:+: Street EMS :+:

[pfmedic]

Last November, one of my instructors came into my basic class and spent five minutes digressing into what he referred to as "Street EMS." Stuff that the book doesn’t teach but can help expedite the process of on-scene treatment through common sense and improvisation. For example:

A strong palpable distal pulse on scene indicates a systolic BP of at least 90mmhg. A weak pulse would indicate a systolic BP of at least 80mmhg. So in your documentation upon arriving on scene and finding a weak radial you would write:

+ Radials >80

A different example using improvisational skills and experience, my other teacher said:

When a combatant patient needs to be strapped down, you should use a cravat to tie one arm over the head and the other at the waist. Separating the arms reduces the pt's ability to force themselves free by 50%.

My suggestion is to use this post to share experiences and tricks of the trade with regard to "Street EMS". Something that the books do not teach that you feel everyone should know as it has been quite useful to you.

Thanks.

-pf

 

[Jon]

Great idea, PF, but a comment or 2 on your facts:

...A strong palpable distal pulse on scene indicates a systolic BP of at least 90mmhg. A weak pulse would indicate a systolic BP of at least 80mmhg...

I've been told between 60-70 mmhg for a radial pulse. 80/90 is too high in my opinion.

...When a combatant patient needs to be strapped down, you should use a cravat to tie one arm over the head and the other at the waist. Separating the arms reduces the pt's ability to force themselves free by 50%...

I've heard both sides of the argument. The other reason I've heard for 1 arm up and 1 down is that it makes it impossible to "fiddle with" the restraits with the other hand.


Also: If you strap the patient to the cot frame and then lift the head slightly, it puts more tension on the restraints, and can be adjusted if needed.

 

[Wingnut]

We went over "street" EMS in my class and were told never ever EVER use it. It's not reliable and we have more resources now where some of the old tricks are no longer necessary and actually could do more harm than help.

As far as restraints...maybe I could see how that might be true, but we're given freedom on how to restrain except we cannot under any circumstances restrain a pt on thier belly.

 

[ffemt8978]

I've been told two sets of numbers for the pulse location to BP:

Radial - 90 or 80
Femoral - 80 or 70
Carotid - 70 or 60

 

[coloradoemt]

Here is one my Dad taught me. Probably more of a use for this in rural EMS, but ya never know... B) This can work in place of a scoop stretcher and if you have the time. I have used it with an entrapped pt on an extended extrication.

Major trauma pt, my dad used a man who had been caught in the PTO shaft on a tractor, and you need to move them, but they are so messed up moving them is iffy. Take a regular sheet and bunch it up lengthwise behind the pts head. In theory it kinda looks like Z's one behind the other. Then with someone on each side of the pt take the leading edge of the sheet and one side pulls one way and slightly under the pt, then the other way, back and forth until completely under the pt. With extra hands once you are ready to move to a board the pt is in a sling and can be lifted quite efficiently. Believe me when I say you can do this with very very minimal movement of the pt.

 

[natrab]

That radial pulse thing is very subjective. Every patient is so different. I've been told it's 90/80/60 as well for radial, brachial and corotid, but I've palpated BPs of 60 on an old lady using her radial many a times. I don't trust it.

And the thing about putting one hand up over their head is that they can contort and bite it. I've seen a patient actually chew throw a soft restraint. We have long straps on our restraints so I can tied their hands to their side and the other end to the foot of the gurney where there's no chance of them untieing it. I tuck their arms unde the rails and if I have to I tape them there to minimize movement. The chest seatbelt seals the deal so they can't slide down.

 

[GaEMT]

Use a KED upside down to stabilize a hip fracture

 

[Jon]

Radial pulse - I've heard 60+ Systolic for radial pulse, 30-40 systolic for carotid / femoral

 

[Bartman]

We went over "street" EMS in my class and were told never ever EVER use it.

"Street EMS" should really be called "Experience EMS"

It does have its place-

But- continue to be careful, critical, and always keep the patient's best interest in mind.

 

[pfmedic]

a little test perhaps

Use a KED upside down to stabilize a hip fracture

I have heard this before. Anyone else heard of or use this method? I would be intersteted in seeing a picture of this in action. Especially since I dont like using PASG so much.


The sheet lift method sounds great! I can think of a host of uses already for that little trick.


As far as the radial/BP relationship, it would seem that a test would be in order. I will take it upon myself to start to compile age, sex, weight, BP and radial presence of the people whom I run and see how they compare by the end of the summer.... if a few others try this then Im sure we can put this puppy to bed. I have alot of blue hairs in my district so I should come across a hypotensive pt at least 3 times a month.

There will always be variations with this method, I can tell already. Nothing takes place of a good old fashioned BP. I would imagine however, that this would be very useful at MCI's of mammoth proportions where time is a precious commodity.

 

[rural_emtp]

Ill or injured patients look that way.
Listen to the throat to determine if a patient is breathing at all. Helpful in seizures.
Don't waste time on a scene where you and your partner are the only ones who speak English.
Treat the patient, not the equipment.
Act like help. This is what the caller expects.
Drive and behave safely. This is someone else's emergency.
You have only one back. Lift safely.
You need the fire department worse than it needs you.
You and your partner are the only ones concerned about your safety.
Always go toward the hospital.
If you need help, call for it.
Be polite. You never know who is standing behind you.
Patient assessment is your most important skill.
You will never know what is going on at a scene until you get there.
Be flexible, but be decisive.

 

[Stevo]

as to vitals ....

I've been first on scene (before the rig) where there have been multiple heavy trauma patients i know where going to be moved quickly....

so when i did vitals i wrote them on the patient

now i know this seems a rather unrefined approach, but given that most criticals move faster than the pertinent info follows , especially when the continuity runs first response>>>bls>>>als>>>e.r. i felt it the thing to do at the time

~S~

 

[Luno]

Pulse locations = pressure

This has been disproven, I'll try and dig up the article, but the only thing substantive about them is "usually" you will lose the radial before the femoral, and the femoral before the carotid.

 

[joemt]

Ok, here's my 2 cents...

Penny #1: I NEVER teach my students what we call "Real World" (Street) EMS while they are in the EMT-B program... why? Because the Registry doesn't test you on "Real World" stuff, they test you on DOT Curriculum from the book.. oh, and there's another reason... some of the "Real World" EMS tricks are shady to say the least...

Penny #2: You can use a KED as a "spine board" for a pediatric patient. Works pretty good actually.

 

[BrandoEMT]

Regarding the use of "never ever" I would have to disagree. Never say never in EMS. Some stuff works in certain situations, there will be times when somethings work better than others. Especially if you teach any form of EMS don't use the word, "never" they will find ways to make you look like an idiot.

B

 

[Maciek999]

Check this one...
Accuracy of the ACLS guidelines for predicting systolic blood pressure using carotid, femoral and radial pulses: observational study. (Deakin & Low, BMJ 2000)
Intro:
ACLS:
presence of carotid pulse SBP 60-70mm Hg
presence of carotid & fem pulse SBP 70-80mm Hg
presence of radial pulses SBP > 80mm Hg
Methods:
Studied sequential pts with hypovolemic shock who had invasive BP monitoring.
Observer blinded to BP reading established the absence or presence of pulses.
Conclusions:
ACLS guidelines overestimate the actual BP of pts with hypovolemic shock by palpation of pulses.
Not reported how pts were resuscitated prior to study, also some were under GA  influence on pulses?

1st group: 3 pulses present
2nd group: Cartoid and femoral pulses present
3rd group: Cartoid pulse only
4th group: No pulses palpable

 

[Luno]

Yep

that was what I was looking for... thanks -luke

 

[Ridryder911]

I will have to locate it .. but there are 2 studies showing, estimating blood pressure by pulse perfusion is a fallacy. That it cannot be accurately determined. I know they are considering removing the discussion for ATLS altogether.

R/r 911