Cooling of burns - why US EMS (and first aid responders) needs to change its practices

Melbourne MICA

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I wrote to N.A.S.E.M.S.O. recently suggesting the burn first aid component of their latest guidelines (below) should be reviewed and changed to incorporate a 20 minute water cooling model with basic dressing such as use of clingfilm wrap. There is a preponderance of dry dressing approaches among more than 20 different model used in US EMS (N.A.S.E.M.S.O.'s only recommends dry dressing).

So the question for comrades here is, show me your backing studies because of the 20 or more practiced none can be supported by the level of evidence I can produce for a 20 minute model - (and yes I am aware there are many temperature variations in different parts of the US). Any up for the challenge?

(https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines-2017-PDF-Version-2.2.pdf)
 

Tigger

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Here's a little insight, lot's of our guidelines aren't supported by evidence. That doesn't mean that's how everyone practices or even that our guidelines follow that of the "national model." In fact I am not really even familiar with NAESMO model and while it might be a nice research project, I have enough trouble keeping my different individual agencies guidelines separate in my head.

Not all states have statewide treatment guidelines. Some states have a framework for what is allowed and what isn't and then leave it up to agencies to work with that. Others leave it completely up to the medical director. There are states that have burn care guidelines similar to what you put forth (Massachusetts did when I worked there) as well.

Could you post exactly what evidence you have for your treatment plan? Or what the treatment plan is? Currently we just follow the regional burn center's recommendations, which do not match yours.
 
OP
M

Melbourne MICA

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Thanks Tigger.

No insights necessary. I fully appreciate everything you have described especially the absence of anything resembling what could be described as a well accepted "standard" approach to burn first aid - unfortunately, especially in US EMS but it doesn't stop there. The experts who publish recommendations also can't make up there mind. We're talking the ABA, BBA, ANZBA, ERC, NZGG, NASEMSO, ISBI, JRCALC.

Having said that, the 20 minute water cooling approach has gained traction in the last few years with just about everybody except the US, some European countries and maybe some South American - (not sure about that). There still remains work to do among private sector groups, charities and first aid bodies and the hydrogel companies have their hooks into many sectors of pre-hospital care

So overall its still a bloody train wreck but with some promise on the horizon.

So my motivation and that of colleagues in the UK (I'm based in Australia) is to see this situation overturned - by lobbying everyone to adopt a "standard" model - simply put, the administration of a single block of 20 minutes of cooling with running water between 2-15 deg C up to 3 hrs from injury event in all thermal burns followed by covering with clingfilm or a clean sterile dressing.

That's the essence of the approach. No hydrogels, no dry dressing, no caveats like <"X" %TBSA, or age, or depth etc.

As for evidence, it will have to wait till I get home from shift. I still work with Ambulance Victoria. I have been trying to write this all day. Will update tonight my time. Cheers
 
OP
M

Melbourne MICA

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Before uploading studies that support this model I think it is important to recognize just how this process works in the chronology of care from the event itself right through to the ED door - a bit of background.

(Sorry up front if this all sounds like a bit of a story I'm throwing at readers).

The commonly held view is that EMS delivers or is responsible for first aid care and other interventions in acute burn injury. In part this has arisen perhaps because the lay public still use many unsupported, frankly idiotic measures to manage burns comfortably nestled somewhere between cultural myths and internet brain farts; toothpaste, Turmeric powder, egg whites, cow dung, potato peels, vinegar, even additional heat applied to the burn.

Most surveys show only about 20-30% apply recommended first aid (water cooling) and even then not for the recommended duration. Worse still the hydrogel companies have their noses in all the markets. First aid bodies like the Red Cross and St John Ambulance teach water cooling models of burn care and then go and stock thier for-sale first aid kits with hydrogels. And many EMS bodies have fallen for the marketing as well.

In the US as you say Tigger, there are many approaches without any consistent basis of decision making, ignoring national or state based guidelines and often coming about simply because the local medical director said so.

It's also true many EMS practice guidelines have a poor foundation in evidence.

However, this is not the case with burn first aid. In a general sense the clinical benefits for water cooling for burns have been well documented since the 1930's. The St John first aid organisation pioneered a water cooling burn first aid model in 1969 - "cool, cover and carry".

There were multiple studies between about 1936 (Rose), through the 1950's and 60's (King , Offeigson, Boykin, Shulman and others) through to the past year. Since the early 2000's there have been a number of more specific and defining studies including porcine studies by Bartlett (2008) and Cuttle (2009) that established the 20 minute cooling "sweet spot" as well as confirming the water cooling model more generally. In addition there have now been 4 large cohort studies (Wood 2016, Harish 2018, Harish 2019, Griffin 2019) one RCT (Choi 2018) verifying and demonstrating the efficacy of water cooling for 20 minutes and a number of other studies (Nguyen 2002 - case series on water as first aid, Coates 2002 - volunteer study on hydrogels for pain Mx, Tobalem - warmed water cooling in rats 2013, Wright 2015 - the mechanisms of water cooling, Goodwin 2015 - SR on hydrogels, Schnell 2008 - spray mist water cooling) and many others exploring various aspects of water cooling in thermal burn injury. I will upload all these and other files tomorrow.

So my question to US EMS is why isn't water cooling a widespread practice across your jurisdictions? (I can hear hypothermia somewhere in the responses. I will also upload the only pre-hospital studies on that as well - Weaver 2016, Lonnecke 2008, Singer 2010, Zeigler 2010 and a couple of others).

regards
Melbourne MICA
 

DrParasite

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I haven't looked at any of the studies or what you posted, but many/most EMS places follow the direction from their nearest burn center. We (EMS people) are not the experts on burns and burn treatments; that is left up to the burn doctors, and their outreach people usually spread the word to the EMS agencies and medical directors. And yes, we do need to trust and rely on our local medical director to be up to date on the latest and greatest things that we should be doing (after all, that's why they have MD after their name, and provide us with medical direction).

I've had people tell me that says dry sterile dressing was the best, wet sterile dressing, use a firehose to rinse it off (as long as the water is running, the source doesn't matter) and then cover clean sheet; it doesn't matter, since it's just going to be coming off in the ER and then debrrided. And yes, I've heard some of the old wives tales regarding burn treatment; however, most in EMS don't follow them.

EMS will not, and should not, be the lead agency in burn treatment; that information should come from the burn experts, the burn centers doctors, and we should be following their guidance and direction.
 
OP
M

Melbourne MICA

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Hi DrParasite. I appreciate your point but its not about EMS deciding alone on treatment although plenty do this anyway. Just look look at the use of hydrogels in EMS despite the almost complete lack of evidence for their efficacy.

Problem is there has been so little attention paid to this area most likely because of the poor evidence base previously and the pragmatic attitude of most of the experts you mention who have taken a very conservative line on pre-hospital practice. Problem is even they cannot agree on the correct approach.

I have to disagree with your suggestion pre-hospital burn first aid doesn't really amount to much - "it doesn't matter, since it's just going to be coming off in the ER and then debrrided" because this is entirely at odds with the evidence. Water cooling of burns is associated with massive clinical benefits in the short and longer term and all of the studies I have cited so far and many others attest to this fact. ( I can detail further if you would like more information)

As for who should make the decisions; evidence should be the basis of decisions not expert opinion - this includes the burns associations, resuscitation councils, first aid responder organisations and major burns centres. Justification to adopt consensus positions was earlier based on the low levels of available evidence for pre-hospital practice. This position is no longer valid because we now have a solid base of information from many levels of research that not only validates water cooling as the best approach but also confirms prior studies indicating 20 minutes is the best duration for maximum clinical benefit. The 2019 Harish cohort study now also provides data demonstrating clinical benefit even in large burns. Prior evidence seemed to suggest cooling worked best in smaller TBSA burn injuries.

The fact so many EMS bodies have failed (refused) to adopt a single burn first aid model attests to the poor attention given to the evidence base in my view, so I am out there challenging them on this issue. I have also done this with NASEMSO in the US, JRCALC in the UK, the resuscitation councils, all the major burns associations and first aid groups. I have also written personally to every Australian ambulance service , charity groups and private sector bodies, as well as all the hydrogel companies who view me as the Prince of Darkness in some circles. I've cost them a lot of money your see.

But I have asked all these bodies and now my colleagues in US EMS the same question because I am certainly going to show you mine. And I have spent the better part of 8 years doing this.
 

silver

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There were multiple studies between about 1936 (Rose), through the 1950's and 60's (King , Offeigson, Boykin, Shulman and others) through to the past year. Since the early 2000's there have been a number of more specific and defining studies including porcine studies by Bartlett (2008) and Cuttle (2009) that established the 20 minute cooling "sweet spot" as well as confirming the water cooling model more generally. In addition there have now been 4 large cohort studies (Wood 2016, Harish 2018, Harish 2019, Griffin 2019) one RCT (Choi 2018) verifying and demonstrating the efficacy of water cooling for 20 minutes and a number of other studies (Nguyen 2002 - case series on water as first aid, Coates 2002 - volunteer study on hydrogels for pain Mx, Tobalem - warmed water cooling in rats 2013, Wright 2015 - the mechanisms of water cooling, Goodwin 2015 - SR on hydrogels, Schnell 2008 - spray mist water cooling) and many others exploring various aspects of water cooling in thermal burn injury. I will upload all these and other files tomorrow.
So you are telling me there is only 1 maybe real study then?
 
OP
M

Melbourne MICA

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So you are telling me there is only 1 maybe real study then?
No and I'm not sure how you came to that conclusion. Burn care in pre-hospital has been hamstrung by orthodoxies and ambivalence. Few people have believed the pre-hospital element of burn care really amounts to much. This has meant little investment in the sector including in research which is both expensive and ethically difficult in burns - how do you have an untreated control in a burns trial of water cooling for example. So the data has come mostly from animal and experimental and observational study methodologies although we do have at least one RCT (Choi 2016). But before people say that's crappy evidence they should realise its common in burn research overall for the same ethical and practical reasons.

So it will remain up to hospital and Uni researchers for the moment to provide the research evidence.

That is, until we have a standard model of burn first aid care.

If pretty much everyone - and not forgetting EMS isn't the only provider of first aid - is applying the same treatment then we have a homogeneous cohort - a very large one at that, suitable and sufficiently cost effective for direct research by pre-hospital entities - EMS.

SO ambulance can do research into its own practices because we have tens of thousands of patients all getting the same care and tens of thousands of providers all delivering the same care - (and believe it or not I think our role is not to deliver this first aid cooling - ideally this should be done before ambulance arrives but we need to ensure this has been completed so we can move to the next elements of care).

The end result of this is to use the promotional power of EMS aided by its own research to help move the lay public to the same standard model as well. When this happens will have a seamless chronology of burn care that use all the parties involved in the process. What is the point of a lay person putting toothpaste on loved ones burns only to see the paramedic put on a hydrogel or just a sheet over the injury.

ALL burn first aid care needs to include water cooling as the evidence clearly shows its benefits are so profound hey cannot be ignored.

So my mission is not to conduct studies - I clearly can't do this as an individual.

Instead my aim is to help shape practice by changing peoples minds by challenging them to reexamine their own orthodoxies.
And my most powerful tool is evidence.

So my question again is show me your evidence. Go out and ask your medical director, or county clinical group, state body or NASEMSO what studies support their current position on burn first aid especially models that don't use or under-utilize water cooling.

- and I will tell you they are wrong and I can prove it.
 
Last edited:

PotatoMedic

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I'd love to read the research on burn care that you have. Send me what they are or even the doi and I can look them up.
 

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