Central Lines Prehospitally

[Akulahawk]

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

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

 

[Ecgg]

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

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

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

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

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

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













I've said

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

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

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

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

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

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

 

[Handsome Robb]

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

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

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

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

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

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

 

[VFlutter]

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

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

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

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

 

[ExpatMedic0]

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

 

[medicsb]

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

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

 

[Aidey]

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

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

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

 

[medicsb]

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

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

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

 

[Aidey]

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

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

 

[usalsfyre]

contact with them is going to be fairly rare

I found it was several times a week.

and lack of adequate vascular access, rarer.

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

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

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

 

[Bieber]

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

 

[Carlos Danger]

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

Have you ever tried it?

It is not feasible. Trust me.

 

[Carlos Danger]

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

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

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

Proper training and experience is a given - no one should be performing any intervention without the proper training, physicians included.

 

[chaz90]

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

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

 

[medicsb]

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

Proper training and experience is a given - no one should be performing any intervention without the proper training, physicians included.

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

 

[Bieber]

Have you ever tried it?

It is not feasible. Trust me.

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

Thanks.

 

[VFlutter]

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

Thanks.

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

 

[Bieber]

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

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

 

[Carlos Danger]

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

Thanks.

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

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

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

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

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

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


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

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

 

[Clipper1]

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

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

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

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