is a broken arm an ALS or BLS call?

[JPINFV]

they taught us trend in my recent basic class for shock.

EMS isn't exactly known for being up to date on things like this. After all, I'm willing to bet that your course also taught you that supplemental oxygen was harmless, so give it early, often, and in copious amounts.

 

[princessretard]

They don't even teach it in NM anymore for that reason haha

wait, so why exactly is it useless to put someone in trendelenberg? just so i know. 'cause i took my emt course about a year ago and they were still teaching us that. maybe having the blood flow to your center/heart is not so true??? i dont know.

 

[EMS/LEO505]

Ct.

Big difference from the south west lol

 

[DrParasite]

wait, so why exactly is it useless to put someone in trendelenberg? just so i know. 'cause i took my emt course about a year ago and they were still teaching us that. maybe having the blood flow to your center/heart is not so true??? i dont know.

PHTLS no longer teaches to put people in Trend, now it's lay them supine, and transport them to the er so they can receive IV fluids or blood.

 

[JPINFV]

wait, so why exactly is it useless to put someone in trendelenberg? just so i know.

There's no evidence that it works. The handful of studies done are generally small in size, fairly weak and with varying patient populations (sometimes healthy adults, sometimes adults immediately after giving blood, etc), but they've all consistently failed to show (and, by "show," I mean like they might get one subject to have an increase in BP, without evidence of an increase in cardiac output, otherwise no real change, little less a statistically significant change) any increase in blood pressure between laying supine and being in trendelenburg. They have shown, though, increases in intercranial pressure, and an increase in work needed to breath (shifting abdominal contents), among other adverse effects.

Another problem is that different studies test different things. There's a difference between trendelenburg (defined as a full body, head down tilt. Essentially unheard of in prehospital care), and passive leg raising (just the raising of the legs; commonly called "trendelenburg"), but again, regardless of what was tested no difference was found.

 

[TransportJockey]

They don't even teach it in NM anymore for that reason haha

Yep, it was being phased out when I was in Mike's class in the end of 07

 

[46Young]

There's no evidence that it works. The handful of studies done are generally small in size, fairly weak and with varying patient populations (sometimes healthy adults, sometimes adults immediately after giving blood, etc), but they've all consistently failed to show (and, by "show," I mean like they might get one subject to have an increase in BP, without evidence of an increase in cardiac output, otherwise no real change, little less a statistically significant change) any increase in blood pressure between laying supine and being in trendelenburg. They have shown, though, increases in intercranial pressure, and an increase in work needed to breath (shifting abdominal contents), among other adverse effects.

Another problem is that different studies test different things. There's a difference between trendelenburg (defined as a full body, head down tilt. Essentially unheard of in prehospital care), and passive leg raising (just the raising of the legs; commonly called "trendelenburg"), but again, regardless of what was tested no difference was found.

Hey, I'm not trying to call you out, but I'd like to be able to quote studies to others at my dept as to why trendelenberg (passive leg raising, I like that) is ineffective. Would you have any links to studies in regards?

 

[Smash]

There's no evidence that it works. The handful of studies done are generally small in size, fairly weak and with varying patient populations (sometimes healthy adults, sometimes adults immediately after giving blood, etc), but they've all consistently failed to show (and, by "show," I mean like they might get one subject to have an increase in BP, without evidence of an increase in cardiac output, otherwise no real change, little less a statistically significant change) any increase in blood pressure between laying supine and being in trendelenburg. They have shown, though, increases in intercranial pressure, and an increase in work needed to breath (shifting abdominal contents), among other adverse effects.

Another problem is that different studies test different things. There's a difference between trendelenburg (defined as a full body, head down tilt. Essentially unheard of in prehospital care), and passive leg raising (just the raising of the legs; commonly called "trendelenburg"), but again, regardless of what was tested no difference was found.

This. Trendelenberg position was never intended to be used for shocked patients. It was (and is) a means of moving the abdominal contented during surgery to better get at the bits that need chopped. Or at least the bits that the surgeon wants to chop

Sing RF, O'Hara D, Sawyer MAJ, Marino PL Trendelenburg Position and Oxygen Transport in Hypovolemic Adults Ann Emerg Med March 1994; 23:564-567

Miyabe M, Namiki A The Effect of Head-down Tilt on Arterial Blood Pressure After Spinal Anesthesia Anesth Analg 1993;76:549-552.

Sibbald WJ, Paterson NA, Holliday RL, Baskerville J The Trendelenburg Position: Hemodynamic Effects in Hypotensive and Normotensive Patients Crit Care Med 1979;7:218-224

Reuter DA, Felbinger TW, Moerstedt, Kilger E, Lamm
P, Goetz AE Trendelenburg Positioning After Cardiac Surgery: Effects on Intrathoracic Blood Volume Index and Cardiac Performance Eur J Anaesthesiol 2003;20:17-20.

 

[TransportJockey]

Hey, I'm not trying to call you out, but I'd like to be able to quote studies to others at my dept as to why trendelenberg (passive leg raising, I like that) is ineffective. Would you have any links to studies in regards?

Ive got one that kinda states that :
http://www.cjem-online.ca/v6/n1/p48

 

[JPINFV]

No worries... I normally try to post sources for those posts anyways.

Good first stop for prehosptial evidence based medicine is the Dalhousie University EMS evidence based medicine site:

http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=207#Trendelenburg

Also:
"Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T? "

Fairly good review even though it's starting to get a little old (published in 2005).
http://ajcc.aacnjournals.org/cgi/content/full/14/5/364

 

[EMS/LEO505]

Yep, it was being phased out when I was in Mike's class in the end of 07

Yup, now its all about the MAST pants haha

 

[TransportJockey]

Yup, now its all about the MAST pants haha

Please tell me you're joking. They were falling out of favor back when I was in class for anything but pelvis stabilization. Hell, most services in NM don't even carry them, even if they are on the NMPRC stocking list.

 

[EMS/LEO505]

Well there's a debate on them, mike has a couple people help him in lab and they're from sandoval, tijeras. They use them a lot out there, but not much here so idk lol

 

[Babalu]

Now here's an interesting question:

Say you're in a tiered system with medics in fly cars.

Do you take an ALS resource off the road during a busy day to provide ~5min of pain relief for a broken arm? Or do you keep the medic out for something else happening?

This pretty much sums up my EMS system, but with a few extra details. The nearest hospital is about 15-20 mins away, which also provides an ALS fly car for the surrounding area which carries 2 medics so typically one rides with PT and the other goes back. Because they only provide one fly car, ALS can be tied up very easily. While it would be unfortunate if the PT had to endure considerable pain during transport, it's wiser in my situation to avoid the mentality that anything and everything must have ALS. Of course there are exceptions to these kinds of things, compounding injuries such as soft tissue injuries like deglovings would make ALS more appropriate.

 

[TransportJockey]

Well there's a debate on them, mike has a couple people help him in lab and they're from sandoval, tijeras. They use them a lot out there, but not much here so idk lol

Are you in Mike F or Mike V's class (I was in F's class)? And yea, SVFD does tend to use them a lot, but they've gotten some of CNMs last few medic classes, so hopefully that will start to go away. As for Tijeras... I don't know a lot about that area other than it's on the edge of BCFD and AAS response areas... and neither of those services carry PASG

 

[LonghornMedic]

This pretty much sums up my EMS system, but with a few extra details. The nearest hospital is about 15-20 mins away, which also provides an ALS fly car for the surrounding area which carries 2 medics so typically one rides with PT and the other goes back. Because they only provide one fly car, ALS can be tied up very easily. While it would be unfortunate if the PT had to endure considerable pain during transport, it's wiser in my situation to avoid the mentality that anything and everything must have ALS. Of course there are exceptions to these kinds of things, compounding injuries such as soft tissue injuries like deglovings would make ALS more appropriate.

So if you were a patient having 9/10 pain, you'd be okay with no pain meds for the 20 min drive in? Keep in mind you've already waited 10 minutes from the time 911 was activated, 10 minutes sitting on scene doing the assessment and another 10-15 minutes to get into an ER bed, see a doc and get meds. By the time you finally get pain meds on board it has been roughly an hour. Let's say in that hour your ALS fly cars did nothing more than watch TV. Still think it was a good idea? Treat what you have now, not what may(or may not) happen.

 

[JPINFV]

^
...but remember, pain medication doesn't decrease mortality, therefore it's useless and paramedics shouldn't be used at all! [remove tongue from cheek]

 

[Scott33]

Don't assume that there will be a nurse waiting for the patient to arrive, with pain meds already drawn up. I have seen people wait for quite a while for pain relief. "10-15 minutes" is a little ambitious.

Pain scale is an important factor in determining the ESI category, but usually a simple, uncomplicated extremity fracture in a patient with no risk factors will be an ESI-4 (as with strains and sprains which can be equally as painful). This puts them behind about 75% of every other patient in the ED, or roped in with everyone else in fast-track.

It all depends what else is going on, but I think it is reason enough to consider giving pain relief prehospitally whenever possible / applicable.

 

[MrBrown]

You forgot to include each and every employer that chooses to hire employees without degrees, and also those that give no hiring preference to degreed medics, either. That's maybe 90% of the employers out there. Along with the FD's you have all those hospitals, privates, and muni third services.

That is a problem, however even the two year EMS Degrees seem to have been watered down with a bunch of management or general education requirements which means you spend maybe half your time learning what is already an inadequate amount about the praxis of prehospital medicine.

In the countries that require Bachelors and Advanced Degrees for Paramedic or Intensive Care level we focus specifically on Paramedicine and specalise from semester one of year one with maybe one general education class required across the three years of the degree. Mind you this is a feature of all our degrees because we do thirteen years of high school at least in NZ and I believe in all Commonwealth countries.

...99+% of accepted students have an undergrad degree and something like 30% (IIRC) have some type of graduate degree upon starting medical school. How can this be considering that the minimum requirement isn't even a bachelors degree?

In Australia where graduate medical education co-exists with the traditional six year courses they require a Bachelors Degree.

bls i think. emts can treat and splint fractures. if pt experiences nausea, vomiting, maybe even shock because of the fx, well...they can treat for that too and then do a rapid transport to the hospital. so bls.

Oh please stop saying things.

trendelenberg position, give high flow 02, rapid transport to hospital...that's all a basic can do i guess. not much i know but its a broken bone. there are other traumatic calls where yeah als should definitely be called for intercept. but this one sounds like you can bls it to the ER.

Once again may I point out that the American notion of BLS vs ALS is utterly hillariously ridicoulous?

 

[DrParasite]

Pain scale is an important factor in determining the ESI category, but usually a simple, uncomplicated extremity fracture in a patient with no risk factors will be an ESI-4 (as with strains and sprains which can be equally as painful). This puts them behind about 75% of every other patient in the ED, or roped in with everyone else in fast-track.

question: would the person with the " uncomplicated extremity fracture" who now has a prehospital IV and is medicated in the field have a higher or lower ESI number, and would he or she be treated in front of the 75% of other patients due to now being under the influence of analgesics and with the prehospital IV already started?