P.A. ALS intervention study

[Woodtownemt]

Today NPR ran a story of how Philadelphia EMS was having a open house to discuss the study they are about to commence. Basically they are trying to see if ALS intervention is worth staying and playing vs minimal intervention and a whole lot of diesel. Penetrating trauma will be dispatched certain run numbers. Odds with get full ALS intervention on scene. Evens get rushed to the ER. What are your thoughts on the process?

 

[Woodtownemt]

http://www.npr.org/sections/health-...ictims-of-violence-or-gamble-with-their-lives

 

[BobBarker]

EMS is not the coroner, so they should not transport deceased patients. Work on scene until ROSC or termination after efforts. The only exception that I see to this rule is drownings, electrocution and pediatrics(only because I have seen this a couple times in some protocols in SoCal).
Now, if the patient is not deceased and certain interventions need to take place, it shouldn't be done in the back of an ambulance unless absolutely necessary. CPR, putting an IV/IO and even bagging is much harder to do in an ambulance that's going 60MPH to the closest hospital.

 

[DesertMedic66]

EMS is not the coroner, so they should not transport deceased patients. Work on scene until ROSC or termination after efforts. The only exception that I see to this rule is drownings, electrocution and pediatrics(only because I have seen this a couple times in some protocols in SoCal).
Now, if the patient is not deceased and certain interventions need to take place, it shouldn't be done in the back of an ambulance unless absolutely necessary. CPR, putting an IV/IO and even bagging is much harder to do in an ambulance that's going 60MPH to the closest hospital.

But staying on scene starting an IV on a GSW patient isn't the best option. What that patient needs is surgery and guess what is not found in the back of the ambulance?

 

[Ensihoitaja]

It seems weird that they need to study this. Our priority for these patients is always short scene times/rapid transport to a trauma center with management as needed en route.

We actually just had some training with our trauma surgeons, and they flat out said that they'd rather have a patient with a short scene time and nothing done than a patient with a long scene time. Getting lines/airways en route is the goal, but it's more icing on the cake.

I think this shows that we're doing something right, too:

The Rocky Mountain Regional Level I Trauma Center at Denver Health has Lowest Mortality Rate Among All Academic Hospitals.

• A survival rate of 96 percent for blunt trauma, such as those injuries sustained in motor vehicle crashes and ski accidents.
• An 86 percent survival rate for penetrating trauma, such as impalements and gunshot wounds.
• An overall survival rate of 95 percent.

http://www.denverhealth.org/medical-services/trauma-center/choose-denver-health

 

[SpecialK]

How is the study even necessary?

I've said it before, and I'll say it again:

The primary role of ambulance personnel when we see a patient is to:

(1) Make a diagnosis of what is most likely wrong with them, then
(2) On the basis of (1) determine what their healthcare needs are, and
(3) Having determined (2), find the most effective and efficient way of meeting those needs.

So, I see a patient who has been shot, stabbed or otherwise has major trauma. They need to be seen at a major trauma hospital without significant delay. Staying on scene to do things which in the "overall context" are not clinically significant is pointless because it detracts from (2) and (3) above.

At the very least load and treat enroute.

Are these principles just not taught in the US or something? Seriously?

 

[BobBarker]

But staying on scene starting an IV on a GSW patient isn't the best option. What that patient needs is surgery and guess what is not found in the back of the ambulance?

Oh yea, I'm not saying stay on scene for 30 minutes trying to get an IV in after failing 4 times. I'm saying try once real fast and head out. What does it take you, 2 minutes to get an IV in? Delaying 2 minutes is probably not going to do much harm and if you get the IV in great, will most likely help a little.

 

[Ensihoitaja]

That's 2 minutes you're delaying definitive care, in one of the few cases minutes matter. Besides, it's not THAT hard to get an IV in a moving ambulance.

 

[StCEMT]

EMS is not the coroner, so they should not transport deceased patients. Work on scene until ROSC or termination after efforts. The only exception that I see to this rule is drownings, electrocution and pediatrics(only because I have seen this a couple times in some protocols in SoCal).
Now, if the patient is not deceased and certain interventions need to take place, it shouldn't be done in the back of an ambulance unless absolutely necessary. CPR, putting an IV/IO and even bagging is much harder to do in an ambulance that's going 60MPH to the closest hospital.

With something like a cardiac arrest or a heroin OD, I would agree. However that's because 1. is my protocol (though I do like CCR more) and 2. an OD can be a quick fix.

When it comes to major trauma, what am I going to do? Not anything that will fix the problem. However, I do have 3 adult and 2 pediatric level 1 trauma centers that will definitely be able to help. The most I will play with on scene is controlling any major bleeding and slapping on a TQ or whatever. IV's aren't that hard to do while moving if you pay attention to what's ahead and bagging isn't necessarily that hard while moving either. Besides if you have an intubated patient and a vent, use it.

 

[EpiEMS]

Today NPR ran a story of how Philadelphia EMS was having a open house to discuss the study they are about to commence. Basically they are trying to see if ALS intervention is worth staying and playing vs minimal intervention and a whole lot of diesel. Penetrating trauma will be dispatched certain run numbers. Odds with get full ALS intervention on scene. Evens get rushed to the ER. What are your thoughts on the process?

Makes total sense to try it out - replication is at the heart of good science. That being said, we have good evidence that rapid transport is key here (the OPALS study, evidence from Philly PD's transport of penetrating trauma patients, more evidence from Philly PD, that allegedly controversial Medicare data study, etc.).

 

[dutemplar]

Let's see, on scene for major trauma...

Drop an LT unless you abjectly need to RSI or go surgical, pop the chest bilaterally (if indicated), pericardiocentesis (if remotely applicable), pelvic binder (if indicated), exsanguination control (if applicable), and run like hell. I/O or IV can be done enroute so you can effectively thin out the blood, ultrasound (if available) enroute. The minor bandaging, minor splinting, making patients pretty, enroute...

Philly has a history of cops taking victims, tossing them in cars, and driving like hell without EMS. Then again, when you have lengthy EMS call queus...

 

[EpiEMS]

I/O or IV can be done enroute so you can effectively thin out the blood.

I hope nobody's pouring in NS/LR like Johnny and Roy used to. I can't help but wonder if this is one of the material causes of the poor(er) ALS trauma outcomes.

 

[dutemplar]

I hope nobody's pouring in NS/LR like Johnny and Roy used to. I can't help but wonder if this is one of the material causes of the poor(er) ALS trauma outcomes.

Gotta love the old days... bilat 14ga EJs and a few liters.

 

[Rialaigh]

I don't see the point in the study other then to add some more fuel to the "ALS makes no difference in outcomes" fire which makes it more difficult to get paid essentially...

My protocol where I work is penetrating or blunt trauma of a life threatening nature (with a pulse) goes in the truck and goes to the hospital after correction of immediate life threats (tourniquet placement, direct pressure, possibly a bvm) . Vitals, assessment, airway management, IV access, and anything else is gravy on the way to the hospital. I had a GSW victim last shift, scene time was under 3 minutes. He had a pulse and it was life threatening so he went in the truck and we left.

 

[BobBarker]

I would also think that the amount of people you have to help you and your distance to the hospital/trauma center makes a huge difference. If your used to having 3-4 medics/emt's on your ambulance able to assist, load and go because almost everything can be done enroute as you have plenty of hands. It's much harder with only 1 person in the back to manage a life threatning trauma victim, especially if he/she needs to be bagged, IV and other interventions along the way.

 

[StCEMT]

I would also think that the amount of people you have to help you and your distance to the hospital/trauma center makes a huge difference. If your used to having 3-4 medics/emt's on your ambulance able to assist, load and go because almost everything can be done enroute as you have plenty of hands. It's much harder with only 1 person in the back to manage a life threatning trauma victim, especially if he/she needs to be bagged, IV and other interventions along the way.

If it is that bad of a call, I will probably tube them and throw them on a vent while my partner controls bleeding. No need to bag. Even if I got an IV, I am not gonna flood them with fluids, so that is lower on my list of immediate concerns. ABC is pretty much the extent of my immediate what do I care about and IV + fluids comes after those 3.

 

[BobBarker]

If it is that bad of a call, I will probably tube them and throw them on a vent while my partner controls bleeding. No need to bag. Even if I got an IV, I am not gonna flood them with fluids, so that is lower on my list of immediate concerns. ABC is pretty much the extent of my immediate what do I care about and IV + fluids comes after those 3.

Unfortunately no vents over here.

 

[Nova1300]

I think we may be missing the point of this study a bit. Granted, I haven't seen the study protocol but it doesn't appear that they are looking for outcomes in terms of time spent on scene doing interventions. They are trying to determine if patients do better with implementation of invasive treatment in the field vs. providing minimal prehospital care.

There will be an enormous number of confounders here, which I hope they will adjust for in post-hoc analysis (long extrication times, pre-existing co-morbidities, extended transport times, patient age, injury severity, etc.)

Everything we do in the prehospital world has an effect on the patient's physiology. Even something that seems as inconsequential as starting an IV has physiologic sequelae. And certainly insertion of IO or induction and instrumentation of the airway or initiation of positive pressure ventilation can cause perturbations. Those things may prove to be useful in certain patient populations or certain injury severity. And they may prove to be harmful in others. Maybe they are helpful in the field, or maybe they are only helpful if you do them right before putting a scalpel to the abdomen.

I would pose the question that has been posed so many times before- what if the human body is better at maintaining its own homeostatic mechanisms in the case of massive trauma and all these things we do only serve to throw off that homeostatic balance? Even venipuncture alters what the body is doing. Will this study tease that out? Certainly not. But it will give us a broad idea of whether poking patients with things when they are in physiologic extremis and still at some distance from the stabilization of the operating room is helpful or harmful.

I'm certainly not a blind follower of evidence based medicine. As I have stated before, I think it is very difficult to broadly apply evidence to the critically ill population. However, if our ultimate goal is to improve survival, these are questions that must be investigated. And, they must be investigated multiple times, in multiple populations, in multiple places before any real conclusions can be drawn.