Prehospital Lactate Meters

[JakeEMTP]

JakeEMTP, your attitude is offensive. Either give us a good explanation for your high and mighty attitude or knock it off. Veneficus has more education than 1/2 of us put together, which gives him the right to have an attitude sometimes. You on the other hand are coming off as a jerk.

Let him fight his own battles unless you think he isn't able to on his own. He made statements he needs to back up. He made his hospital ER sound like its staff was too stupid to initiate a sepsis workup which has been put out there for many years. An ER nurse is not so stupid an ICU nurse has to hold her hand starting an IV, sending labs and getting fluids started. Nor should an ER doctor be incapable of doing some intervention unless an Intensivist is there.

Why are CVA, AMI and trauma alerts ok, but sepsis alerts aren't?

Stroke and AMI Alerts may need more interventions than what can be done in the ER. A Stroke Alert tells the Radiology department to hold off on that next elective scan. It also can ready the interventional neuro and radiology team. An AMI can be more than just getting a 12 lead and a few labs. The AMI alerts a cath lab and often the patient will go directly to the cath lab if a stemi. Many sepsis patients can be handled in the ER for the initiation of treatment and the majority will be admitted to a telemetry unit and not ICU. If all of the patients who had an elevated lactate level needed an ICU bed and an intensivist there wouldn't be enough ICU beds anywhere and health care would be through the roof with intensivists as consulting for every patient. But, strokes and AMIs should get at least a neurologist or cardiologist if the hospital is rated as providing certified services.

 

[FLdoc2011]

Been reading through the thread and hoping it hasn't gotten completely out of hand..... but honestly at this point outside of studies/clinical trials, I'm not sure prehospital lactate has a role.

Even when I'm admitting someone lactate is just one of MANY things I look at and most of the time it doesn't change management that we've already to started or it's used more as marker to help with judging effectiveness of interventions.

I'm sure some places are calling "sepsis alerts" but is that really changing clinical outcomes? Like others have said there's really no intervention initially that can't be done in the ER by the ER physician. Lactate is one of several markers that technically can define "severe" sepsis vs sepsis but that's really not going to change prehospital or initial ED management.

It seems these sort of things get personal quickly. I certainly applaud EMS for wanting to advance but like any other area of medicine we need to think before just slapping on another test, especially talking about adding on a test prehospital where the cost/barrier to entry is a lot more than just adding a point of care lactate to an ER that already has the equipment and infrastructure.

Chances are the ER/hospital is going to run their own lactate anyway right away. After all, it's not THEIR machine they have calibration records for, and they certainly couldn't bill for it.

 

[Veneficus]

He made his hospital ER sound like its staff was too stupid to initiate a sepsis workup which has been put out there for many years.

I didn't interpret it that way.

Anyway, not all hospitals are equal and I don't think it speaks to the quality of the staff when there is a delay in a sepsis workup.

One reason is if a patient presents as "not really sick" the workup may be delayed until the first set of diagnostics the hospital performs comes in.

In the geriatric population, nonspecific complaints, especially from unreliable patients can also cause delays through no fault of the staff.

I would also like to point out that while sirs/sepsis guidlines have been out for many years, they do change regularly, and doctors and hospitals that have research going on in the topic change much faster than the guidlines. That can make other institutions seem or actually be very far behind.

An ER nurse is not so stupid an ICU nurse has to hold her hand starting an IV, sending labs and getting fluids started. Nor should an ER doctor be incapable of doing some intervention unless an Intensivist is there.

You keep using that stupid word... I am not sure why.

An ER is not the place for sick people, medical or surgical. There is far more to taking care of sepsis patients that what an ED can provide for. It is not a matter of provider ability, it is a matter of resources.

Most EDs suffer everytime they have to pull a nurse from staffing to sit on a sick patient. If they don't the patient suffers.

There is also the issue of things like glycemic control, invasve monitoring, etc etc that is not realistic in an ED.

I have played both sides of the ED resuscitation argument. But after some learning and experience, have changed my position that ED resuscitation should be no different than EMS, as temporary as possible until the expert assuming long term care can be brought in. With minutes being preferable.

I also know more than a few ED docs who advocate the same. Perhaps because they are putting aside their ego in order to better serve the patients?

Many sepsis patients can be handled in the ER for the initiation of treatment and the majority will be admitted to a telemetry unit and not ICU.

I think this is facility specific. At the academic facility I am at, all suspected SIRS and septic patients go to a respective ICU. I am personally involved in the neonatal sepsis research, and I can attest, there is no place equal or better than a unit, and no service sufficent that is not a unit. As with any pathology, early, specific, intervention is of the best benefit.

If all of the patients who had an elevated lactate level needed an ICU bed and an intensivist there wouldn't be enough ICU beds anywhere and health care would be through the roof with intensivists as consulting for every patient.

I think this is an equation of 2 unrelated things.

As was pointed out by Londonmedic, there are many causes of elevated lactate. While often used, lactate level is not always specific to septic (or for that matter any) shock. Sometimes with sensitivity approaching only 30%. The cause of elevated lactate must be determined.

As for intensivists, there are not enough now. With a further projected shortage, I have even seen estimates by 2020 only 24% of the positions will be filled.

It has been my observation that anytime an intensivist consults for a patient, there is usually some benefit. In intensive medicine there is a culture of approaching the patient as a whole, not as a single organ or system. A global clinician is much cheaper than a cardio consult, a nephro consult, a neuro consult, etc on the same patient.

It is also better for patients until they can have their individual organs sent to the best respective service and then reassembled prior to discharge.

It is not to say the intensivist is the answer to everything, but the perspective brought definately doesn't go amiss.

Did you know that outside of the US, it is often orthopods and anesthesia that manages not only the EDs, but EMS as well?

 

[Aidey]

No, you interpreted it as him making his hospital staff sound that way. You make it sound like you work in a very well off privileged system that always has plenty of beds and available staff. A hospital doesn't have to suck in order to need as much heads up as possible.

It isn't just about who can do what. It is about having enough people available, while not ignoring 1/2 of the other patients in the ED. Same as a code team within a hospital. It is about having continuity of care. A truly sick sepsis patient is not a patient you want to sit on in an ED for very long. Having ICU staff down there means getting the ball rolling on what will need to be done once the patient is transferred, and it means that at least one person will have been with the patient since they arrived.

An AMI is more than a 12 lead and labs. They may also need fluids, pressors, multiple drips hung and intubation. Hmmm, kind of sounds like what might be done to a sepsis patient doesn't it?

No one is saying every patient with an elevated lactate needs an ICU bed. What they are saying is that having one more assessment tool allows for a high specificity in diagnosis which means the right patients get the right treatment faster. That is almost exactly what we use a 12 lead for.

 

[abckidsmom]

I hear what you're saying, Aidey, but I really think that the level of prealert necessary for a septic patient is possible just through assessment alone.

ICU staff are not going to be coming down to the ER to check on a patient with a lactate > 4. ER staff are going to evaluate the patient, determine their hemodynamic stability, and get them an ICU bed.

The treatment for sepsis can be rather complex, but in the initial stages, it's easily managed in the ER.

I do not support spending hundreds of more dollars for yet another new toy that isn't going to change treatment or outcomes for patients. We water down the "alert mentality" if we have an alert for every random thing.

 

[FLdoc2011]

Certainly agree with the above two posts. We routinely get called down to the ED once it's none the patient is going to the ICU.

At least here in the US the ED is all about moving meat and at least they certainly don't want a critical pt in the ED longer than needs to be.

 

[Veneficus]

We water down the "alert mentality" if we have an alert for every random thing.

I think the alert mentality came from the need of having to tell EMS providers seemingly obvious things to get them to stop taking patients to the nearest ED all the time.

Take the trauma patient to the trauma facility.

Take the cardiac patient to the cardiac facility.

The same with stroke.

In some states it even had to be put into legislation.

 

[usalsfyre]

Certainly agree with the above two posts. We routinely get called down to the ED once it's none the patient is going to the ICU.

At least here in the US the ED is all about moving meat and at least they certainly don't want a critical pt in the ED longer than needs to be.

Quoted for truth. Ask any ED director what their primary concern is. After the Pavlovian "Press Ganey" answer they'll mention throughput.

 

[Aidey]

Been reading through the thread and hoping it hasn't gotten completely out of hand..... but honestly at this point outside of studies/clinical trials, I'm not sure prehospital lactate has a role.

...

I'm sure some places are calling "sepsis alerts" but is that really changing clinical outcomes? Like others have said there's really no intervention initially that can't be done in the ER by the ER physician. Lactate is one of several markers that technically can define "severe" sepsis vs sepsis but that's really not going to change prehospital or initial ED management.

The study in Denver did show a reduction in mortality. Hopefully someone here has access to the results and can post them.

In discussions with other people on this same topic, one of the things that has come up as been the negative impact EMS' impression of the patient has on the speed they are treated in the ED. Basically, EMS views the patients as BS and their report to the ED downplays how sick they potentially are. The ED is biased by this attitude, and thus the patients aren't deemed acute.

For example. I work in a paramedic/basic system. It is extremely common to be called to a nursing home by for grandma who isn't acting right or some other seemingly dumb reason. These calls are almost always turfed to the basic, who rarely asks very many questions of the nursing home staff. They are babysat on the way to the hospital with minimal assessment, and at the hospital minimal report is given.

How much faster would the ED staff recognize they have a potentially septic patient on their hands and implement their sepsis protocol if the patient had a full paramedic work up, with lactate?

 

[JakeEMTP]

Did you know that outside of the US, it is often orthopods and anesthesia that manages not only the EDs, but EMS as well?

It is that way in some places in the US also. I believe that is why EMS physicians are trying to get their specialty recognized.

There are national guidelines for sepsis and there are data bases for collection of data. Nothing new there.

Don't want to get into any pissing match with you Vene. That is pointless. I've read some of your posts on other forums over the past 6 or 7 years. -_-

 

[abckidsmom]

The study in Denver did show a reduction in mortality. Hopefully someone here has access to the results and can post them.

In discussions with other people on this same topic, one of the things that has come up as been the negative impact EMS' impression of the patient has on the speed they are treated in the ED. Basically, EMS views the patients as BS and their report to the ED downplays how sick they potentially are. The ED is biased by this attitude, and thus the patients aren't deemed acute.

For example. I work in a paramedic/basic system. It is extremely common to be called to a nursing home by for grandma who isn't acting right or some other seemingly dumb reason. These calls are almost always turfed to the basic, who rarely asks very many questions of the nursing home staff. They are babysat on the way to the hospital with minimal assessment, and at the hospital minimal report is given.

How much faster would the ED staff recognize they have a potentially septic patient on their hands and implement their sepsis protocol if the patient had a full paramedic work up, with lactate?

A lot quicker, especially if the paramedics did their jobs. Even by your language in your post, you realize that the medics are "turfing" the patients they should be caring for.

IMO, in a P/B system, the medic should be doing well over 3/4 of the calls. It is what it is. Would you want your mom turfed to the basic and not properly assessed?

 

[JakeEMTP]

How much faster would the ED staff recognize they have a potentially septic patient on their hands and implement their sepsis protocol if the patient had a full paramedic work up, with lactate?

Full Paramedic workup? More than what you normally do or an expanded lab set? Must be nice to have all the time in the world to do a bunch of labs and check all of the medical records. How long do you want to spend on scene? Next to fluids, the patient will need antibiotics which you can not provide.

 

[abckidsmom]

Full Paramedic workup? More than what you normally do or an expanded lab set? Must be nice to have all the time in the world to do a bunch of labs and check all of the medical records. How long do you want to spend on scene? Next to fluids, the patient will need antibiotics which you can not provide.

In my experience:

Full Basic workup: Name, age, complaint, associated symptoms, vitals, history, transport.

Full Paramedic workup: All of the above plus critical thinking based on physiology.

Just a thought. I don't do any more workup for my patients than my basic partners, but I apply the most underappreciated tool in the ambulance to every problem I approach: my brain.

 

[ah2388]

Full Paramedic workup? More than what you normally do or an expanded lab set? Must be nice to have all the time in the world to do a bunch of labs and check all of the medical records. How long do you want to spend on scene? Next to fluids, the patient will need antibiotics which you can not provide.

Why on earth would drawing labs pre-hospital, administering fluids, or obtaining a medical record(keeping in mind the information most patients have), prolong scene times? I would imagine that these devices, if useful, would be used primarily in rural or semi rural systems with medium to long transport times (20min+?)

Its obviously a concept that deserves continued exploration to see if there is benefit for prehospital providers to be performing this type of POC testing.

As others have said, the value of this device comes from early recognition, which may help to prevent the pt's who present as "stable" from being triaged and "sat on" in the emergency department in favor of other patients. I do not imagine the delay in care would be >90minutes, so the next question may become whether or not that delay is significant enough to justify the cost.

I may be misinterpreting, but it seems that some in this thread may be hesitant for change. I think the opposite must be come true in many ways if the current system model is to remain viable long term.

 

[JakeEMTP]

Why on earth would drawing labs pre-hospital, administering fluids, or obtaining a medical record(keeping in mind the information most patients have), prolong scene times? I would imagine that these devices, if useful, would be used primarily in rural or semi rural systems with medium to long transport times (20min+?)

Its obviously a concept that deserves continued exploration to see if there is benefit for prehospital providers to be performing this type of POC testing.

Obtaining a medical record or just a brief summary or face sheet doesn't always cut it.

How many cartridges are you going to carry with you POC machine? How will you store them? Will you have them ready for all 911 calls?

How will it change what you do to treat your patient? Will you be able to do blood cultures on the first stick and will the hospital trust them? Most prefer to draw their own cultures. What about all of the other cultures and lab work that goes with a sepsis diagnosis? Just one or two lab values are only a small part of the story. It is like a pulse ox SpO2. It is just one number and not really adequate to tell how the organs are perfusing.

Think about all of the factors involved.

Critical Thinking can be applied but to be effective you have the education to utilize the data you are gathering from all of the new gadgets. I think I already said this when another person wanted iSTATs on every EMS truck. What will it change?

Chances are if you are bringing a sick patient to an ER from a nursing home a long distance, the staff or even physician will have called in some lab values and a report to the ER.

Alot of places are trying to stop duplication of services which are costly and painful. It is not about more skills on your resume but whether you actually change how you can treat a patient. Doing stuff that will be repeated again and again in the hospital probably isn't the best idea. We already have protocols for BP and HR. If you can't give a more detailed description of your patient to get across the idea the patient is sick, more gadgets isn't going to do you any good.

 

[FLdoc2011]

The study in Denver did show a reduction in mortality. Hopefully someone here has access to the results and can post them.

In discussions with other people on this same topic, one of the things that has come up as been the negative impact EMS' impression of the patient has on the speed they are treated in the ED. Basically, EMS views the patients as BS and their report to the ED downplays how sick they potentially are. The ED is biased by this attitude, and thus the patients aren't deemed acute.

For example. I work in a paramedic/basic system. It is extremely common to be called to a nursing home by for grandma who isn't acting right or some other seemingly dumb reason. These calls are almost always turfed to the basic, who rarely asks very many questions of the nursing home staff. They are babysat on the way to the hospital with minimal assessment, and at the hospital minimal report is given.

How much faster would the ED staff recognize they have a potentially septic patient on their hands and implement their sepsis protocol if the patient had a full paramedic work up, with lactate?

Do you have details on that study? Depending on where it is I may have access to it.

 

[Aidey]

How many cartridges are you going to carry with you POC machine? How will you store them? Will you have them ready for all 911 calls?

For the record the Lactate Pro monitor is the most commonly used one. It is ~$400* and as hard to use as a glucometer. Athletes have used them for years for training purposes. It is much more like a glucometer than an I-Stat.




*This is the price we were quoted when we looked into them.

 

[FLdoc2011]

I'd have to look into some of these studies to see exactly how they're implementing this, but I just don't see where it's needed, at least for now.

If it's anything like our POC machines, it's going to take probably close to 10min for a result. Transport times vary sure, but 10min into a transport you get back a lactate of 5, what does that change? Hopefully by that point you're thinking sepsis anyway and have fluids or something going.

The only reason I could see right now is in specific areas (rural or not) where this is specifically a major issue where certain hospitals don't have the resources or would have to transfer the patient out. I don't work in an area like that so I can't comment on that, but I would think those would be very limited circumstances that may find a use for specific prehospital diagnostics such as this.... but certainly not for the majority of markets.

 

[Aidey]

The Lactate Pro 1 takes 1 minute, and the Lactate Pro 2 (which isn't yet available in the US) takes 15 seconds. Here is the website for the manufacturer. http://www.fact-canada.com/LactatePro/lactate-pro-portable-analyzer.html

Unfortunately I don't have the information on the study. There are a few people from CO here, hopefully they will.

 

[NYMedic828]

I don't have anywhere near the experience you folks do only being a medic for a year but here in NYC we usually just notify the hospital ahead of time if we are bringing a more sickly patient in.

Usually give a notification for hypovelemic shock if the signs and symptoms are present but never call it sepsis via radio or paperwork. Can assume its sepsis, can tell the hospital what you think but you can't justify that rule-out in the field.

We get an IV, maybe two, give fluids and drive.

I like having more toys as much as the next guy, but is it really necessary or should we be focusing on improving upon what we already have first.