Paramedics Using Ultrasound Machines

JPINFV

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I would like to know what the history and physical said before crediting prehospital ultrasound.
 

medic417

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lol, LIVER. stupid auto correct
 

Carlos Danger

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I was trained to do FAST exams in 2001 as a flight paramedic. It was part of a study that unfortunately never ended up happening.

It wasn't that hard to learn then, and with the better machines these days, it's probably a little easier now.

However, I don't see this changing patient care. Would you not transport a patient who you suspect may have abdominal trauma, just because the FAST was negative?

Even in this case, it doesn't sound like it actually changed the care at all. They were already enroute to the ED. Unless the patient was in shock, he probably did not go right to the OR despite what the FAST said. And if he was in shock, did they need an ultrasound in the ambulance to tell them to call ahead with a trauma alert?

It may have some other applications in the field, such as determining a tamponade or help starting lines, but those seem like small benefits for the cost in technology and training.
 
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Clipper1

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Personally I'm all for them despite the idiotic arguments others will make against them.
Let's start with ego. If you fail to understand some of the limitations for US and for your agency by assuming all comments made concerning this are idiotic then you are not grasping the whole concept. The US will not replace what basic knowledge you might be lacking for assessment. The US will only confirm what you should already suspect.

Why did the Paramedics in the article pull out the US to have a look? If there were other significant findings than why not just do what they normally would per a trauma protocol for the appropriate facility? Why waste more time?

No hospital is going to go only by one prehospital US. This would be very short sighted. Did the Paramedics rule out all other injuries or just rule in the most obvious? The patient would probably still get a CT Scan. The injury may not need surgery at all. Or, there might be multiple injuries which need surgical repair. Just rushing a patient to the OR to repair on obvious injury and then have them crash/die due to a secondary less obvious injury is not good either.

In very rural areas when a helicopter might need to be called. But, it would be best served if the images can be viewed in real time or close to it by the ER Physician/Surgeon or Radiologist. Telemedicine would be the better way to go if you are going to invest in more techology. Hospitals might even share the cost.

In areas with a hospital on every corner and many of them with some level of trauma certification, then probably not. If there is a children's hospital nearby, why drop a kid off at an adult facility? Even for minor injuries they are best served by a staff with routinely treats children.

Slipping the media a good PR story always helps to get more money for the latest and greatest. Some do forget that these machines need to be updated and maintained which can be more costly than the initial purchase.
 

medicsb

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I question whether it actually made much of a difference. Though the reporters and the FD play this up dramatically, I'd be curious to know if the kid even went to the OR. The majority of liver lacs do not need surgery.
 

medic417

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Oh it would not change our care in the field. So then we should not do something that might result in quicker patient care once they arrive at the hospital. Heck with that reasoning lets stop doing anything to the patients and just load them and transport to the hospital because the hospital can care less what EMS tells them. :rolleyes:

If that is how your hospital treats you and what you tell them I feel sorry for you.
 

Clipper1

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Oh it would not change our care in the field. So then we should not do something that might result in quicker patient care once they arrive at the hospital. Heck with that reasoning lets stop doing anything to the patients and just load them and transport to the hospital because the hospital can care less what EMS tells them. :rolleyes:

If that is how your hospital treats you and what you tell them I feel sorry for you.
What do you mean by quicker care? You also gain respect from a hospital by giving a good assessment report and recognizing an urgent situation based on your assessment. I think many Paramedics are able to determine the appropriate level of care center based on assessment and trauma criteria. What gets many Paramedics noticed by physicians in the hospital is their ability to do more with less.

If your patient is serious enough to where you think a US is needed and a trauma alert is necessary which summons the surgeons, why do something which will be repeated again in the ER or a CT Scan done immediately? Are the surgeons going to take your diagnosis that only one injury is evident? Does your one US rule out all injuries? The US rules in what you might suspect. It may not rule out all possibilities. The ER physician and the surgeon will repeat. No need to return repeatedly to the OR for something missed based on just one assessment.

Yes, some patients do need to be taken to the hospital, especially children. Are you able to repair a liver in the field? How long are you going to wait around if the patient is symptomatic? An adult might have time but a child can decompensate quickly.

This is a little different than a cardiac cath where the interventional cardiac doctor will examine now only the suspected artery but also the others. The ECG also can not determine if the patient need to go to the OR immediately for a CABG. This is one known limitation of an ECG. An ECG is only one small picture.

Also, the article is one story about a child. How many times has the US been used and something missed which may not have been news worthy because they were not good PR for more equipment?
 
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Carlos Danger

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Oh it would not change our care in the field. So then we should not do something that might result in quicker patient care once they arrive at the hospital. Heck with that reasoning lets stop doing anything to the patients and just load them and transport to the hospital because the hospital can care less what EMS tells them. :rolleyes:

If that is how your hospital treats you and what you tell them I feel sorry for you.
"It's going to be expensive and it won't change patient care. But I think we should do it anyway".

Let's just add this one to the "examples of why EMS is stuck years behind the rest of medicine" file.
 

medicsb

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Oh it would not change our care in the field. So then we should not do something that might result in quicker patient care once they arrive at the hospital. Heck with that reasoning lets stop doing anything to the patients and just load them and transport to the hospital because the hospital can care less what EMS tells them. :rolleyes:

If that is how your hospital treats you and what you tell them I feel sorry for you.
I don't think it is idiotic to ask for evidence of benefit. I don't think it needs to change how the care is altered prehospitally, though it would be nice, but it would be prudent to have data to show that it can be reliable enough for trauma teams to act on. And if they do act on it, how will it change management for them? Will it produce time savings? Will it change patient outcome?
 

JPINFV

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Oh it would not change our care in the field. So then we should not do something that might result in quicker patient care once they arrive at the hospital. Heck with that reasoning lets stop doing anything to the patients and just load them and transport to the hospital because the hospital can care less what EMS tells them. :rolleyes:

If that is how your hospital treats you and what you tell them I feel sorry for you.

What's the point of looking for something that won't change your treatment? If it's something like a FAST scan, I seriously wonder how many positives are found in patients not already destined for a trauma center. This is different than, say, that 12 lead in a diabetic female with abdominal pain where a STEMI results in a cath lab notification and rerouting to a STEMI hospital.
 

medicdan

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"It's going to be expensive and it won't change patient care. But I think we should do it anyway".

Let's just add this one to the "examples of why EMS is stuck years behind the rest of medicine" file.
I work in and around a service that is doing a study on prehospital FAST. The thought is that it can change care in a change in destination (towards, not away from a trauma center), and has the opportunity to influence notification and preparation of an OR or CT scanner, to speed care on arrival. At this point, providers can only perform the FAST if they have no other more pressing patient care interventions.
 

JPINFV

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I work in and around a service that is doing a study on prehospital FAST. The thought is that it can change care in a change in destination (towards, not away from a trauma center), and has the opportunity to influence notification and preparation of an OR or CT scanner, to speed care on arrival. At this point, providers can only perform the FAST if they have no other more pressing patient care interventions.
I would bet $20 that the trauma team is going to repeat a FAST exam in the bay simply because the risks of an exploratory laparotomy are simply that great.
 

Clipper1

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If a trauma alert is called, a surgeon will be part of the team with the OR on alert along with radiology. The CT Scanner will be cleared and all nonemergent patients put on hold until the alert is cleared.

If it is a small hospital, the ER Physician will have to show need to summon a surgeon or call a flight/ground transport team. If the injury is serious requiring a higher level of care and should be transferred immediately, calling the surgeon and wasting time for his or her arrival could be detrimental. Not all surgeons and hospitals are appropriate for all injuries. If the injuries are not that severe but still need a surgeon, chances are the few minutes to get to the hospital and into a CT Scanner will not prolong definitive care. Getting the injuries (all and not just focusing on one) identified and the patient the most appropriate care should be the goal.

If the decison to transport to another facility, the ER Physician will need to provide labs and radiology results to the trauma center or hospital of a higher care level for the transfer to be confirmed. If the prehospital US does not transmit or make a digital copy it will have to be repeated or a CT Scan done. The technology used in prehospital should be able to communicate or be compatable with the hospitals.
 

medicdan

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I would bet $20 that the trauma team is going to repeat a FAST exam in the bay simply because the risks of an exploratory laparotomy are simply that great.
I wouldn't make that wager, I'm sure the ED resident and/or surg resident will repeat the FAST, but the potential exists for a more precise prearrival notification. This is not to replace ED assessment or management, but augment or provide notification. I live and work in a large urban area with plenty of trauma resources, but our preliminary data has shown that paramedics can successfully identify abnormalities, and in smaller communities, can be used for notification successfully.
 

FLdoc2011

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Ultrasound is one of the tougher imaging modalities to learn and master, there are whole fellowships based around it.

At this point, at least, I'm with most others in thinking this isn't a tool needed in prehospital setting at this time. Maybe down the road the landscape and technology will and change it will have a good, defined role prehospital, but right now I don't see it.

Can certainly study it and run some trials, that's how we ultimately advance care, but to have it in a defined, useful role is quite a ways off if at all in my mind.

Logistics of maintaining machines, training, costs, whether it will change management, who will ultimately be responsible for interpreting the images, etc.... are just some of my questions.
 

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