Central Lines Prehospitally

[Clipper1]

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

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

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

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

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

 

[usalsfyre]

Two physicians should come up with a viable alternative.

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

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

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

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

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

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

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

 

[jwk]

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

 

[Merck]

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

 

[Carlos Danger]

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

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

 

[Clipper1]

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

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

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

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

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

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

 

[Aidey]

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

 

[Clipper1]

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

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

 

[JPINFV]

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

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

 

[FLdoc2011]

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


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

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

 

[Carlos Danger]

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