EMT-Basic IV

[Ridryder911]

Rid has a point... studies can be performed and sometimes results swayed to support one groups position. A study could be performed with results saying we should do away with EMS all together.

Actually, there was one not that long ago. If I recall placed in ACEP publication as the description of that possibly just load and go would be in the best interest as no real drastic changes of outcomes has developed with EMS. The benefits of cost reduction and less delaying of detailed care.

Like described, if one has thought about it; there probably was a study performed. If there was a study performed, then there was probably another study performed to discredit that study or challenge it.

R/r 911

 

[ResTech]

Along those same lines of the study your referencing... I remember a few years back a study was done in LA County where they evaluated outcomes of trauma patients who arrived by EMS (ALS) and those who arrived by private auto.

The study found that the patients who arrived by private auto had a statistically much better outcome than the group that arrived by EMS. The study contributed the improved outcomes in the private group due to no scene delay caused by calling 911, EMS response, IV starts, patient packaging, etc. The patient was simply loaded in a car and transported immediately after injury to the hospital bringing the trauma patient to definitive care much sooner.

 

[VentMedic]

I remember a few years back a study was done in LA County where they evaluated outcomes of trauma patients who arrived by EMS (ALS) and those who arrived by private auto.

If I was in LA County and a trauma patient, POV would also be my preference unless daedalus or JPINFV was around.

 

[daedalus]

If I was in LA County and a trauma patient, POV would also be my preference unless daedalus or JPINFV was around.

Why thank you! My preference would be Vent if I was ever in need of any sort of emergency transfer.

There will be better days in Southern California, one future JPINFV medical director at a time.

 

[ResTech]

I have a few preferences on here... but for other reasons than medical expertise!

 

[CAOX3]

Best available research is cold hard science. Also, the MAST system was certainly part of science. It was tried and it failed. That is what science is, for example, Newtonian physics is wrong (replaced by Relativity), yet we still use it to make basic predictions because it works at the crude level. There will be a day when we come up with something better than Relativity. This is science, always dynamic, and humble. We diligently work to disprove things once accepted and strive for better theories, while using what works best at the time.

Definition of science:
Source- nasa.gov

The very definition of science is application of research.

Again when EMS decides to base tratment on evidence based medicine, just because it happens in a few areas.....

 

[CAOX3]

This is all cute warm and fuzzy but can we get back on topic here, I mean if your done with the lovefest....

 

[Level1pedstech]

Would a delayed transport time make a difference in your opinions on fluid resuscitation in the field. Maybe I should have made my agencies needs a little more clear. We have an average response time from our ALS provider of 30 minutes, that's on a good day in the summer. On a bad day in the winter at the far reaches of our coverage area we may be looking at 60 minutes or more. We bring in life flight when needed but weather often will keep them from making it in. Ground transport to the nearest med center is at best going to take 45 minutes, level one will be an additional 15 minutes, There are all sorts of relay and meet options but for easy figuring lets use the following scenario. We are looking at 20 minutes to respond to the scene,an additional 45 minutes for arrival of ALS and a 60 minute transport time. We have critically injured patients from an MVA, they may already be hypothermic after being exposed to the elements (a very frequent scenario in our area), if we are looking at the above time frame (2+ hours) before our patients hit the ED doors would you be okay with providing warm fluids as long as protocols are followed? If not could you explain why.

 

[daedalus]

Would a delayed transport time make a difference in your opinions on fluid resuscitation in the field. Maybe I should have made my agencies needs a little more clear. We have an average response time from our ALS provider of 30 minutes, that's on a good day in the summer. On a bad day in the winter at the far reaches of our coverage area we may be looking at 60 minutes or more. We bring in life flight when needed but weather often will keep them from making it in. Ground transport to the nearest med center is at best going to take 45 minutes, level one will be an additional 15 minutes, There are all sorts of relay and meet options but for easy figuring lets use the following scenario. We are looking at 20 minutes to respond to the scene,an additional 45 minutes for arrival of ALS and a 60 minute transport time. We have critically injured patients from an MVA, they may already be hypothermic after being exposed to the elements (a very frequent scenario in our area), if we are looking at the above time frame (2+ hours) before our patients hit the ED doors would you be okay with providing warm fluids as long as protocols are followed? If not could you explain why.

Absolutely not! Your fluid resuscitation might actually kill the patient in your scenario. Lets break down why.

You are going to be decreasing the hematocrit (% of RBCs in blood/volume) by providing saline or ringers to this patient, which will further drop oxygen carrying capacity of the blood, which will make the shock even worse. Remember that shock is not defined by BP or blood loss, but by lack of perfusion of oxygenated blood to vital tissue beds. The treatment for blood loss secondary to trauma is not fluid replacement, but surgery to stop the blood loss. I reccommend Dr. Jeffery Guy's lectures available through iTunes for free. Guy is a burn and trauma surgeon attending at Vanderbelt University . Leading experts in trauma are strongly recommending against aggressive fluid resuscitation in the field and the ED. The only safe fluid for these patients is of course blood, and in your case in the field, O-, which you are not going to have access to.

Also, as you stated, the patient is hypothermic. You might remember to warm the fluids, but others may not. Water has an excellent capacity to remain cool, which is one of the reasons our body uses it in the first place.

If I was an ALS provider, I would start an IV on this patient and provide no fluids unless the blood pressure was below 90. Than I would titrate to control it at around 90 mmhg. It would be dangerous for me to do such, and I would be high tailing it to the trauma center (safely of course). It would be even worse for EMTs to initiate this treatment while waiting for ALS.

 

[Ridryder911]

Would a delayed transport time make a difference in your opinions on fluid resuscitation in the field. Maybe I should have made my agencies needs a little more clear. We have an average response time from our ALS provider of 30 minutes, that's on a good day in the summer. On a bad day in the winter at the far reaches of our coverage area we may be looking at 60 minutes or more. We bring in life flight when needed but weather often will keep them from making it in. Ground transport to the nearest med center is at best going to take 45 minutes, level one will be an additional 15 minutes, There are all sorts of relay and meet options but for easy figuring lets use the following scenario. We are looking at 20 minutes to respond to the scene,an additional 45 minutes for arrival of ALS and a 60 minute transport time. We have critically injured patients from an MVA, they may already be hypothermic after being exposed to the elements (a very frequent scenario in our area), if we are looking at the above time frame (2+ hours) before our patients hit the ED doors would you be okay with providing warm fluids as long as protocols are followed? If not could you explain why.

Something hard to convince those in EMS is it is not always the best interest to go to the nearest but to take them to most appropriate. Have you developed a "trauma plan" where first response can place HEMS on stand by? Hopefully, your HEMS carries O-.

Alike what daedalus described is permissive hypotension and the wash out theory. This information has been out there for at least 15 years. Does any of your personnel have PHTLS or ITLS as it has been discussed for over at least 10 years.

One has to be very careful on rewarming, as more and more research has demonstrated. When you start rewarming patient many things occur. More than I have time to discuss but basically increased bleeding and the release of free radical enzymes, acidosis, etc. Do some lit research on Google scholar and you will be surprised on the ton of information on this subject. In fact, many are inducing controlled hypothermia on patients and increasing survivability.

R/r911

 

[Level1pedstech]

Good points and the advice is well taken. As always I would follow protocol and the guidelines set down by my MPD. I do still question patient stability with the long transport time. What if we move the patients condition to stable with no signs of shock but positive for hypothermia, a very common scenario with all the snowmachine riders we have in the winter months. As far as warm fluids, I will usually toss a bag or two of NS on the dash to warm them up if its a winter scenario. In a cold environment it actually makes a big difference.

Just for the record I almost always have radio communication and will receive direction from my responding medic, it would be rare for me to be without the advice of an advanced provider. Maybe I should have also mentioned this before hand.

 

[Level1pedstech]

Something hard to convince those in EMS is it is not always the best interest to go to the nearest but to take them to most appropriate. Have you developed a "trauma plan" where first response can place HEMS on stand by? Hopefully, your HEMS carries O-.

Alike what daedalus described is permissive hypotension and the wash out theory. This information has been out there for at least 15 years. Does any of your personnel have PHTLS or ITLS as it has been discussed for over at least 10 years.

One has to be very careful on rewarming, as more and more research has demonstrated. When you start rewarming patient many things occur. More than I have time to discuss but basically increased bleeding and the release of free radical enzymes, acidosis, etc. Do some lit research on Google scholar and you will be surprised on the ton of information on this subject. In fact, many are inducing controlled hypothermia on patients and increasing survivability.

R/r911

Our transport agency makes the call on where the patient ends up, they are seperate from my department but are well aware of all thats involved with transports out of our area including which facility best suits the patients needs.

I took PHTLS a few years ago but its time for a refresher. Its a great class even for basics but moves very quickly, I would like to see a few more hours added to cover the ever expanding material.

 

[daedalus]

One should optimally pre read a lot of the provided text before actually attending the PHTLS/ITLS class. The classroom portion is really an overview.

Things are not always as they seem in emergency medicine. Our efforts should do no harm and hasten to help, read: get these patients to the surgeon with no further damage than already done, all while treating what we can safely treat in the field. Alike what rid has said, HEMS should be called to provide transport to trauma facilities, along with the HEMS having access to advanced education and scope.