# Treating On Scene/En Route



## Jersey (Feb 27, 2010)

We're conducting a study, and was just curious to get a little bit of an informal discussion going here along these lines:

What treatments/interventions do you perform on scene? Specifically,

Initiate an IV line
Place the patient on a 3 lead ECG
Initiate a 12 lead ECG
Administer medications (ACLS)
Administer non ACLS medications.

This should be a pretty interesting discussion to see how our colleagues around the country do things differently. 

All the best


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## 8jimi8 (Feb 27, 2010)

3 lead, or 12 lead if indicated.  Initial impression and ABC's, rapid / focused assessment.  Everything else needs to be done in the back of the bus.  The organization where I volunteer for 9-11 EMS has a 10 minute scene time standard of care.  The fire department where i volly at doesn't transport, so whatever you can get done before the rig shows up is fair game... if it is warranted for the patient's care.


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## medic417 (Feb 27, 2010)

On scene time limitations are quickly becoming a thing of the past because a few extra minutes starting treatments in the field such as thrombolytic therapy can save 30 minutes to more than an hour if we were to wait to the hospitals.   We need to start practicing medicine rather than being taxi drivers.


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## reaper (Feb 27, 2010)

Exactly. You cannot answer this poll, without knowing what you are treating. The majority of Pt's you see can have most interventions done on scene. There is no rush.

Very few Pt's are ever in need of scope and run tactics. Treat your Pt's, not your protocols!


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## Epi-do (Feb 27, 2010)

reaper said:


> Exactly. You cannot answer this poll, without knowing what you are treating. The majority of Pt's you see can have most interventions done on scene. There is no rush.
> 
> Very few Pt's are ever in need of scope and run tactics. Treat your Pt's, not your protocols!



+1

Now if only my officer agreed with this statement.  Unfortunately he is of the mentality that we need to get everyone to the ambulance and enroute to the ER ASAP.  I figure I am about due for another "talking to" about it, because I still try to do as much as I can onscene.  Once he starts getting antsy though, I have to move to the truck.

Yes, there are some patients I would prefer to just get moving with and work as much as I can on the way to the hospital, but those patients are few and far between.  The majority of them, time isn't really a huge factor for though, and are actually better served by getting a better assessment and history while onscene.


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## mycrofft (Feb 27, 2010)

*I answered #2 as a compromise.*

SOME cases benefit more from a longer on scene period, SOME need a snatch and run, most fall in between, because of reasons eveyone's tired of hearing me talk about. Rule out or in these "SOME" groups and work from there.


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## 8jimi8 (Feb 27, 2010)

Well, 

I have yet to lead an ALS unit, I've never lead a BLS unit.  I've always been 3rd rider and followed my lead's instructions.  I am definitely keeping an open mind to your opinions.


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## FLEMTP (Feb 27, 2010)

mycrofft said:


> SOME cases benefit more from a longer on scene period, SOME need a snatch and run, most fall in between, because of reasons eveyone's tired of hearing me talk about. Rule out or in these "SOME" groups and work from there.



Im with you on the "it depends" answer.. i didnt vote in the poll.. because it really depends on what you're looking at. If you get on scene, and someone is shot, or its a trauma alert.. im gone before you realize i was there...literally.. 2 minute scene times...

if I arrive on scene of a chest pain, the FIRST thing im doing is a 12 lead to rule out an acute MI... because that completely changes the destination and treatment course you're going to use. 

Altered level of consciousness is another good example.. you grab and go.. get in the truck.. begin transport. then find out the sugar is only 20.. you treat them.. and have an awake alert and conscious patient who either doesn't want transport.. or doesn't need transport.

Respiratory distress ... you need to do a good assessment. If i have a CHF exacerbation, im going to get them on my cot, in the truck, get a 12 lead.. 2 IV lines, initiate a tridal drip, and reassess them from there.. and either transport if they begin to improve.. or perform a Drug assisted intubation and get them on a ventilator with some PEEP if they arent improving.. ALL before i transport... while i still have my partner handy.. and a controlled enviroment (ie: not flying down the road lights and sirens trying to push meds, ventilate and intubate)

So it really depends on the situation... I think another user hit the nail on the head.. we need to start assessing and treating our patient's rather than giving them a fast glorified taxi ride. 

In fact, here is the perfect example.. you get a call for a pediatric unknown.. walk in the house, and mom is freaking out and the kid is in cardiac arrest... how many of you are going to grab the kid and run like hell for the ER? (im talking ALS... BLS is a completely different story)
How many of you are going to work the child right where you're at.. and give them your best 20 minutes.. with good quality CPR and a good quality airway? (BLS airway typically, especially with children)

We just had this chat in our latest dept inservice and PALS renewal... our medical director and our Captain in charge of education and training made it a point to tell us to work the child on scene, and give it your best. The time  you waste running for the truck and doing haphazard CPR all the way to the ER is going to ruin that child's chances for survival if there are any... not to mention, if the child does not recover ROSC on scene, you can pronounce and call the ME (at least in my agency, yours may be different) rather than transporting a dead child to the ER, which puts you, your crew, and the general public at risk...not to mention taking a dead child out of a house like that may be destroying and removing valuable evidence should this become a criminal case with law enforcement.

Just some examples.. YMMV


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## MrBrown (Feb 27, 2010)

If you restrict your study to those treatments, your study is flawed. 

It all depends what you are treating.  We have a principle called LATER, load and treat enroute but that is not always done, it depends what we are treating!


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## TransportJockey (Feb 27, 2010)

FLEMTP said:


> Im with you on the "it depends" answer.. i didnt vote in the poll.. because it really depends on what you're looking at. If you get on scene, and someone is shot, or its a trauma alert.. im gone before you realize i was there...literally.. 2 minute scene times...
> 
> if I arrive on scene of a chest pain, the FIRST thing im doing is a 12 lead to rule out an acute MI... because that completely changes the destination and treatment course you're going to use.
> 
> ...



Probably one of the best responses I've read on this topic. I agree fully.


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## Shishkabob (Feb 27, 2010)

Obviously it depends.

For the sake of argument, on scene can be in the back of the ambulance infront of the scene.


Cardiac in origin can stay on scene.  If it's an MI, the 15 minutes we spend doing a 12lead, IVs, and initial round of drugs saves what, an hour in the ER?  Plus we can get them to the proper hospital once we know what's going on.

Stroke gets moving once I get an IV started, as they need to get to a CT scanner.

Shortness of breath depends, as well.  If it's asthma and they are reacting to my treatments, we'll probably stay as they might refuse transport.  Refractive asthma starts to get moved.  CHF?  Try to get moving once I get the earliest interventions done.

Major trauma?  Just like is taught-  cspine and airway are one scene, everything else is done in motion.



But each call is depending on how they present.  If it doesn't seem major or time sensitive, no reason we cant start treatment on scene for a bit.




PS-- 3000 posts!


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## DrParasite (Feb 27, 2010)

Linuss said:


> Obviously it depends.
> 
> For the sake of argument, on scene can be in the back of the ambulance infront of the scene.
> 
> ...


+1 

there is no definitive answer, however, I will say this: how many ALS procedures will provide definitive care?  more over, how many NEED to be done on scene, vs enroute?

as a general rule (very general), I try to load and go almost every patient that is going to be transported to the hospital.  there are generally jobs holding in my city, and the less time is spent on scene the sooner we are available for the next job.

however, if a patients condition requires treatment on scene (12 lead, unconc diabetic, airway complications), then we do what is in the patients nest interest.


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## abckidsmom (Feb 27, 2010)

DrParasite said:


> +1
> 
> there is no definitive answer, however, I will say this: how many ALS procedures will provide definitive care?  more over, how many NEED to be done on scene, vs enroute?
> 
> ...



This. 

We certainly could spend 15-20 minutes on scene with every patient, getting the most complete history in the history of patient care, treating and checking boxes all the way down the protocol, or we could do the best, most efficient, expiditious job possible, clear up and serve the next customer.

In our system, HOURS are wasted each and every day with people lollygagging and not having a goal to GET OFF THE SCENE already!  Yes, it's important to provide the best care possible to the patient.  It's also possible to do this very quickly, and en route to the hospital. 

The complex situations described by FLEMTP are few and far between, and there's really not good reason why you can't get a 12 lead or check blood glucose in under 5 minutes on the scene.  Treating a CHFer and evaluating whether your interventions are working is sitting, wasting time on the scene.  Get the treatments going, get moving.  If you need to stop to reassess or to intubate, at least you haven't spent 15 minutes sitting on the scene.


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## 8jimi8 (Feb 27, 2010)

i'm glad i stayed open-minded
seems like prioritization and common sense must rule the call.


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## Akulahawk (Feb 28, 2010)

The systems I've worked in have generally short transport times. I try to make my transport decision early and as part of my Tx plan. For patients that get transported, it's matter of when it's appropriate to do so. Once a transport decision has been made, I'm going to be working towards getting that patient transported. I'll have started what I need started so that I can be further along the Tx plan. My Tx doesn't stop because I've started moving the patient...


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## LondonMedic (Feb 28, 2010)

reaper said:


> Exactly. You cannot answer this poll, without knowing what you are treating. The majority of Pt's you see can have most interventions done on scene. There is no rush.
> 
> Very few Pt's are ever in need of scope and run tactics. Treat your Pt's, not your protocols!


You could argue the opposite and say that few patients need full, time consuming, assessment and treatment on scene. Walk them on, transport, walk them off, get another job and increase productivity.


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## redcrossemt (Feb 28, 2010)

I tend to stay on-scene for a few minutes to initiate treatment that will benefit the patient immediately. Obviously our assessment including BGL/12-lead, airway control/oxygen/CPAP, and usually nebulizer, D50, narcan, fentanyl/morphine... Again, depends on the patient's condition and what they need vs. what I can do. IV if needed to immediately treat the patient. 

I tend to get going on things that need hospital intervention now... trauma alerts, AMI, CVA, anything that needs surgery now, etc.


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## FLEMTP (Feb 28, 2010)

abckidsmom said:


> The complex situations described by FLEMTP are few and far between, and there's really not good reason why you can't get a 12 lead or check blood glucose in under 5 minutes on the scene.  Treating a CHFer and evaluating whether your interventions are working is sitting, wasting time on the scene.  Get the treatments going, get moving.  If you need to stop to reassess or to intubate, at least you haven't spent 15 minutes sitting on the scene.



Just to put this out there.. but I tend to get a lot of complex calls with sick patients... I generally follow the same plans for the various different types of calls on most patients, as appropriate.. and my average scene time for the past year and a half is approx 23 minutes... which is below the agency average of 28 minutes. 

We have a very diverse area we cover.. from more urban areas with a fairly short transport time of 5-10 minutes, rural farm areas with 30-60 minute transports depending on the destination... all the way to 60 minute plus transports to get off of some of our barrier islands and to the closest trauma center or STEMI facility. We do have our own HEMS... however with only one aircraft, its never a guarantee that it will be up and running or available.  

We also have the ability to do any intervention the ER will for about the first hour or so of treatment, with the exception of surgery..


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## LondonMedic (Mar 1, 2010)

FLEMTP said:


> We also have the ability to do any intervention the ER will for about the first hour or so of treatment, with the exception of surgery..


Without knowing precisely what you can and can't do I can think of several.

While a paramedic may be licensed and able to do these interventions, give these drugs and perform these investigations, are they always the right person to do it? Do they have enough immediate help and supervision? Do they have enough experience? Are they ultimately delaying definitive management because there are some other things that the hossie can do in that first hour?


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## FLEMTP (Mar 1, 2010)

LondonMedic said:


> Without knowing precisely what you can and can't do I can think of several.
> 
> While a paramedic may be licensed and able to do these interventions, give these drugs and perform these investigations, are they always the right person to do it? Do they have enough immediate help and supervision? Do they have enough experience? Are they ultimately delaying definitive management because there are some other things that the hossie can do in that first hour?



You do bring up some good points. That's where good decision making comes into play.. something our agency stresses very much so. Granted, no two paramedics will run a call the same way, I'd like to think that most of us here with my agency would make the right call on the right treatment, and think of things in the best interest for the patient. 

We have a VERY competitive hiring process, and we get approx 400 applications per open paramedic position ... so we can be very picky about the type of education and experience our new hires have..and we have a very rigorous field training program. In fact, very few people come into our organization as a paramedic from the start, even if they are a licensed paramedic. Most paramedics will chose to hire in and work as an EMT until they get a firm grasp on the level of care and decision making that our agency demands... and then they promote up to paramedic.  I chose to come in as a paramedic, and I think I made the right decision... but no two people are the same in that aspect.

The point to all of that, is that we have to use our education, and experience to make the appropriate decision as to what would benefit the patient the best, and follow through on that decision.  Do we make the absolute right decision 100% of the time? No, of course not, but we do learn from our mistakes and learn from our decisions. We have a great QA/QI program here and our command staff assigned to that program does a great job on follow up with the ER's to help us decide if we did make the right decision, and if not, how to improve our decision making process so that we can make the right call down the road.

As far as the help goes, we have typically two man crews on the ambulance.. some times a third person if staffing allows it. We dual respond with the fire dept in all areas of the county, and all of them are trained to the BLS level, with about half of the county being ALS... so we have plenty of hands, and plenty of resources. We have the ability to call additional EMS units if we need a hand while transporting, and our supervisors are available as additional hands or for consultation. Our medical director also encourages us to use the ER docs as a resource should we encounter something we are not familiar with for a consultation. We don't really need to seek orders from them, as we are not required to seek orders for anything we do... but its great to know I have that available to me.

I would like to see our agency expand our care even more to allow some additional diagnostic tools to be used, such as checking electrolyte levels, checking for presence of cardiac markers and enzymes, and ultrasound capabilities. Right now we are in a budget crunch, so for right now that type of improvement is on the back burner.


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## Veneficus (Mar 1, 2010)

FLEMTP said:


> I would like to see our agency expand our care even more to allow some additional diagnostic tools to be used, such as checking electrolyte levels, checking for presence of cardiac markers and enzymes, and ultrasound capabilities. Right now we are in a budget crunch, so for right now that type of improvement is on the back burner.



We agree on many things, but I have to respectfully point out/ask.

I have worked with the istat for troponin in the hospital, it is way too sensitive and tempermentl machine for a rig I think. If you dropped a piece of equipment with any weight on the desk it was on it would error out. With one test taking roughly ten minutes and the lab controls required, it doesn't seem like it would be of much benefit. Especially since even in the ED all it seems to serve is hich service the pt is admitted to. Not to mention it makes cards real angry when you call them with the 0.1ng positive result. I am not sure it is a good idea to have EMS worry about an admitting dx. and the service. 

As for other electrolytes, I think serious considertion should be given to the cost/benefit ratio. I think it would be a major challenge to get hospitals to accept your lab values, which means a pt will be double billed in all likelyhood. Also if you are not going to have treatment protocols for it, would it really be anything more than a toy? Does your service have the time or desire to maintain lab certification for such?

Ultrasound I can see having several good uses. (Ultrasonography is very much underutilized in the US compared to Europe) Probably definately worth the money and training involved.

Would you be willing to share the reasons you think the labs would be beneficial or justify the cost and time in the prehospital setting?


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## EMSLaw (Mar 1, 2010)

PHTLS, as I recall, discusses the platinum ten minutes - the amount of time you should be on scene with the patient before initiating transport to definitive care under the bright, harsh lights of the OR.  

But it all depends.  Medical patients might require a more detailed history.  EMTs don't have much problem grabbing a set of vitals, getting a history, and being off the scene in 10-15 minutes.  But medics have a lot more to do.

On the other hand... I've been at calls where medics kept us on scene for up to 35 minutes after their arrival, taking 12-leads, a detailed history, etc., etc.  It was almost more than I could bear, since had the medics not shown up... the patient would have been in the ER for 25 minutes by the time we even cleared the scene.  And medics hereabouts don't like to be reminded (not that I would ever say such a thing on scene) that the M in MICU stands for /mobile/.  (And the response would be "We're a mobile ER, we bring the ER to the patient!  It has nothing to do with treating en route!")

So, there's a balance.  Does the patient need to be stabilized before they can be moved?  How far is the hospital?  How long will it take to extract the patient from between the bathtub and toilet bowl and get him or her into the rig down fifteen icy steps and an unshoveled driveway?  

As a Basic, I'm a firm believer in load and go, mainly because there's so little we can do, and the best intervention is often rapid transport.  But with higher levels of training comes greater ability to do something on scene before transporting.


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## FLEMTP (Mar 2, 2010)

Veneficus said:


> We agree on many things, but I have to respectfully point out/ask.
> 
> I have worked with the istat for troponin in the hospital, it is way too sensitive and tempermentl machine for a rig I think. If you dropped a piece of equipment with any weight on the desk it was on it would error out. With one test taking roughly ten minutes and the lab controls required, it doesn't seem like it would be of much benefit. Especially since even in the ED all it seems to serve is hich service the pt is admitted to. Not to mention it makes cards real angry when you call them with the 0.1ng positive result. I am not sure it is a good idea to have EMS worry about an admitting dx. and the service.
> 
> ...



well.. for example.. you get a diabetic patient who "just doesn't feel well" and hasn't all day.. you do all the standard tests.. and you dont see a STEMI on the 12 lead.. maybe some nonspecific ST changes.. so you take the patient to a hospital that doesnt have interventional cardiology available there.. because its a diabetic not feeling well.. common scenario...
You get the pt to the ER, and they check their cardiac markers.. and find a non st elevation MI in progress.. 

Now, the same scenario with the istat.. you run the cardiac markers and are able to recognize the patient will need a interventional cardiac facility.

Checking basic lab values and electrolytes can allow for a more educated decision making process. If you get a patient who is short of breath, pale, weak, etc.. and you cant seem to find a reason.. you check the CBC and find they have a low RBC count.. you can give advance warning to the ER that they are in need of a transfusion.

On longer transports (which we do have here in my agency) it would allow you to determine if a trauma patient is slowly bleeding out but still compensating for the bleed.

It would allow you to find out that the altered LOC patient you've picked up isnt altered because they are having a CVA, its because they've got an infection that you are able to ascertain because of the elevated white blood cell count.

You can check pH levels on people to help make a decision to place CPAP or intubate.. or whether bicarb would be needed on an acidotic patient..or being able to know a blood gas on a patient would be very beneficial in determining their overall respiratory status and help you make a more educated treatment decision. 

You get a patient with renal insufficiency who's serum level potassium is high, and you decide you want to intubate for whatever reason.. and you push a depolarizing neuromuscular blocker, and spike their serum potassium to a fatal level... you've killed that patient while trying to help them. a potassium level can tell you if this a safe idea or not.

I know some of these seem to be very outside our "scope of practice" but I feel that it can be a realistic goal for EMS in the future and certainly not outside the realm of possibility for something akin to a real Advanced Practice Paramedic... a step above what a paramedic does today.

As far as the durability of the istat device and other lab checking values, they can be redesigned to become more rugged. Imagine back 10 or 15 years ago when someone suggested putting a computer in a moving vehicle.. im sure people doubted the feasibility because they were just too delicate of a machine.. now we have computers you can run over or throw at a wall and they still keep ticking.. 

I like to strive for the future, and believe that we can better ourselves as a profession.. I just wished more people did the same.


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## Veneficus (Mar 2, 2010)

*friendly debate*



FLEMTP said:


> well.. for example.. you get a diabetic patient who "just doesn't feel well" and hasn't all day.. you do all the standard tests.. and you dont see a STEMI on the 12 lead.. maybe some nonspecific ST changes.. so you take the patient to a hospital that doesnt have interventional cardiology available there.. because its a diabetic not feeling well.. common scenario...
> You get the pt to the ER, and they check their cardiac markers.. and find a non st elevation MI in progress..
> 
> Now, the same scenario with the istat.. you run the cardiac markers and are able to recognize the patient will need a interventional cardiac facility.



This is probably area specific I guess. 

Even still, I would just point out to you that what the ED thinks is a significant troponin and what cards does has considerable variation. You may be logging a lot of miles and transporting a considerable amount of people to a hospital that will be filling up and fighting about what to do with a majority of the patients. I find Istat to be more useful in admitting disposition than a diagnostic. especially since a positive result should be confirmed by a standard lab.



FLEMTP said:


> Checking basic lab values and electrolytes can allow for a more educated decision making process. If you get a patient who is short of breath, pale, weak, etc.. and you cant seem to find a reason.. you check the CBC and find they have a low RBC count.. you can give advance warning to the ER that they are in need of a transfusion.



I just don't think this will have much impact. If the patient is not about to die, there is plenty of time for blood typing and figuring out what is wrong, before you start pulling out blood. In more obvious scenarios like a ruptured esophageal varicy or other GI bleed it is superfluous. Not to mention it doesn't rule out anemias or other blood issues. Cost to benefit just doesn't seem there. 

As for electrolytes, unless you are planning to treat them in the field and the patient is not emergent enough and can wait for the results, why bother?



FLEMTP said:


> On longer transports (which we do have here in my agency) it would allow you to determine if a trauma patient is slowly bleeding out but still compensating for the bleed.



Without a blood product or surgical way to stop bleeding this information seems inconsequential. 



FLEMTP said:


> It would allow you to find out that the altered LOC patient you've picked up isnt altered because they are having a CVA, its because they've got an infection that you are able to ascertain because of the elevated white blood cell count.



But if they are so altered wouldn't there be more gross clinical signs? Even if you knew the WBC are you going to start ab therapy? Even in a more subtle case like an appendicitis, I can't see how it would help. How does knowing a WBC count make a difference? (in EMS of course)



FLEMTP said:


> You can check pH levels on people to help make a decision to place CPAP or intubate.. or whether bicarb would be needed on an acidotic patient..or being able to know a blood gas on a patient would be very beneficial in determining their overall respiratory status and help you make a more educated treatment decision.



I will cautiously agree this may be a good idea in the field but i have reservations. 



FLEMTP said:


> You get a patient with renal insufficiency who's serum level potassium is high, and you decide you want to intubate for whatever reason.. and you push a depolarizing neuromuscular blocker, and spike their serum potassium to a fatal level... you've killed that patient while trying to help them. a potassium level can tell you if this a safe idea or not.



If you are planning a field RSI are you really going to wait for the labs to be done? "Killed the patient" is a bit dramatic for me, but if for some reason you suspect there is renal insufficency, or a hyper K for any reason, why not just use a different med?



FLEMTP said:


> I know some of these seem to be very outside our "scope of practice" but I feel that it can be a realistic goal for EMS in the future and certainly not outside the realm of possibility for something akin to a real Advanced Practice Paramedic... a step above what a paramedic does today..



It is not the scope of practice, that can always be changed. I think it is just a cost/benefit imbalance. I'd like to think I carry the banner for bringing more advanced "hospital" medicine to the field, but I am just not convinced Labs are going to be of much use unless you are using them to avoid transporting to an ED. Which is going to increase your scene times considerably. Reducing transport I think is a good idea. Or even doing labs as a mobile continuum of primary care. But in the current version of "EMS" in the majority of US, I remain unconvinced these diagnostics would be useful enough to justify the cost.



FLEMTP said:


> As far as the durability of the istat device and other lab checking values, they can be redesigned to become more rugged. Imagine back 10 or 15 years ago when someone suggested putting a computer in a moving vehicle.. im sure people doubted the feasibility because they were just too delicate of a machine.. now we have computers you can run over or throw at a wall and they still keep ticking..



Supposedly Istat troponin device was made to be usuable by EMS. But in order for the device to read properly, it must be on a level surface without vibration. Don't take my word for it, I encourage you to call a sales rep and ask if you can try one out. But I have a strong suspicion I know what your review will be.

Also consider the cartriges need to be refridgerated. As do the daily controls. Between the blood draw and the actual machine processing time it takes about 10-15 minutes.(providing there is no error which resets the clock) If the result comes back positive you still have to do more detailed testing. 

I haven't got to use the bedside blood gas device personally, as when I am in the ICU my role is not to deal with that, but I will get the dirt on it Thursday. 



FLEMTP said:


> I like to strive for the future, and believe that we can better ourselves as a profession.. I just wished more people did the same.



As do I. But the role I see these diagnostics useful for EMS is not in emergency, but in an extension of primary care. Something many EMS agencies are not eager to embrace.


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## redcrossemt (Mar 2, 2010)

veneficus said:


> but the role i see these diagnostics useful for ems is not in emergency, but in an extension of primary care. Something many ems agencies are not eager to embrace.



+1...


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## FLEMTP (Mar 2, 2010)

Veneficus said:


> This is probably area specific I guess.
> 
> Even still, I would just point out to you that what the ED thinks is a significant troponin and what cards does has considerable variation. You may be logging a lot of miles and transporting a considerable amount of people to a hospital that will be filling up and fighting about what to do with a majority of the patients. I find Istat to be more useful in admitting disposition than a diagnostic. especially since a positive result should be confirmed by a standard lab.



This is why you coordinate with the cardiac facilities in your service area when you implement the istat... find out what they would like to see as far as an acceptable level and an unacceptable level requiring transport to a cardiac facility. I understand some areas this might not be feasible but in our county we have one health system managing the 4 out of 5 hospitals we transport to most commonly and the 5th one is where our medical director practices... so its very feasible here.



> I just don't think this will have much impact. If the patient is not about to die, there is plenty of time for blood typing and figuring out what is wrong, before you start pulling out blood. In more obvious scenarios like a ruptured esophageal varicy or other GI bleed it is superfluous. Not to mention it doesn't rule out anemias or other blood issues. Cost to benefit just doesn't seem there.
> 
> As for electrolytes, unless you are planning to treat them in the field and the patient is not emergent enough and can wait for the results, why bother?
> Without a blood product or surgical way to stop bleeding this information seems inconsequential.



I do admit you have a point here... I will also point out when i made this post it was 130 in the am, i was on shift, and not thinking as clearly as I should have  so much of this is wishful thinking.








> But if they are so altered wouldn't there be more gross clinical signs? Even if you knew the WBC are you going to start ab therapy? Even in a more subtle case like an appendicitis, I can't see how it would help. How does knowing a WBC count make a difference? (in EMS of course)
> 
> 
> 
> ...



Not everyone has access to multiple paralytic medications. We carry succinylcholine and thats it.




> It is not the scope of practice, that can always be changed. I think it is just a cost/benefit imbalance. I'd like to think I carry the banner for bringing more advanced "hospital" medicine to the field, but I am just not convinced Labs are going to be of much use unless you are using them to avoid transporting to an ED. Which is going to increase your scene times considerably. Reducing transport I think is a good idea. Or even doing labs as a mobile continuum of primary care. But in the current version of "EMS" in the majority of US, I remain unconvinced these diagnostics would be useful enough to justify the cost.



With the increase in calls for service, and the commonality of non acute presentations of patients, transporting to destinations other than the ER or using these diagnostic tools to justify a non-transport situation to reduce workload on the ER's... which we all know non-emergent and non-acute conditions add to the overcrowding of the ER's. A change like this is almost a certainty if something is to be done about the situation.





> Supposedly Istat troponin device was made to be usuable by EMS. But in order for the device to read properly, it must be on a level surface without vibration. Don't take my word for it, I encourage you to call a sales rep and ask if you can try one out. But I have a strong suspicion I know what your review will be.
> 
> Also consider the cartriges need to be refridgerated. As do the daily controls. Between the blood draw and the actual machine processing time it takes about 10-15 minutes.(providing there is no error which resets the clock) If the result comes back positive you still have to do more detailed testing.



We do carry a decent sized refrigerator in our ambulances now, for ativan, succinylcholine, and for our ROSC thereputic hypothermia IV fluids, so storing the cartridges wouldn't  be an issue.

If the test comes back positive, of course there needs to be more detailed testing performed, in the ER, but it may help make a transport decision that would better benefit our patient. It can  also benefit the hospitals in a situation where someone does not need the services of a interventional cardiologist by reducing the frequency of EMS bringing in anyone with chest pain, irregardless of the etiology behind it (cardiac vs. other medical vs. trauma) just because they are a STEMI treatment facility.

Id also like to point out there are services across the US are already doing trials and using istats... Rapid Response in Michigan is one example



> I haven't got to use the bedside blood gas device personally, as when I am in the ICU my role is not to deal with that, but I will get the dirt on it Thursday.
> 
> 
> 
> As do I. But the role I see these diagnostics useful for EMS is not in emergency, but in an extension of primary care. Something many EMS agencies are not eager to embrace.


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## VentMedic (Mar 2, 2010)

FLEMTP said:


> Checking basic lab values and electrolytes can allow for a more educated decision making process. If you get a patient who is short of breath, pale, weak, etc.. and you cant seem to find a reason.. you check the CBC and find they have a low RBC count.. you can give advance warning to the ER that they are in need of a transfusion.
> 
> On longer transports (which we do have here in my agency) it would allow you to determine if a trauma patient is slowly bleeding out but still compensating for the bleed.
> 
> ...


 
The iSTAT has been used on transport for well over 10 years and has passed the testing for FDA approval for out of hospital situations.

There's a little more to it then just treating a couple of numbers and if just for renal patients to determine a K+ level...well it is a renal patient.

There is also the issue with increasing education to meet the demands of labs value treatment plans. Even for ABGs, another stick in the artery would have to be done and then treatment correlation between the other labs before you treat the pH. We do not treat on just an ABG result when it comes to Bicarb. We also rely on mentation more than numbers as to if we intubate. By the time you do the art stick, wait for the results and then think about it, you probably don't know how to recognize respiratory distress. We may have a 7.1 pH but if it is from N/V/D and the patient is alert, no intubation.

The cartridges for the iSTAT are very expensive and sensitive. You will have to take out of the refrigerator what you might need enroute and hope you can use them sometime in the next few hours. You would also have to find a lab for oversight or your company would have to file the paperwork as an independent lab. Very few labs want the responsibility of overseeing EMS with iSTATs and some are reluctant to provide the oversight for flight teams even if they are associated with the hospital. Some lab managers have seen the way the glucometers are treated. Tracking competencies, QA and the QC monitoring can be time consuming and costly. You would also have to attempt to find a way to recover your costs for the lab tests which at this time might be difficult for EMS providers. 

For Troponin levels, there are too many things that can also give fale positives. Unless it is truly going to make a difference in your destination, it may be just one more gadget that is costly and that money could be spent elsewhere. 

Also, just like the ECGs, the tests will be repeated in the ED. CLIA and a few other agencies want evidence that the blood and technology were properly handled with the proper training and competencies readily available. This is why prehospital blood draws have been frowned upon. Few EMS agencies want to do meet the standards required.


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## triemal04 (Mar 2, 2010)

VentMedic said:


> Also, just like the ECGs, the tests will be repeated in the ED. CLIA and a few other agencies want evidence that the blood and technology were properly handled with the proper training and competencies readily available. This is why prehospital blood draws have been frowned upon. Few EMS agencies want to do meet the standards required.


Not necessarily; same as bypassing the ER with a STEMI, if the troponin level was elevated it could potentially be cause to go to the cath lab even if there were no ecg changes.  But, I can see it going the other way and the pt being evaluated in the ER as well.  This would probably be a good time to use FLEMTP's idea about talking to each hospital before hand to find out how high a troponin level they would be concerned about.

As things currently are, the place where an iSTAT would have the most difference would be an area with longer transport times, as well as still having the option of going to several hospitals.  For inside a city there is still a use for it I think, but not as much.


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## VentMedic (Mar 2, 2010)

triemal04 said:


> As things currently are, the place where an iSTAT would have the most difference would be an area with longer transport times, as well as still having the option of going to several hospitals. For inside a city there is still a use for it I think, but not as much.


 
An MI is just one situation where a patient might require the services of a cardiac center. There are many other reasons which may not show a positive troponin or ECG.  Are you going to divert or bypass a cardiac center when the patient is having chest pain that can not be immediately diagnosed just based on the troponin or ECG?


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## triemal04 (Mar 2, 2010)

VentMedic said:


> An MI is just one situation where a patient might require the services of a cardiac center. There are many other reasons which may not show a positive troponin or ECG.  Are you going to divert or bypass a cardiac center when the patient is having chest pain that can not be immediately diagnosed just based on the troponin or ECG?


Probably.  But then I'm just a dumb ol' paramedic and don't know any better.  (trust me, that was SARCASM).

It's not so much the issue of NOT going to a cardiac center, but going TO a cardiac center with someone who is otherwise not presenting as a cardiac patient, as well as having another piece of information that can be presented to a hospital to, hopefully, get them ready to appropriately and rapidly treat the patient.

There would need to be quite a bit of training and education on how to use and interpret the results before a system could appropriately use something like the iSTAT, as well as interfacing with various hospitals.  If used right, it's another tool that could help with care.  But, if used wrong, then it definitely has the potential to cause harm to some patients and create problems.


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## LondonMedic (Mar 3, 2010)

triemal04 said:


> Not necessarily; same as bypassing the ER with a STEMI, if the troponin level was elevated it could potentially be cause to go to the cath lab even if there were no ecg changes.  But, I can see it going the other way and the pt being evaluated in the ER as well.  This would probably be a good time to use FLEMTP's idea about talking to each hospital before hand to find out how high a troponin level they would be concerned about.


I would be concerned about any troponin raise, particularly the 12hr peak value, but I would (and could only) evaluate that in view of their history, renal function and septic screen.

The only real difference I can see it making to EMTs is loading with asp, clop and possibly LMWH if it's positive. But I feel that in the absence of a good cardiac history _and_ STE on ECG that the patient needs a formal work-up and evaluation before considering onward transfer for PCI.

However, I appreciate that this may work differently in the states where there are millions of primary PCI centres and they're all want more money.


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## VentMedic (Mar 3, 2010)

Things to consider in the U.S.:

Only 50% of the U.S. ALS EMS services have 12-Lead ECG capability and these services may have them on only 75% of their trucks. (AHA reference)

Less than that have ETCO2 monitors. But then there are also studies coming out which if you just followed the ILS guidelines for ETCO2 and not realize all the factors that influence the relationship of PaCO2 and ETCO2, the numbers will not represent the goal your want to achieve. 

(The Utility of Early End-Tidal Capnography in Monitoring Ventilation Status After Severe Injury: Warner KJ, Cuschieri J, Garland D, et al. J Trauma 2009;66:26–31)

There will also be many lab values which you won't treat because they are expected and may be be normal for certain disease processes. Just seeing on set of numbers without a broader diagnostic differential will be misleading and some may be inclined to "spot" treat by correcting one number only to fail to see its relationship with many other values.

The iSTAT is used in many prehospital situations to confirm what you may already suspect. For most, it will not change what you do or are capable of doing. If the patient has chest pain, with or without the iSTAT you will probably being going to the most appropriate facility. If you are staying on scene for 20 minutes for a lab value, which may be inconclusive, to tell you which direction to head for whatever hospital, you probably aren't doing that patient much good. You might even be using the iSTAT to make up for any lack in your own confidence or assessment ability. More expensive gadgets will not make up for whatever deficiencies that already exist. 

While you might think you are able to work with expanded protocols, there are many services that are not ready. Anybody remember some of the issues with RSI and how it was attempted by services that probably should be doing more than BLS airways? 

The same issues again would come about which include medical oversight and competency training both initial and maintenance. Again, let's look at something that was the pride of EMS which is intubation. Poor initial training and failure of the agencies to oversee the competency levels have put that one skill in the spotlight.

Of course there is the cost. You may have to justify an additional $500 - $1500 fee attached to an already expensive ambulance bill especially if POC testing may be done on almost everyone which it might be only because some can. 

These same issues also prevent many hospitals from doing POC testing. While many of the major EDs do have this capability as do some progressive smaller EDs, that number is not growing rapidly nor is the iSTAT's use on many CCT or Flight teams. Unless you have a great distance to cover, it probably won't change anything you do or your destination as determined by a good assessment.

Finally, the U.S. still has not established a minimum education level for the Paramedic with even a college level A&P. Some still only have the A&P out of Nancy Caroline's book. Unless all of your Paramedics received the same high calibre education, you will still have those with a 3 month cert from a PDQ medic mill to deal with. It will be a long time before the iSTAT will be on every fire truck.


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## ah2388 (Mar 3, 2010)

VentMedic said:


> Things to consider in the U.S.:
> 
> Only 50% of the U.S. ALS EMS services have 12-Lead ECG capability and these services may have them on only 75% of their trucks. (AHA reference)
> 
> ...



good post


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## FFMedic75 (Mar 3, 2010)

I think what can and should be done is very dependent on the situation.  For example a patient with Abd trauma should be obviously transported as rapidly as possible to the nearest Trauma Center, but lets consider a patient having an anaphylactic reaction.  A paramedic in most locations can administer every treatment which can be delivered in the ED.  So why should some extra time not be taken to allow for immediate treatment of the patient's condition.  Immediate treatment could prevent complications if administered immediately.  Most of us are able to work while moving, however some situations warrant immediate treatment in the patient's living room.  A good rule of thumb, if you can immediately give definitive care or need to do something to stop a patient from dying in the next 5 minutes stop and do it.  If your patient is critically ill or injured and you cannot give definitive care transport them immediately and get done what you can in route to the ED.  If the patient is stable and legitimately in need of care take the time to do the extra things that to improve the situation (i.e. give pain meds to a patient with a fracture prior to attempting to move them.).


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## triemal04 (Mar 4, 2010)

LondonMedic said:


> I would be concerned about any troponin raise, particularly the 12hr peak value, but I would (and could only) evaluate that in view of their history, renal function and septic screen.
> 
> The only real difference I can see it making to EMTs is loading with asp, clop and possibly LMWH if it's positive. But I feel that in the absence of a good cardiac history _and_ STE on ECG that the patient needs a formal work-up and evaluation before considering onward transfer for PCI.
> 
> However, I appreciate that this may work differently in the states where there are millions of primary PCI centres and they're all want more money.


Sure.  I agree that if troponin was the only thing elevated it might not be the best idea to head directly to a cath lab; this would be something that would need to looked into before using a piece of equipment like that.  I think what it comes down to is that, like everything we use, there can be a use for it prehospital, but it needs to be used correctly, and people need to be able to interpret the results correctly.


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## RescueYou (Mar 5, 2010)

Completely dependant upon the call.


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