May 25, 2012)

Simusid said:


> This has been bugging me since the call a few days ago.   We arrived on scene to an elderly female unresponsive following an unwitnessed fall.  My parter very quickly said "head bleed" and off we went to the hospital.  Within a very short time the ED confirmed a pretty severe subarachnoid hem and the next decision was either medflight to boston or IFT to Providence RI.   The family wanted her to go to RI but the problem was that it's hard to get IFT quickly after 11 PM.  We happened to still be there doing paperwork and cleaning up and the Dr. asked if we could do the IFT even though we're a 911 truck.  We said of course (still have coverage in town) and off we go with a nurse and respiratory therapist.



you did well, under 8 (over 24) herniate, hyperventilate. In cases with increased ICP there runs a risk of a hernia, how do you lower that risk? Hyperventilate. O2 causes blood vessel constriction, means less blow flows of the vessel wall and into the sub arachnoid space, more blood that piles up compresses against the brain and pushes it down. by hyperventilating you are delaying that from happening. In my opinion your call was the right call.


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## TatuICU (May 26, 2012)

JakeEMTP said:


> When you get into critical care transport and ICUs it is a whole different ballgame. They may go by minute volume and will give a higher rate with smaller tidal volumes with each squeeze to protect the lungs and still get the CO2 they want. You might  see their vents set at a rate of 30 -40 with the low side for tidal volume setting. Also unless we know what other factors like ph or if the pt was acidotic for some other reason or if they aspirated with lung problems, it is hard to tell what a good rate is for this pt.
> 
> Too little information given to form a conclusion if the rate was too fast or even too slow.



Correct.  iSTATs would be useful in the field for a long list of reasons.


----------



## JakeEMTP (May 26, 2012)

TatuICU said:


> Correct.  iSTATs would be useful in the field for a long list of reasons.




In CCEMT-P class, we learned the ph and some acidosis is usually a later change when the body is decompensating which is why they stress that the guidelines in BCLS and ACLS are generally more for an acute event which is where bagging at only a rate of 8 comes from.  I think ETCO2 would be just as good in the field for a new patient.  I don't see any advantage of an iSTAT for this especially if you don't know some of the other labs for the type of acidosis or don't carry what you need to treat it.  When a pt is on all of the pressors and hypothermia for any length of time, you will see changes but without a bigger picture from lots of labs you can't just treat a ph. Our CCT truck doesn't carry much more than what we do on ALS so unless the hospital initiates it we can't do much. Most of our patients have a base line ABG so the Rt will tell us how to set the vent which is usually are rate of 20 or more and sometimes less than 500 for tidal volume.


----------



## TatuICU (May 26, 2012)

JakeEMTP said:


> In CCEMT-P class, we learned the ph and some acidosis is usually a later change when the body is decompensating which is why they stress that the guidelines in BCLS and ACLS are generally more for an acute event which is where bagging at only a rate of 8 comes from.  I think ETCO2 would be just as good in the field for a new patient.  I don't see any advantage of an iSTAT for this especially if you don't know some of the other labs for the type of acidosis or don't carry what you need to treat it.  When a pt is on all of the pressors and hypothermia for any length of time, you will see changes but without a bigger picture from lots of labs you can't just treat a ph. Our CCT truck doesn't carry much more than what we do on ALS so unless the hospital initiates it we can't do much. Most of our patients have a base line ABG so the Rt will tell us how to set the vent which is usually are rate of 20 or more and sometimes less than 500 for tidal volume.



I don't mean to call into question the merits of a "CCEMT-P" class, but with all due respect, you will generally see changes in labs, particularly on your ABGs, before you see severe symptoms arise which is why when a pt finally hits the toilet your labs are so whacked out as opposed to just a tad off kilter.  

But in all fairness I wasn't offering commentary on this particular scenario, but rather on the sentiment of your previous post regarding the fact that there is "too little info given to form a conclusion."  I don't know where you work EMS at, but I worked at a service where we were 45-60 minutes away from even a level IV center, so iSTATs would be very useful for us.  I'm also unsure of what you mean by "type" of acidosis.  With labs including pH, pO2, CO2, HCO3, and Base excess/deficit, you should be able to pin it down and iSTATS offer all of those labs and more including K+, HCT, Na+.....

And MOST of your patients should have a vT<500.


----------



## JakeEMTP (May 26, 2012)

TatuICU said:


> And MOST of your patients should have a vT<500.



Not really if it is an EMS vent. Alot of protocols are written with a middle of the road tidal volume of 500. EMS vents don't have a way to compensate for their circuits like the ICU vents. The reps should tell you it will vary anywhere from 50 - 100 of volume lost in the circuit.  Those single flimsy flex tubes on the ATV are :censored::censored::censored::censored: and the patient probably doesnt get half the volume.

They also taught use ABGs don't give much of the story. We also can't do arterial sticks per the state even on CCT.  Only RNs can. You don't just throw bicarb at everyone either. It was discussed that low bicarbs on an ABG doesn't always mean you should give it.  If you don't carry blood or potassium, what good do a bunch of labs do. Even that is just a snapshot as ER docs will tell you when they use the istat.

Flight teams and teams like Pedi or neonatal use the istat but they have everything in their bags that they might have in an ICU and their transports are long.


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## usalsfyre (May 26, 2012)

JakeEMTP said:


> Not really if it is an EMS vent. Alot of protocols are written with a middle of the road tidal volume of 500. EMS vents don't have a way to compensate for their circuits like the ICU vents. The reps should tell you it will vary anywhere from 50 - 100 of volume lost in the circuit.  Those single flimsy flex tubes on the ATV are :censored::censored::censored::censored: and the patient probably doesnt get half the volume.
> 
> They also taught use ABGs don't give much of the story. We also can't do arterial sticks per the state even on CCT.  Only RNs can. You don't just throw bicarb at everyone either. It was discussed that low bicarbs on an ABG doesn't always mean you should give it.  If you don't carry blood or potassium, what good do a bunch of labs do. Even that is just a snapshot as ER docs will tell you when they use the istat.
> 
> Flight teams and teams like Pedi or neonatal use the istat but they have everything in their bags that they might have in an ICU and their transports are long.



An iStat would be extremely useful for formulating things like ventilation stratagies, treating electrolyte derangement, ect. That said, I can't get normal crews to control the effing glucometer....

Whoever taught you ABGs don't tell you a lot doesn't know how to interpret ABGs. ETCO2 is kinda useful by itself. But it doesn't tell you PaCO2 without knowing the gradient. Your ETCO2 may be 35 with a PaCO2 of 80, you won't know till you have an ABG in hand.


----------



## TatuICU (May 26, 2012)

JakeEMTP said:


> Not really if it is an EMS vent. Alot of protocols are written with a middle of the road tidal volume of 500. EMS vents don't have a way to compensate for their circuits like the ICU vents. The reps should tell you it will vary anywhere from 50 - 100 of volume lost in the circuit.  Those single flimsy flex tubes on the ATV are :censored::censored::censored::censored: and the patient probably doesnt get half the volume.
> 
> They also taught use ABGs don't give much of the story. We also can't do arterial sticks per the state even on CCT.  Only RNs can. You don't just throw bicarb at everyone either. It was discussed that low bicarbs on an ABG doesn't always mean you should give it.  If you don't carry blood or potassium, what good do a bunch of labs do. Even that is just a snapshot as ER docs will tell you when they use the istat.
> 
> Flight teams and teams like Pedi or neonatal use the istat but they have everything in their bags that they might have in an ICU and their transports are long.



I would re-evaluate the education you received regarding ABGs. It certainly doesn't tell the whole story but it can sure tell you alot.  And who said anything about throwing bicarb at people? Not sure where that's coming from.


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## jwk (May 26, 2012)

TatuICU said:


> I would re-evaluate the education you received regarding ABGs. It certainly doesn't tell the whole story but it can sure tell you alot.  And who said anything about throwing bicarb at people? Not sure where that's coming from.



Ditto - ABG's can tell you a ton.

Hopefully nobody is throwing bicarb at anyone anymore without an ABG.


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## JakeEMTP (May 26, 2012)

usalsfyre said:


> Your ETCO2 may be 35 with a PaCO2 of 80, you won't know till you have an ABG in hand.



I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital. You mention PaCO2. That value is from the artery. That is what the a stands for.  The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number. I also can not think of one state that allows Paramedics to stick arteries in the field.  Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care. The heart and brain are not that forgiving. Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation.  Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either. 

To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.


----------



## TatuICU (May 27, 2012)

JakeEMTP said:


> I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital. You mention PaCO2. That value is from the artery. That is what the a stands for.  The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number. I also can not think of one state that allows Paramedics to stick arteries in the field.  Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care. The heart and brain are not that forgiving. Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation.  Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.
> 
> To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.



can i ask how long you've been in actual critical care settings?


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## usalsfyre (May 27, 2012)

JakeEMTP said:


> I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital.


Or by iStat. That said, CCT is not about speed. I've run two hour scene times on CCT IFTs before, it took that much to be able to move safely. 



JakeEMTP said:


> You mention PaCO2. That value is from the artery. That is what the a stands for.


Got that, I've looked at ABGs once or twice .



JakeEMTP said:


> The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number.


Unless there is a change in hemodynamics or alveolar status, the PaCO2 to ETCO2 remains the same. So if there's a PaCO2 of 60 and an ETCO2 of 55, it will be 40 and 35 respectively after changes. 



JakeEMTP said:


> I also can not think of one state that allows Paramedics to stick arteries in the field.


Not all of us are bound by what a state EMS administrator thinks we need to be doing. You can also draw off an a-line.



JakeEMTP said:


> Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care.


Sometimes your giving your patient a death sentence by not optimizing them for transport. There is a time to fish or cut bait. However, taking a truly mismanaged CCM patient (and it happens more often than you think) and throwing them in the truck where you don't have the help, equipment or room to work without trying to at least start correcting the issues is negligent. 




JakeEMTP said:


> The heart and brain are not that forgiving.


Hence why CCT is a distinct discipline.



JakeEMTP said:


> Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation.


The training needs to. Furthermore, ALS crews don't need to be doing ICU to ICU trips.



JakeEMTP said:


> Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.


You lost me here. The will work short-term with a vent as well as an Ambu bag. Maybe better, because the breath is delivered in a far more controlled manner.



JakeEMTP said:


> To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.


Knowing is sometimes half the battle. Some of us also carry the pharmacology to correct a lot of this.

I'm not sure where you took CCEMT-P. It doesn't sound like you were taught by true subject matter experts though, rather by someone who had a tenuous grasp of the material.


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## Handsome Robb (May 27, 2012)

JakeEMTP said:


> Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.



We use vents on KING tubes all the time without any problems. Sure they get swapped to an ETT when we get to the hospital. The KING and Combi by definition are rescue airways. Not definitive airways. 

Is an ETT better? Yes. But our doc wants a KING during arrests, any other time it's an ETT.


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## TatuICU (May 27, 2012)

I won't beat a dead horse as usalfyre has touched on most everything.  

However, just to kind of expound on his final point, there is no real standardization when it comes to "CC"EMT-P.  There are many "CC"EMT-Ps out there who got the designation after a laughable two week course taught by other "CC"EMT-Ps who think they have critical care experience because they transport vents and *gasp* more than 3 gtts.  

Conversely, I've had the pleasure of having paramedics during an in hospital 6 month CCEMT-P program who have gotten to come recover CABGs with us, really learn about hemodynamics, really learn about ventilation, and in general get some actual critical care experience in dealing with a variety of situations.  Those are people where there is actual continuity of care and I wish there was a different way to recognize them instead of lumping them in with the two-weeker wannabes.  

In any case Jake, I would look into a different program.

You talk about "sticking" arteries and not being allowed to. How many critical care transports have you actually done? i ask because most critical care transports deemed critical enough to be called "critical care" transports usually have an art line to monitor BP which is very easy to draw off of. And as far as the "vents with fancy knobs" comment, I have to ask how you transport critical pts that are in APRV mode or other non-CMV/SIMV settings?  If the critical care truck does not have critical care equipment, then it is not a critical care truck and should not bill as such.


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## hyperlyeman1 (May 27, 2012)

JakeEMTP said:


> I guess if you have tons of time to spend on scene you can do all the labs which will have to be repeated in the hospital. You mention PaCO2. That value is from the artery. That is what the a stands for.  The gradient won't be the same since venous blood will give you a different value and you'll be chasing the wrong number. I also can not think of one state that allows Paramedics to stick arteries in the field.  Some of us know our limitations for scope of practice and feel a patient is best served with some of these procedures done in a hospital simultaneouly with a lot of the other tests to get the patient the best care. The heart and brain are not that forgiving. Most ALS crews don't have fancy ICU ventilators with alot of knobs and the training hasn't caught up to alot of lab interpretation.  Maybe we should figure out how to improve intubation since a King or Combi isn't going to work that well with a ventilator either.
> 
> To the others, if you aren't going to correct with some pharmacology, what is the point of doing all the labs? Basic vent instruction also told us that you can chase numbers with a vent just so long and you do more damage than good.




When did medics get labs?:glare:


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## usalsfyre (May 27, 2012)

hyperlyeman1 said:


> When did medics get labs?:glare:



On every CCT I do.


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## hyperlyeman1 (May 27, 2012)

What is the purpose of labs in the field, I get their importance in the hospital setting and their use as a diagnostic tool. But unless you have an extremely long transport time or are on an ift (in which case labs most likely have been done already), why waste the time to do them? In the event of a true emergency that would warrant their use, wouldn't our time be better served treating the patient instead of screwing around with labs? Just my .02


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## JakeEMTP (May 27, 2012)

TatuICU said:


> You talk about "sticking" arteries and not being allowed to. How many critical care transports have you actually done? i ask because most critical care transports deemed critical enough to be called "critical care" transports usually have an art line to monitor BP which is very easy to draw off of. .



You wanted iStats and ABGs in the field.



TatuICU said:


> Correct.  iSTATs would be useful in the field for a long list of reasons.



Now you have resorted to making me out to be an *** since I said there were many limitations to the scope and the education. WTF? Not everyone can be a hotshot ICU nurse like you make yourself out to be. 

A field Paramedic can not do an art stick. Patients we see in the field do not come with an A-line already  inserted just waiting for EMS to come. In you nice little ICU you have doctors who put the lines in for nurses and to give you orders for when to draw.

I never said CCEMT-P was a big *** title of some type which is why I stated the limitations.

You want all the conforts of an ICU but you seem to now know there are limitations in the fields both in education and training for equipment. 

You and usalfyre seem to think another new toy will make up for whatever else you fail at. If you can't assess, you just get an ultrasound or an iStat to make up for it. A ventilator to hook up to a King will make up for not being allowed to intubate and look really impressive here. You have people asking how to take a BP or what to do with an ETCO2 or to guess an EKG but you want to jump right into doing a bunch of labs when you don't have the stuff down  you should be doing.

Alot of us know what we should improve on and don't rush into getting equipment just to boost our egos.


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## hyperlyeman1 (May 27, 2012)

JakeEMTP said:


> You wanted iStats and ABGs in the field.
> 
> 
> 
> ...




I likes new toys  labs would be great  as a diagnostic tool.  As are blood pressures, rhythms, 12 leads and the 50 other things we have to worry about while upside down under a car. If we spent another 10 minutes obtaining blood and doing labs, we may be doing CPR instead of just using cpap. Our job is to get them to the hospital as fast as safely possible. Anything that delays that process can cause a negative outcome in our patients


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## JakeEMTP (May 27, 2012)

I don't think any ER doctor is going to call an ICU doc just to put an art line in before they transfer a Subarachnoid bleed to another hospital either.

I have seen nurses telling the doc they need to order bicarb stat because of the ABG result and to be told how stupid they were by the doctor since they didn't have a clue about the rest of the labs such as anion gap or the medical condition. You can easily over treat the wrong thing by putting all your focus on just a handful of labs and knowing only the stuff from Paramedic school which alot of us should know that is only a small part of medicine knowledge.  All the toys might sound great but if you aren't going to treat any of the lab values whats the point.  You can really :censored::censored::censored::censored: up a patient by thinking you know it all from a few number on an iStat when your education does not support it.  Try being a Paramedic first and getting that stuff right. The field isn't the same as an ICU so those who think they need all the toys to assess a patient are going to be disappointed as Paramedics.


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## usalsfyre (May 27, 2012)

JakeEMTP said:


> You wanted iStats and ABGs in the field.


They are indeed useful for both field and IFT calls.



JakeEMTP said:


> Now you have resorted to making me out to be an *** since I said there were many limitations to the scope and the education. WTF? Not everyone can be a hotshot ICU nurse like you make yourself out to be.


You want to talk about CCEMT-P class and critical care medicine? Welcome to the deep end of the pool. Your going to end up looking and feeling like an idiot a lot at first. I've been doing CCT a little while, and I still regularly feel like one. Coming in with a chip on your shoulder will make it worse. 



JakeEMTP said:


> A field Paramedic can not do an art stick. Patients we see in the field do not come with an A-line already  inserted just waiting for EMS to come. In you nice little ICU you have doctors who put the lines in for nurses and to give you orders for when to draw.


We've moved well beyond the context of the field setting here. Not to mention there are some "field" paramedics who do do things like arterial sticks, ultrasounds, ect. Just because its not done at your shop doesn't mean it doesn't exist. 



JakeEMTP said:


> I never said CCEMT-P was a big *** title of some type which is why I stated the limitations.


Yet you threw it out there as a qualifier. 



JakeEMTP said:


> You want all the conforts of an ICU but you seem to now know there are limitations in the fields both in education and training for equipment.
> 
> You and usalfyre seem to think another new toy will make up for whatever else you fail at. If you can't assess, you just get an ultrasound or an iStat to make up for it. A ventilator to hook up to a King will make up for not being allowed to intubate and look really impressive here. You have people asking how to take a BP or what to do with an ETCO2 or to guess an EKG but you want to jump right into doing a bunch of labs when you don't have the stuff down  you should be doing.


I'm rather fond of saying CCM could probably be done in a mud hut if the provider is good. I never questioned your physical exam skills, yet you seem to feel the need to question mine. I assure you I'm up to snuff in that area. I've worked with providers who peruse these forums. That said all of the things above make life easier. 



JakeEMTP said:


> Alot of us know what we should improve on and don't rush into getting equipment just to boost our egos.


Perhaps a commentary on your own inadequacies? The equipment mentioned is nothing about ego. CCT is based around one thing. Bringing an ICU level of care to transport the patient. If you can't provide that level because of your own knowledge gap you should not be doing CCT. Period. Full stop. 

The biggest issue I see here is that your still thinking like a 911 FD medic with a 5 minute transport. CCM means thinking hours, days and even weeks down the road. That means making decisions in an informed environment with things like labs, imaging, ect available. You might be with the patient for an hour or more, seemingly small changes (that you may need to make) can have a profound effect. Its this understanding that differentiates the true CCM providers from the posers.


----------



## TatuICU (May 27, 2012)

JakeEMTP said:


> You wanted iStats and ABGs in the field.
> 
> 
> 
> ...



Before I attempt to reply to the rest of this asinine babble,  you do realize that in addition to working in an ICU, I'm also a practicing paramedic in a 911 system for longer than is care to admit.  Also I find it mildly ironic that someone without an understanding of something like arterial blood gases, is calling other people's assessment skills into question.  assessments are what lead to those things being ordered.  And if you actually believe that RNs and RRTs in ICUs call physicians to order labs, diagnostics, etc in emergency situations then I would say that either A. You're angry for some reason and speaking illogically, B. you have little to no experience and thus have no frame of reference, or C. You are just completely out of touch with reality. By the time you have that physician on the phone you had better have answers and be in the process of stabilizing that patient.  But then again, Ive worked with a ton of medics in my career that actually believe they are just as good as "mobile physicians" because "they don't need orders for anything" lol. 

And you never answered any of my questions. Why?


----------



## usalsfyre (May 27, 2012)

hyperlyeman1 said:


> I likes new toys  labs would be great  as a diagnostic tool.  As are blood pressures, rhythms, 12 leads and the 50 other things we have to worry about while upside down under a car. If we spent another 10 minutes obtaining blood and doing labs, we may be doing CPR instead of just using cpap. Our job is to get them to the hospital as fast as safely possible. Anything that delays that process can cause a negative outcome in our patients





JakeEMTP said:


> I don't think any ER doctor is going to call an ICU doc just to put an art line in before they transfer a Subarachnoid bleed to another hospital either.
> 
> I have seen nurses telling the doc they need to order bicarb stat because of the ABG result and to be told how stupid they were by the doctor since they didn't have a clue about the rest of the labs such as anion gap or the medical condition. You can easily over treat the wrong thing by putting all your focus on just a handful of labs and knowing only the stuff from Paramedic school which alot of us should know that is only a small part of medicine knowledge.  All the toys might sound great but if you aren't going to treat any of the lab values whats the point.  You can really :censored::censored::censored::censored: up a patient by thinking you know it all from a few number on an iStat when your education does not support it.  Try being a Paramedic first and getting that stuff right. The field isn't the same as an ICU so those who think they need all the toys to assess a patient are going to be disappointed as Paramedics.



Spare me the hyperbole. I've done a decade of 911 and can count on one hand I've been "upside down in a car". The number of truly time sensitive calls is probably <5%. A medic should be able to recognize these. 

If the education is not there, then provide it. If your people don't want to learn how to safely transport these patients send them packing. We can do better. Lowest common denominator has no place in CCM/CCT.


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## JakeEMTP (May 27, 2012)

[





usalsfyre said:


> If the education is not there, then provide it. If your people don't want to learn how to safely transport these patients send them packing. We can do better. Lowest common denominator has no place in CCM/CCT.



This was not about CCT to begin with. You and  nurse Tatu wanted iSTATs in the field.  

Just how many hours does your state require its Paramedics? Doesn't Texas only require 600? Others are barely at 1000. Does everyone in your 911 ALs have a bachelors degree in EMS? Everyone? You sure make your education sound superior to all of us. I bet most don't have a 2 year degree or even any college. It is usually those with the least amount of education who want to cut others down especially when they have already stated they know their deficiencies.  Get over yourself and see that education for Paramedics isnt' that great so don't go preaching to me about mine. I know what I can and can not do but you don't seem to know what your limitations are.  

Just how do you think all 911 EMS systems are going to provide istats on every truck?  Hell most dont have 12 leads or ETCO2. Y

ou haven't said how it will make any difference for a field paramedic doing 911 calls. Are you going to expand all of the meds to be given?   If you can not tell if a patient might be getting a low HCT or Hb by all of that red stuff on the ground maybe you should get an istat but I don't think that will make you a better Paramedic.  Do you really need to get an ABG right after you intubate? I would rather have an ETCO2 and a stethoscope. By the time you do all of that you could be in the ER and the patient won't have to go through another poke at their artery. How many people do you need onscene while you do all of this stuff? I have been doing this a long time and have managed to get patients to the ER just find without wasting time on things that I can't treat. What next? A CT scanner on every truck. 

I don't think TatuICU deserves a reply with her attitude towards Paramedics. Not all of us believe they are doctors with the exception of usalsfrye.


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## hyperlyeman1 (May 27, 2012)

usalsfyre said:


> Spare me the hyperbole. I've done a decade of 911 and can count on one hand I've been "upside down in a car". The number of truly time sensitive calls is probably <5%. A medic should be able to recognize these.
> 
> If the education is not there, then provide it. If your people don't want to learn how to safely transport these patients send them packing. We can do better. Lowest common denominator has no place in CCM/CCT.



So are you suggesting that we draw labs on every call when you know full well the hospital will redo them and disregard ours? And those time sensitive calls... The ones where labs matter, are the ones where it would be impractical to draw. And tell me again how said labs would change our treatment? My protocols don't specify what to do for a patient who's abg is off, but they do tell me what to do when they are in respiratory distress. And I know that the patients abg will be off if they are in respiratory distress. So the abg in effort will only tellus something we already know, correct? So again why waste time?


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## TatuICU (May 27, 2012)

JakeEMTP said:


> [
> 
> This was not about CCT to begin with. You and  nurse Tatu wanted iSTATs in the field.
> 
> ...



This post is nothing but one non-sequitur after another. Cute with the "her" comment, but if there is anyone in this thread acting like a little girl with their feelings hurt, it sure isn't me.  Neither usalfyre or myself made the argument for iSTATS on every call. You're making yourself out to be some sort of "critical care" transporter which you obviously are not. An actual critical care transport can take place on the ground over the course of several hours, state to state, etc.  It is in these instances where it would be useful and also prehospital when your transport times to a facility are greater than 45-60 minutes.  Once again, I'd be willing to bet I've been a practicing paramedic far longer than yourself so my attitude toward paramedics is a bit more in depth than the hurt feelings assessment you're offering. 

And I do believe  usalfyre holds a real degree. As for myself, I received my AS as a paramedic and a BSN so I'm not sure where your rant about educational standards are coming into play? 

In any case, this tread has gone way off the rails.  I can't wait until paramedics are required to have Bachelor degrees or at least an AS. We need it badly.


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## TatuICU (May 27, 2012)

hyperlyeman1 said:


> So are you suggesting that we draw labs on every call when you know full well the hospital will redo them and disregard ours? And those time sensitive calls... The ones where labs matter, are the ones where it would be impractical to draw. And tell me again how said labs would change our treatment? My protocols don't specify what to do for a patient who's abg is off, but they do tell me what to do when they are in respiratory distress. And I know that the patients abg will be off if they are in respiratory distress. So the abg in effort will only tellus something we already know, correct? So again why waste time?



Once again, you are out of left field and in no way addressing the issue of CCT And again, if you're actually arguing that ABGs prehospital with transport times of greater than 45-60 minutes then I really don't see te point in even trying to discuss this subject with you


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## TatuICU (May 27, 2012)

JakeEMTP said:


> The field isn't the same as an ICU so those who think they need all the toys to assess a patient are going to be disappointed as Paramedics.



Once again, I ask how long you've been in the field. And again I remain a practicing paramedic in a 911 system.  

But in any case, shouldn't a "CC"EMT-P at least know what they're talking about when it comes those "toys" since they did plunk down the money to learn what they were after all?

Which road are you trying to go down here? And ABGs are well within both NREMT-P and RN educational standards.   There's idiots everywhere, I assure you of that.  And I wouldn't recommend talking about how "stupid" other people are, coming from this line of work.  I used to do that a lot in my younger days and always wound up getting frightfully embarrassed, so you know, just a word of advice there.


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## TatuICU (May 27, 2012)

hyperlyeman1 said:


> I likes new toys  labs would be great  as a diagnostic tool.  As are blood pressures, rhythms, 12 leads and the 50 other things we have to worry about while upside down under a car. If we spent another 10 minutes obtaining blood and doing labs, we may be doing CPR instead of just using cpap. Our job is to get them to the hospital as fast as safely possible. Anything that delays that process can cause a negative outcome in our patients




Upside down under a car? I can think of maybe 10-20 instances in my entire career where extrication was going to take long enough for me to actually get under the car and begin real treatment for severely critical patients.

As usal said, 90% of EMS calls are for GOMERS who would not be at risk for deterioration if they simply got a ride with a friend or drove themselves.


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## hyperlyeman1 (May 27, 2012)

I am not.in any way addressing cct. Most medics don't run cct. Most run 911. And coming from a medic who has worked cct (2 years actually) never once have I been on a unit with the capability to do any sort of lab. and how many hands are in the back of your cct units? When you have a ripping call how can you spare those hands our the time? I never said it want useful info. Is not necessary though. And going back a few posts to your less than 5% of calls are time sensitive/critical... That holds true for cct too doesn't it? Most cct calls can be handled by an rt... So are you going to draw labs on those patients who are on a vent going back to hospice care?


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## hyperlyeman1 (May 27, 2012)

TatuICU said:


> Upside down under a car? I can think of maybe 10-20 instances in my entire career where extrication was going to take long enough for me to actually get under the car and begin real treatment for severely critical patients.
> 
> As usal said, 90% of EMS calls are for GOMERS who would not be at risk for deterioration if they simply got a ride with a friend or drove themselves.



Agreed 100%. So why do labs on those goners? Waste of time.


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## TatuICU (May 27, 2012)

hyperlyeman1 said:


> Agreed 100%. So why do labs on those goners? Waste of time.



Agreed, and once again, no one is suggesting that we should.  Most medics can't even apply oxygen at appropriate times, and we certainly waste too much money in EMS to be nonsensically doing these types of things.


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## TatuICU (May 27, 2012)

hyperlyeman1 said:


> I am not.in any way addressing cct. Most medics don't run cct. Most run 911. And coming from a medic who has worked cct (2 years actually) never once have I been on a unit with the capability to do any sort of lab. and how many hands are in the back of your cct units? When you have a ripping call how can you spare those hands our the time? I never said it want useful info. Is not necessary though. And going back a few posts to your less than 5% of calls are time sensitive/critical... That holds true for cct too doesn't it? Most cct calls can be handled by an rt... So are you going to draw labs on those patients who are on a vent going back to hospice care?



huh? The entire point that Jake "CC"EMT-P was trying to make was in regard to CCTs.  That's why we're talking about it.

And yes, most "CCT" calls aren't really CCT.  There's just something (3 gtts, whatever) that allows the EMS service to bill it as though it is one.  Which I really don't blame them.  We don't get reimbursed as much as we should on the whole so I have no problem with billing the :censored::censored::censored::censored: out the hospital anytime you can.  Though I can't imagine any call going to hospice care being deemed "CCT", ever.  A vent is not critical care.  A vent is a vent.  Any run of the mill medic can handle a vent.  Hell we had basics take a short course with med direct approval and they handle most uncomplicated vented transfers headed to NHs, etc.


Headed to play golf.  Will check back later if the thread is still open.


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## hyperlyeman1 (May 27, 2012)

TatuICU said:


> Agreed, and once again, no one is suggesting that we should.  Most medics can't even apply oxygen at appropriate times, and we certainly waste too much money in EMS to be nonsensically doing these types of things.



Again, I agree entirely. I don't know what the argument is about lol.  EMS, at least in my area is really pushing education. Most new medics I know are getting as degrees.


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