Is EMS treatment a farce?

[Veneficus]

Personally I don't think its a fair question Vene. Especially considering fluid resuscitation/responsiveness is a grey area. Hell when one of the major recommendations by, what many would consider an expert on this very topic (Paul Marik), is essentially give it a try and see what happens.

For something like fluid resuscitation there is no great indicator of your end points, most good studies have shown that almost everything we use to measure it is voodoo (including most of the PE findings we associate with it).

I do consder it a fair question.

One of the only reasons fluid resuscitation is a grey area is because for a long time, in many areas, it has been all or nothing. However, in the ICU environment, fluid balance has been the norm for a long time.

Not just in cases such as hemorrhage, but also in neuro pathologies, as well as renal pathologies. Certainly in MODS as well.

When dscussing overload, I read 5 studies today on its increase of mortality with another handful I need to go over tomorrow. The best centers at fluid balance are using <10% over calculated as the benchmark, with mortality decreasing from 50% to 39% that may not seem like much, but these are patients in which 3 or more organs are failing so that is a big deal.

From the EMS standpoint, and actually resucitation in general, fluid overload is a problem. If you do not think so, consult the studies on fluid resuscitation and cerebral edema (with corresponding mortality and morbidity) in cross-clamp aneurysm repair.

To sum up, overfluid resus kills people.

Now if you are trying to pick a fight on quantitative endpoints, I will agree there are no good ones. But you will be hard pressed to pick any quantitative score or chart that actually does make a major difference with the literature to prove it. Even when they are commonly accepted.

In my opinion these scores are part of the problem. Trying to make medicine so simple anyone can do it simply by starting or stopping treatment at specific numeric parameters just doesn't work. Claiming that it works "sometimes" When those "sometimes" are such low percentages is no better than guessing.

Probably why there are no definitive studies showing the benefits of many of these quantative endpoints and they are constantly being revised, edited, debated, etc.

Moreover, there may never be good studies because of the ethical limits.

I will also nit pick ad say there is a difference between "give some fluid and see what happens" and "2 large bore IVs wide open."

Here is the conclusion, from the review of research by Dr. Marik.

"By virtue of its simplicity, accuracy and availability as a continuous monitoring tool, dynamic monitoring of the pulse pressure, stroke
volume and pulse oximeter plethysmographic waveform would appear to be the ideal methods for the titration of fluid resuscitation in
critically ill patients undergoing mechanical ventilation. Echocardiographic methods of assessing ventricular function and size
complement the information obtained by these dynamic indices of fluid responsiveness. Measurement of EVLW and IAP may be
useful in preventing volume overload. These data should be interpreted in the context of the patients' clinical condition as well as
other parameters including the chest radiograph, PaO2/FiO2, urine output, renal function and cumulative fluid balance. The CVP and
PAOP no longer have a place in modern hemodynamic monitoring."

Bolded type better articulates my point. Maybe I need to start a blog so people will follow my observations too.

When EMS provider claim they are experts, more knowledge and ability is expected.

 

[Veneficus]

ICV diameter is an indirect method of measuring CVP...and CVP is garbage. Great review of fluid responsiveness on medscape. Thus far the only "monitor" that shows any integrity is pulse-pressure variation, but even this is only accurate in the extremes and only in mechanically ventilated patients (<9% or >13%).

Which again proves the point, you may not get an accurate quantitative measure that determines what is best, when to start or when to stop.

 

[downunderwunda]

I have come into this late, but I would like to address the original posters claims of bolus without thinking.

I am an Aussie & we have adopted evidence based practice in fluid administration. Dehydration only get fluids if unable to take oral fluid. Hypovolaemia get 100ml bolus to maintain a systolic BP about 90. That's permissible hypotension.

We have moved away from D50 to D10 in saline. Our protocols/guidelines are to monitor the patient whole giving up to 15g/150ml.

We also titrate fluids into head injury patients to maintain cerebral perfusion. Not a rapid bolus.

I reject your assertion that ems does not keep up but correct it by saying ems falls behind because of

1. Lack of education.

2. Insisting that, in some countries, ems be commingled with fire instead of being allowed to be the stand alone profession it should be.

3. Failure of medical directors to follow latest trends & implement them post haste when the evidence is there.

4. The inability of some providers to comprehend why these changes need to take place.

 

[DrParasite]

I have shared that thought for many years. The more I learn, the more feeble ACLS is.

question from the uneducated... what is feeble about ACLS? Is it the fact that ACLS as a plan of action is feeble, or because the drugs used in ACLS need to be changed to be more effective?

I happen to think that if something works, and is the best thing that works, than there is no problem with doing it as the standard practice is a good thing.

3. Failure of medical directors to follow latest trends & implement them post haste when the evidence is there.

which is good and bad. the knife cuts both ways; the latest trend might be shown to be deficient after "enough" evidence is gathered, and the bleeding edge techniques don't always have enough evidence to support that they work. Not only that, but once you do find a new "trend," and it is implemented system wide, another trend can come out and surpass the original "trend" and become the new thing. in the ER of my former agency, we had 10 to 15 attending physicians. we had close to 125 paramedics of varying education and competency. ensuring they are all on the same page can be a logistical headache (but very doable with enough time, staffing and funding)

and lets not forget that all too often certain practices are supported by the risk management and legal department, not the medical department.

 

[Veneficus]

question from the uneducated... what is feeble about ACLS? Is it the fact that ACLS as a plan of action is feeble, or because the drugs used in ACLS need to be changed to be more effective?

I happen to think that if something works, and is the best thing that works, than there is no problem with doing it as the standard practice is a good thing.

ACLS is based on the epidemiology of out of hospital cardiac arrest. It is a plan assuming that the patient arrested as a the most common revisible side effect of a sudden MI.

It is based on an outdated theory that an MI is caused by sudden and unpredictable onset. (which is obviously not the case or you would never assess for cardiac risk facors, because they would not be relevant)

In the population of SCA with no other comorbid conditions (like the population of the Pacific Northwest) it is the best plan. (though still far from perfect) a far cry from the population of Jersey City.

We know now that the only proven treatments to work are CPR and early defib. Which means that if the patient can be saved, it will, according to the numbers, be by this.

That makes the rest of ACLS totally useless.

In the most recent changes, post arrest care is given some lip service. But one of the 3 critical criteria of ACLS post arrest care is institution or recognition for theraputic hypothermia. Undoubtably an effective therapy, it is not a standard therapy. Most places will not have it available.

Long term definitive airway (aka ET tube) is part of post arrest ACLS care. Which may or may not be beneficial for a variety of reasons too individual to discuss accurately here.

In the hospital, or other healthcare setting, like a dialysis clinic, chemo treatment centers, doctors offices, etc, ACLS takes no account for the comorbid condition most likely the source of arrest. Following ACLS guidelines in these situations is likely to do nothing (AKA no plan) or make things worse.

While at first it may seem intuitive to treat the most common cause of cardiac arrest as the best and primary plan, most healthcare providers will not encounter a cardiac arrest outside of work. (AKA their area of specialty, with its own specific treatments and challenges)

Which means it is not the best plan, or even a good one in most healthcare settings.

In addition to the useless medication regiment, it also doesn't take into account the limits of persons, scope, or ability.

You probably heard the phrase "We do everything on scene that they (are going) do at the hospital."

But that is not only not always true, as most highly capable Academic centers have a host of specialists and diagnostics available to do more.

A false conclusion is reached. ACLS is not everything that the hospital can do, it is all the hospital may be willing or able to do. It doesn't make field providers equal to hospitals or doctors, it brings hospital and doctors down to field provider diagnostic and treatment levels.

The AHA tries to deflect attention to this by stating "these guidlines should be adapted to your area using these guidlines." (AKA, make your own :censored::censored::censored::censored: up where you work, which may or may not follow these guidlines)

Now you may say "We work in EMS so it is our best plan" Which is partially true. But only the CPR and defib is a good part of the plan. That makes bystander response paramount (which we all know) and secondary to that early BLS response.(which according to the research is the best plan) but then ALS shows up with drugs and treatments that may not work or cause harm, that have no evidence backing that it works since the 1600s.

That makes ACLS a desperation kitchen sink approach on top of the proven treatment. Which is all BLS!

In addition to the drugs, ACLS still supports positive pressue ventilation, which when done improperly, which is most of the time by all providers, makes the plan a bad plan. Consider the services now doing CPR with passive vent via NRB showing increased survival.

What ACLS is, and why I think it is still worth teaching, is a desperate attempt to attempt to resuscitate somebody using hospital toys for people who have no idea what they are doing in a crisis situation they may only find themselves in once in their life.

So getting back to a good plan for EMS, how many EMS providers do you know who will likely never be part of a code response or have only ever seen one in their career and needed some easy to remember training to know what to do?

Does that sound like the best plan or a good plan to you?

I would also add, if 700,000 of a million people per year die of SCA secondary to the most common side effect of MI (I like easy numbers) that still leaves 300,000 people a year with no hope of being helped by ACLS at all.

 

[sir.shocksalot]

You probably heard the phrase "We do everything on scene that they (are going) do at the hospital."

But that is not only not always true, as most highly capable Academic centers have a host of specialists and diagnostics available to do more.

I like when you post Vene, I think it's mostly because I agree with you more often than not, and you further my beliefs about EMS. I could make the argument that you make me think about what I do more. By-and-large though it's because you say what I think :rofl:

Moving to the topic at hand, I think such a phrase is used simply because, as far as the average human is concerned, it's true. The problem therein lies when EMS providers start to believe this themselves, and not just regarding sudden cardiac death of suspected myocardial infarction arrests. Although one could argue PCPs and ED physicians can fall into the same trap of thinking "I can fix this" when the best thing to do is send, or take, the patient to a provider who can "fix" it.

Blah Blah Blah

All stuff I agree with.

So getting back to a good plan for EMS, how many EMS providers do you know who will likely never be part of a code response or have only ever seen one in their career and needed some easy to remember training to know what to do?

What about rural doctors and hospitals, they will often see the same dead people, with scarcely more practice? Does all the education in the world make a difference? What if that education is 10 years old? 20?
I think the problem is that for every one amazing provisioner of health care you have another who got fed up with keeping up 15 years ago.
I'm not trying to argue EMS is very good any of this, it's not. I'll argue at length that EMS in the US, as it is currently, provides little benefit to patients.

Does that sound like the best plan or a good plan to you?

I would also add, if 700,000 of a million people per year die of SCA secondary to the most common side effect of MI (I like easy numbers) that still leaves 300,000 people a year with no hope of being helped by ACLS at all.

One more comment from me about ACLS, in the US we thrive on "the one that made it". At times equally: economically, socially, and spiritually. Maybe the point of ACLS isn't to save as many lives as possible. It's to heroically pour or money, time, and efforts into saving one. How many in this forum have worked an arrest "for the family"? For right or wrong I think that is half of the reason ACLS continues as it is.

On to EMS being experts... We aren't. EMS was a band-aid for a wound that was fixed by engineers. Now it's festered into this beast that can't be killed, and does little for patient care. Here is my opinion, Paramedics are good for one thing, and one thing only: pain control. Even with that paramedics in some parts of the country (I'd argue many) do a pretty poor job with that.

The assertion of anything "expert" being provided in EMS would come with a very discerning eye from myself. EMS is an expert of nothing, we simply are to make citizens comfortable, even if that comfort is born out of ignorance. So long as we show up in 8 minutes or less and make as much noise doing it, then the show will go on. I think the question really is, do we take what we do for what it is? Just a dog and pony show for the tax-payers? Or insurance holders? Or do we start asking ourselves, as paramedics, the really hard questions, like are we actually good for anything medically? If not, why? And what can we do to actually make our patients better?

 

[Veneficus]

What about rural doctors and hospitals, they will often see the same dead people, with scarcely more practice? Does all the education in the world make a difference? What if that education is 10 years old? 20?
I think the problem is that for every one amazing provisioner of health care you have another who got fed up with keeping up 15 years ago.
I'm not trying to argue EMS is very good any of this, it's not. I'll argue at length that EMS in the US, as it is currently, provides little benefit to patients.

Sorry, I was sarcastically trying to make the point that because EMS providers see a lot of codes in their career, that ACLS is too oversimplified to be of use to these same EMS providers.

The assertion of anything "expert" being provided in EMS would come with a very discerning eye from myself. EMS is an expert of nothing, we simply are to make citizens comfortable, even if that comfort is born out of ignorance. So long as we show up in 8 minutes or less and make as much noise doing it, then the show will go on. I think the question really is, do we take what we do for what it is? Just a dog and pony show for the tax-payers? Or insurance holders? Or do we start asking ourselves, as paramedics, the really hard questions, like are we actually good for anything medically? If not, why? And what can we do to actually make our patients better?

My opinion is that at current, the most important thing US paramedics do is offer immedate entrance into the healthcare system.

Because of the current US system design they do not do this very efficently, but it is a system flaw beyond the control of EMS, so you cannot fault them for it.

However, EMS is only now starting to capitalize on this service, which is why we are reading threads about community paramedicine.

As for what we can do to make it better, we have covered that ground so many times and know it so well, I am not going to type it again here.

 

[Dwindlin]

I do consder it a fair question.

One of the only reasons fluid resuscitation is a grey area is because for a long time, in many areas, it has been all or nothing. However, in the ICU environment, fluid balance has been the norm for a long time.

Not just in cases such as hemorrhage, but also in neuro pathologies, as well as renal pathologies. Certainly in MODS as well.

When dscussing overload, I read 5 studies today on its increase of mortality with another handful I need to go over tomorrow. The best centers at fluid balance are using <10% over calculated as the benchmark, with mortality decreasing from 50% to 39% that may not seem like much, but these are patients in which 3 or more organs are failing so that is a big deal.

From the EMS standpoint, and actually resucitation in general, fluid overload is a problem. If you do not think so, consult the studies on fluid resuscitation and cerebral edema (with corresponding mortality and morbidity) in cross-clamp aneurysm repair.

To sum up, overfluid resus kills people.

Now if you are trying to pick a fight on quantitative endpoints, I will agree there are no good ones. But you will be hard pressed to pick any quantitative score or chart that actually does make a major difference with the literature to prove it. Even when they are commonly accepted.

In my opinion these scores are part of the problem. Trying to make medicine so simple anyone can do it simply by starting or stopping treatment at specific numeric parameters just doesn't work. Claiming that it works "sometimes" When those "sometimes" are such low percentages is no better than guessing.

Probably why there are no definitive studies showing the benefits of many of these quantative endpoints and they are constantly being revised, edited, debated, etc.

Moreover, there may never be good studies because of the ethical limits.

I will also nit pick ad say there is a difference between "give some fluid and see what happens" and "2 large bore IVs wide open."

Here is the conclusion, from the review of research by Dr. Marik.

"By virtue of its simplicity, accuracy and availability as a continuous monitoring tool, dynamic monitoring of the pulse pressure, stroke
volume and pulse oximeter plethysmographic waveform would appear to be the ideal methods for the titration of fluid resuscitation in
critically ill patients undergoing mechanical ventilation. Echocardiographic methods of assessing ventricular function and size
complement the information obtained by these dynamic indices of fluid responsiveness. Measurement of EVLW and IAP may be
useful in preventing volume overload. These data should be interpreted in the context of the patients' clinical condition as well as
other parameters including the chest radiograph, PaO2/FiO2, urine output, renal function and cumulative fluid balance. The CVP and
PAOP no longer have a place in modern hemodynamic monitoring."

Bolded type better articulates my point. Maybe I need to start a blog so people will follow my observations too.

When EMS provider claim they are experts, more knowledge and ability is expected.

Just so we're clear I'm not defending modern EMS version of fluid resuscitation, my argument is there is no good answer and even people who are considered experts don't really know what the right answer is at this point. Hence my belief your question wasn't fair to begin with.

 

[Veneficus]

Just so we're clear I'm not defending modern EMS version of fluid resuscitation, my argument is there is no good answer and even people who are considered experts don't really know what the right answer is at this point. Hence my belief your question wasn't fair to begin with.

I think the right answer is precison use of fluid.

 

[Carlos Danger]

I think we let paramedics assume that we are experts at resuscitation because most of our dead patients are dead, and it's a low-risk/high-reward situation to let us have at them. Occasionally, we get one that's not quite dead yet, and sometimes we're able to save them.

I think this is the foundation that pretty much underlies most of the problems in EMS.

This is exactly why RSI became common in the field. When the people that paramedics were intubating were all dead, everyone was happy, no matter how many showed up to the ED pulseless, with the ETT in the gut....because it just didn't matter; it wasn't affecting outcomes. Then one day, someone saw fit to let paramedics start paralyzing live people, and suddenly it WAS a big deal when these patients started showing up at the ED, pulseless, with the ETT in the gut.

Almost everything that you learn as a paramedic, and all the protocols you follow, are based on a worst-case scenario where the patient is likely to die without intervention. Add that to the fact that many in the medical community have, frankly, very low expectation for EMS, and the bottom line is that EMS gets away with A LOT of very low-quality practices and outcomes.

How medical directors fit into this equation is, to me, pretty damn simple. They should be held responsible for the protocols that their paramedics follow, as well as - to some extent, at least - the quality of their performance and the way they affect outcomes.

If ED physicians were held to the same standards in terms of their EMS agency's outcomes and practice that they are in terms of their ED's outcomes and practices, you would see a lot of changes in EMS....very quickly.

My opinion is that at current, the most important thing US paramedics do is offer immedate entrance into the healthcare system.

I remember reading about a study a long time ago that looked at how ALS interventions affected outcomes. But if I remember correctly, it found that ALS made a difference in only like 2% of the times that it was initiated, and those were narrow circumstances (severe pediatric asthma, IIRC).

(I don't remember anything about the study, where it was done, methodology, anything. So, like many studies are, it could be pure crap.)

 

[mycrofft]

I hear you oldschool

If my kid or wide's in that 2%, damn skippy it needs doing.

As for the rest of the comment, a parody of some folks: "But there isn't anything an ER can do that we don't do".

 

[Veneficus]

I remember reading about a study a long time ago that looked at how ALS interventions affected outcomes. But if I remember correctly, it found that ALS made a difference in only like 2% of the times that it was initiated, and those were narrow circumstances (severe pediatric asthma, IIRC).

(I don't remember anything about the study, where it was done, methodology, anything. So, like many studies are, it could be pure crap.)

If you are referring to the OPALS study out of Canada and its subsequent follow-ons, it was most certainly not crap. They were very well done multicenter trials. They did however qualify "in the urban setting."

Here is an interesting review of the literature on it.

http://www.lmvas.org/pdf/isenberg.pdf

 

[systemet]

If you are referring to the OPALS study out of Canada and its subsequent follow-ons, it was most certainly not crap. They were very well done multicenter trials. They did however qualify "in the urban setting."

Here is an interesting review of the literature on it.

http://www.lmvas.org/pdf/isenberg.pdf

Every time OPALS comes up, I like to point out the respiratory distress subgroup, that showed a survival benefit with prehospital ALS.

http://www.ncbi.nlm.nih.gov/pubmed/17522399

Granted, there was no RSI (or even sedation-facilitated intubation) in OPALS, but I found this encouraging. While 12-lead is probably in the process of becoming BLS over the next few years, there's plenty of evidence for prehospital 12-lead, which has typically been an ALS intervention. Some systems have shown benefit with thrombolysis.

For now it seems that most of what we do that works isn't necessarily associated with (1) cardiac arrests, or (2) intubating people, at least in most EMS systems.

 

[Veneficus]

For now it seems that most of what we do that works isn't necessarily associated with (1) cardiac arrests, or (2) intubating people, at least in most EMS systems.

How many people here have argued with me on cardiac arrest being the measure of a good EMS system?

Word has not gotten out yet.

If I remember correctly, there was a study on D50 in hypoglycemia that showed no mortality benefit, but a decrease in hospital stay.

I also recall the same being true for respriatory problems like asthma.

The confounder for respiratory though is that certain section of the globe are prone to them and the Northeastern part of North America is one of those places. SO this may limit the value of EMS respiratory treatment in say...Arizona

But generally I think reduction of hospital stay for any pathology is an admirable goal and benchmark of ALS.

 

[abckidsmom]

How many people here have argued with me on cardiac arrest being the measure of a good EMS system?

Word has not gotten out yet.

If I remember correctly, there was a study on D50 in hypoglycemia that showed no mortality benefit, but a decrease in hospital stay.

I also recall the same being true for respriatory problems like asthma.

The confounder for respiratory though is that certain section of the globe are prone to them and the Northeastern part of North America is one of those places. SO this may limit the value of EMS respiratory treatment in say...Arizona

But generally I think reduction of hospital stay for any pathology is an admirable goal and benchmark of ALS.

I think EMS care, when delivered well, can lessen hospital stay.

Even if it's just something like an allergic reaction, there's a domino effect of having patients in the ER for less time, even if it's just hours that are knocked off when the allergic or anaphylactic reaction is treated prior to arrival at the hospital.

I think that the pain that is relieved prehospitally allows the real evaluation of the problem to happen sooner and without tying up ER resources getting an IV, getting the meds, getting the patient comfortable and able to accurately relay their story.

I think that one of the things EMS does great for patients when they are on the ball is that they provide the whole story, neat and tidy, and the patient comfortable and in a gown and with an IV we have provided the service of making things easier for the ER, the patient's entry into the system is quicker, and we've still met our primary mission of driving people to the hospital with very little added effort.

A lot of days, I find that that is the best I've got. It would be a pretty easy thing to study, in patients who arrive at the ER by EMS and are discharged from the ER, how does the total time in the ER compare with patients with the same diagnosis who arrived on their own. And what is the impact on the ER of that?

 

[DrParasite]

You probably heard the phrase "We do everything on scene that they (are going) do at the hospital."

But that is not only not always true, as most highly capable Academic centers have a host of specialists and diagnostics available to do more.

A false conclusion is reached. ACLS is not everything that the hospital can do, it is all the hospital may be willing or able to do. It doesn't make field providers equal to hospitals or doctors, it brings hospital and doctors down to field provider diagnostic and treatment levels.

by that logic, shouldn't we be transporting all cardiac arrests then? since the hospitals can do more than a field provider? just trying to follow where you went with this.

 

[Veneficus]

by that logic, shouldn't we be transporting all cardiac arrests then?.

No.

since the hospitals can do more than a field provider? just trying to follow where you went with this.

Not all hospitals are capable of doing more than field providers.

Not all hospitals that are capable will expend the resources. (For multiple reasons)

Some patients will not be salvagable no matter what hospital you go to or what they do there.

However, if I had a choice between going to a hospital that only attempts to save patients who die from 1 specific etiology or a hospital that will at least try to find another reason, I think I will go with the later.

It is sort of "death panel" like if you ask me for an ED to only try to resuscitate based on epidemiology, but it is what it is.

If your transport destination is not going to do anymore than EMS what is the point of transporting?

We know that CPR during transport is not effective, so if you are going to transport for a more than a few minutes, there no longer is a reason to transport.

On the flip side if you have somebody in cardiac arrest who has missed dialysis for a few days, then you need a dialysis machine, not a cath lab and they are not always found in the same place.

But I would say the deciding factor to transport or not is either identifying a reversible pathology beyond the capability of EMS to treat or a strong indication that SCA secondary to MI was suspected and the person had some sort of finding that suggested they were not dead for hours.

But having said that, I also think it is better for BLS to try their tricks and move towards the hospital rather than wait for ALS in a tiered system because we know that it is the BLS intervention, not the ALS, that will make a difference and ALS might make it worse.

Basically it is a fluid situation, absolute black and white isn't going to work.

 

[jroyster06]

I would venture to say that EMS as a whole is behind the times. It seems like historically we are at least 2 years behind the "cutting edge" medicine of the hospital. In being the medical nerd that I am I find countless Tx that would benifit us in the prehospital setting but have not been implemented because "let's wait for more research" or "it's cheaper this way"

I think that our profession will not improve until we make the transition form "basics are a dime a dozen, and paramedics are on every corner" to skilled providers.

As for myself "I know a lot about some things, a little about alot of things, but am an expert of nothing." EMS as a whole is in a transitional state and we are constancy making dramatic improvements. I think in the near future we will plateau. The only was to curve that is by stricter education. Both in initial and with CE's.

 

[Veneficus]

I would venture to say that EMS as a whole is behind the times. It seems like historically we are at least 2 years behind the "cutting edge" medicine of the hospital.

I do not share your optimistic appraisal of the situation. If your eMS care is only 2 yearsout of date you either have the world's best EMS service or the world's worst hospital. Most US EMS agencies are 30-40+ years behind and completely ignore any evidence that would change practice.

EMS as a whole is in a transitional state and we are constancy making dramatic improvements. I think in the near future we will plateau. The only was to curve that is by stricter education. Both in initial and with CE's.

What are these dramitic improvements you speak of?

I have seen no evidence nor even heard about them.