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

[Melbourne MICA]

Thanks for the query Rick. I appreciate the general premise of EMS scene times vs resourcing and preventing delays to definitive care in hospital.

I'm sure you would also agree however that with the availability of more research, pre-hospital practices have become increasingly aligned to more specific clinical targets that either bring the hospital procedure into the field or compliment an in-hospital procedure e.g. RSI in the field for TBI. https://www.ncbi.nlm.nih.gov/pubmed/21107105. This doesn't mean of course there is no scene time urgency it just means EMS crews showed they had the prowess with adequate training, education and practice to do it without creating added delays at scene.

The analogy to burn care is similar. If an RSI can be done in-field in around 20-30 mins because we know it produces significant end outcome benefits why not burn first aid?

I would argue there is still derision of this idea because few would believe something so ridiculously simple as applying water could produce such extraordinary outcome improvements. At the same time the bogeyman of hypothermia has dominated thinking casting a shadow over water cooling ideas.

Now we have multiple studies that not only confirm the clinical benefits of water cooling but define the parameters of the procedure, something that has been lacking for more than 50 years. What has also been lacking is a precise methodology that modifies our approach to accommodate both cooling and warming. This requires a continuum of care that (ideally) incorporates the public.

I would have to disagree that burn first aid in the 1960's and 70's was even close to the models now being proposed. The idea of water cooling had lots of historical precedent to be sure but wasn't even suggested as a de-facto standard until 1965 when St John first suggested immersion in water and later refined the model to running water in 1969. I even have an original copy of their manual. At the time even hospitals were using tannic acid and other wild treatments. The public were, and still, are using even worse approaches hence the need for a universal standard model.

The 20 minute model of running water cooling is not arbitrary. It is clinically specific based on studies not undertaken until 2008/2009 (Bartlett, Cuttle) with many more since. It is so effective it is well worth staying at scene to complete the full 20 mins or even pause en-route to ED to find a clean water source where no water is available (which is rarely the case BTW).

My view would be that, respectfully, any supervisor who blasted a crew today for doing 20 mins of water cooling has not read the literature and his service needs to change their CPG's. I've uploaded more than 20 PDF's on this topic to EMTLIfe to try to start a conversation here that might filter back in some small way to US EMS.

Thanks for the query.

MM

 

[DrParasite]

I have a question, I see this is a long string. How does a 20 minute scenario fit into a busy EMS systems role.

as a former employee of a grossly understaffed urban EMS system, maybe the justification is that you need more units to handle the call volume, and the AHJ should allocate more funding to allow for addition units to deliver the best care to the citizens of the AHJ?

If I had a truck on the scene for 20 minutes cooling a burn and did not address it, someone was getting theirs asses chewed.

Why? is performing appropriate clinical care frowned upon in your system? is doing what's in the best interests of the patients looked down on? Did the patients in your area not deserve to be treated in a manner that would provide them with the best clinical outcomes?

We did everything we could do to keep hospital down times to 20 minutes.

I'm not sure what that means..... our turnarounds in the hospital were typically 10 minutes, 20 minutes if the ER was busy. might want to restate that for clarrity.

I really don’t think this idea is new, this is what was taught when I took first aid in the late 60s, early 70s.

It's not new, but we have gotten away from doing it in recent years.....

If I was an EMS director, and one of my supervisors gave a crew an *** chewing for providing appropriate clinical, and compassionate care to a burn victim, using a method that was clinically shown to have a positive patient outcome, than I would counsel said supervisor on the inappropriateness of their actions, and the supervisor would apologize to the crew for their unprofessionalism. If it happened again, they would likely spend a few days in time out.

While I completely understand why you don't crews wasting time on scene when they could be transporting to definitive care (and yes, our dispatchers checked on every crew after they were on scene for 20 minutes), when they are performing an intervention that requires crews to stay on scene, and has better outcomes than moving the patient (cardiac arrests are another example), than it's completely appropriate for them to delay transport to continue treatment.

 

[Tigger]

I have a question, I see this is a long string. How does a 20 minute scenario fit into a busy EMS systems role. I retired a few years back as a field supervisor. If I had a truck on the scene for 20 minutes cooling a burn and did not address it, someone was getting theirs asses chewed. We did everything we could do to keep hospital down times to 20 minutes. I maybe missing something here, like you are referring to hospitals or ICCs. If that is true, then this looks great. I really don’t think this idea is new, this is what was taught when I took first aid in the late 60s, early 70s.

Is a 20 minute scene time excessive?

 

[Bullets]

If I had a truck on the scene for 20 minutes cooling a burn and did not address it, someone was getting theirs asses chewed.

You would reprimand your staff for providing treatment?

 

[Melbourne MICA]

I hope comrades don't mind if I interject myself into your conversation at this point. I don't want the key points to be missed.

The first is 20 mins of running water cooling is a clinical goal with clinical outcome measures attached. And the "running" bit is actually clinical as well.

The time frame issue is also hugely important in that we need a model that implements the full 20 mins of water cooling whilst also maximising the time frame to warm patients given the clinical imperative, how long it takes to increase a core temp versus how long it takes to drop one and the fact we don't have active warming technologies in most EMS. A burns patient paralysed for airway Mx is almost impossible to warm adequately without active warming for example.

And there are massive economic dividends to be gained with the 20 minute model wildly out of proportion to the actual number of serious burn events that occur in any given year. Even with relatively small partial thickness injuries there are still gains to be made as evidenced by the example I gave where the burned child had injury sufficient to go to a primary treating hospital with a burns unit but the injury was so well moderated by water cooling treatment and aggressive warming that he he was discharged within hours of the event. No hospital admit, no extra costs.

A standard model based around these ideas is a win-win across the board. And there doesn't need to be any significant scene delays just focused, clinically driven evidence based care.

 

[Tigger]

A standard model based around these ideas is a win-win across the board. And there doesn't need to be any significant scene delays just focused, clinically driven evidence based care.

I don't disagree, but this is not an obtainable goal if the burn care groups cannot even come up with a unified set of guidelines. Perhaps then when medical directors go looking for burn care information to put into our guidelines, we would all end up accidentally agreeing.

 

[Rick813P]

topic

 

[Melbourne MICA]

I don't disagree, but this is not an obtainable goal if the burn care groups cannot even come up with a unified set of guidelines. Perhaps then when medical directors go looking for burn care information to put into our guidelines, we would all end up accidentally agreeing.

Precisely why I am lobbying to establish a standard model literally across as many bodies as I can write to, e-mail, phone or otherwise hassle!! And there have been more successes than you might realise. The first was my own service who have now adopted the 20 minute model in full. I also co-wrote the new British Burn Association Guidelines which I would argue are the most detailed and specific in the world in respect of burn first aid. They also follow the 20 minute model. I have also had positive feedback from all Australian ambulance services who will be reviewing their guidelines particularly in relation to use of hydrogel dressings like Water-Jel and Burnaid. With others I have also contacted many UK services and JRCALC the UK equivalent of NASEMSO many of whom are adopting a 20 minute water cooling/simple dressing model and abandoning hydrogels like their Aussie counterparts. I have also written to private groups, charity bodies, government agencies, first aid organisations like St Johns and the Red Cross even hassled the ERC over their recommendations. There are lots more and my most recent are the ABA and AHA in the US who publish burn first aid guidelines. The Us situation is particularly difficult because there are so many different EMS systems and providers across both public and private agencies. There are thousands of separate or partly independent EMS companies in the US which is why I went for either state bodies and NASEMSO for starters. Without getting into an argument about universal health care, in Australia there are just 7 ambulance services - one for each state and that's all who I had to write to. As I said before, I've pretty much been at this for 9 years now with another paper on the drawing board if corona doesn't get me first.

 

[Rick813P]

I don't disagree, but this is not an obtainable goal if the burn care groups cannot even come up with a unified set of guidelines. Perhaps then when medical directors go looking for burn care information to put into our guidelines, we would all end up accidentally agreeing.

I appreciate you addressing my question. We still use running water for the isolated burns to to extremities. For a long time in the area I live and work in we never had much education focusing on burns. I was a full time street medic and a part time flight medic. How long? I had to feed the horses and clean stalls, and as far as flight medic, I was the one who had to shove it off the side of the hill and grab and hold on Hoping for a short flight.
We were the. Trained in ABLS, advance burn life support. We were taught fluid replacement, glucose monitoring and everything that goes with that. You mentioned hypothermia, we were instructed to use warm fluids and cover large burns with dry dressings to prevent the hypothermia.
(Sorry if my punctuation and and use of capitals is lacking, it is 0400 here and the only time I get quiet.) if I remember correctly hypothermia was a big thing with the class.
I know all EMS service around this rock we call home have the same problems. Not enough staff, to many runs, and not enough money to do more with. I don’t know the answer for the problems, we can just run with what we have, which makes it difficult to do prolong treating in the field.
You mentioned putting people down for intubation. There seems to be a big push for alternate airway management methods now here. LMA’s , King airways, passive ventilation in cardiopulmonary arrest. How about there.

 

[Melbourne MICA]

Sorry Tigger/Rick - seems to be some cross wiring of comments in this conversation.

 

[Rick813P]

No problem

 

[ffemt8978]

You would reprimand your staff for providing treatment?

You're suggesting staying on scene for 20minto provide initial treatment, when in that same 20min you can transport the patient ti definitive care in most areas?

 

[Rick813P]

You're suggesting staying on scene for 20minto provide initial treatment, when in that same 20min you can transport the patient ti definitive care in most areas?

We for a long time, by orders of our Medical Directors and we have had several over my 25 years, no longer than 10 minutes on the scene with major trauma. There are exceptions, extrications of course, combative patients, etc. We all were very proficient in obtaining IVs, securing airway, and anything else in the back of the unit. In cases where we had major trauma we supplied Medic from another unit or a Supervisor to assist on the way in. It worked extremely well for us.
Most of the time when we had major burns we did not have a source of running water to cool the burns, if we did we had to worry about hypothermia in route to the hospital. We could use water from an engine company on scenes of fires, but the stuff that comes out of the hydrants, ahhhh, no. It is just the way we have operated. With trauma we always held the theory that cold steel and hot lights would be mor beneficial for the patient. Even burns would benefit from the sterile environment . We would do our best to fluid resuscitate them as much as we could, We were taught that from the time the burns happen until we got there, depending on the size of the burn, we were already behind.

 

[DrParasite]

We for a long time, by orders of our Medical Directors and we have had several over my 25 years, no longer than 10 minutes on the scene with major trauma.

You're missing the point. In a trauma (and yes, burns are a type of trauma, but I digress), the patient needs a surgeon to stop the bleeding, patch the holes, etc. Nothing you do in the field was going to help that, other than making the sure the ABCs were maintained. However, when dealing with a burn victim, there are interventions that you can perform that will have a positive long term effect on your patient's outcomes.

Most of the time when we had major burns we did not have a source of running water to cool the burns

outside of a house fire, were did most of your burns take place? in a residential or commercial structure? did they not have a sink anywhere?

We could use water from an engine company on scenes of fires, but the stuff that comes out of the hydrants, ahhhh, no.

is the water that comes out of a hydrant not running? I mean, it's not like you are drafting from a pond, and the water department does maintain the water supply system. Just crank down the pressure a lot and open the gallonage on the nozzle to the max to not blow the patient's skin off.

It is just the way we have operated. With trauma we always held the theory that cold steel and hot lights would be mor beneficial for the patient.

yeah, well, that theory isn't always right, that's why it's a theory

Even burns would benefit from the sterile environment.

anything you do in the field isn't sterile. heck, the ER is far from sterile. So any intervention you perform will just be removed to be redone in a sterile environment. But that doesn't mean you shouldn't still treat your patient appropriately.

We were taught that from the time the burns happen until we got there, depending on the size of the burn, we were already behind.

Maybe you should have been taught the new research on burns, instead of old dogma?

 

[Rick813P]

All I did was asked a question and explain my situation. Some of you presented great points A few did not. My reference about get moving is concerning major burns, which I believed I addressed. Regardless, I am discussing my little area of the world. We all live in different parts of the world, with different needs and means of addressing them. My question was answered adequately by the forum chief. I then just explained our theory, whether I agree or not.
That being said, there are a few comments here, I will not go into detail, that I refer to as kicking me in the teeth, who are you to do that. Those comments were more than not helpful. ( Capt Jack Sparrow fan). I could go on but there are some big egos here and I refuse to stoke them.

 

[Melbourne MICA]

Maybe you should have been taught the new research on burns, instead of old dogma?

I'd hoped there was an opportunity here to get into the meat of this particular area of clinical care and there still is if comrades are prepared to just discuss the issues and point out key items of interest, problems and so forth such as Tiggers' point about the absence of consensus from expert bodies for example.

If comrades read some of the items I have uploaded they will see I have actually already broached that very point by publishing in the literature directly as well as bringing it up twice now at international burns conferences. And I have received favourable responses from the burns associations and others. For example, my first presentation on that issue was in 2011 at the ANZBA conference in Brisbane where I rolled out a whole bunch of stats on the mish mash of muddled ideas in guidelines from around the globe as well as pointing out there was no good reason to be supporting hydrogels like Water-Jel because there was no evidence they are any good. ANZBA itself had promoted hydrogels in a published statement in 2006. In 2012 they issued a specific hydrogel position statement overturning their previous position.

On another issue there are problems in the US on this area of clinical care because there is no universal model and there needs to be. The subdivisions of decision making authority, the myriad number of EMS models - public, private contractors, private/public, fires services, local hospital run ambulances, Police operated ambulances, part volunteer/part professional mixes etc are a recipe for diversity at the cost of consistent clinical care.

As a result there are more than 20 different types of burn first aid practiced by EMS in the US (and yes elsewhere as well -this is not just about the US, I just happen to be on a US EMS forum), another dozen recommended by burns associations, hospital burns units, various experts, the CDC, AHA and on and on it goes. I copped an absolute bollocking from fellow paramedics here for stating facts about this. Seems national pride trumps rational exploration of problem areas that need it and its true guys. The propensity for individuality and private and local ownership if you like while a great philosophical position is a nightmare for consistency of clinical care especially when evidence is involved. The evidence doesn't discriminate or choose sides. I am simply saying the facts are there for all to see and investigate, none of this is about pissing contests or winners and losers or competitions or idiots and experts or my Johnson is bigger than yours.

Some of you guys have been on this forum for ages. I know because I joined up about maybe 10 years ago. Lets talk not slag each other.

On this burn first aid issue - nothing else - my original challenge stands. The US burn first aid situation is a basket case. Prove me wrong then lets hassle your bosses, medicos to explain why there is no single universal model used that is based on fact not "old dogma" or peoples opinions. Its an opportunity to good to miss - paramedics can and should drive change.