Is it really practical to be identifying such subtle changes in many prehospital environments (actual question, not rhetorical)? I get that its our job to be turning chaos into order to a degree, but there is a limit. You take a major trauma pt. Blunt pelvic, abdominal and chest trauma. They're proper sick but you don't quite have all the hands or space your need. You're pouring morphine into them but you're still not quite on top of their pain yet. They're moving about a lot. Screaming/talking/moaning. You feel like you're on top of most of the picture. They weren't obviously tensioning when you started but they've had a bit of fluid because you've been chasing some some ?pelvic trauma related haemodynamic instability, and they're still a bit dicey in that way. Their O2 sats drop a bit but you have to trouble shoot some pleth waveform issues on top of everything else. At some stage you have to move or are already moving down a bumpy road, rocking and rolling around in the back. I'm completely open to the idea that I might be wrong and that I should be managing my time better or something, but I just can't see a lot subtly happening in that environment, with the exception of some special situations.
Medical answer: it depends.
If you have a seriously crashing patient that is the focus of all of your efforts, taking time to measure for tracheal deviation is on my list at about the same priority level as what I plan to do for lunch after the call. (actually slightly lower)
I also wouldn't be too concerned with tracheal deviation when transport time is only a few minutes. But when you start to get in the 45+ minute range, I don't like surprises.
But, when your scenario changes to being soley responsible for airway and breathing, then using clinical skills to anticipate and prepare for ongoing complications is certainly indicated. Especially if all you are doing is squeezing the bag. If you are tasked with managing an airway, you should do it 100%.
Not all pneumos present in multitrauma and even when they do, they most often appear over time, not on initial patient contact. Perhaps the population I have seen the most pneumos in during street time is people who were assaulted with fists and feet. So when you are evaluating a person who looks hemodynamically stable and you are deciding if you are going to turf him to a lower level of care or leave him onscene to his own devices, a little bit of clinical accumen may go a long way.
In major incidents, it is a tool of retriage and reassesment in anticipating your future transport and resource needs.
In austere conditions, I think the ability to function without dependancy on technological resources is absolutely a must.
Personally, I am a reformed sinner, when I was being taught these "primitive" techniques, I was quick to complain and point out all the modern wonders of technology.
But having worked in disasters, with indigent populations who could not afford such technology, and in austere conditions, I am more than sold on the need to have these "archaic" skills.
I have adopted the philosophy of a few of my teachers that anyone can use technology, but knowing what to do when you don't have it and being able to apply that knowledge is really what seperates the men from the boys.
Technology should amplify ability, not replace it.
(But I would still be grateful if anyone would buy me one of those pocket sized ultrasounds for whatever holiday or occasion strikes you)
Yeah but the 'lowest common denominator' argument come in here. If you are captain of the good ship clinical practice guideline and you're sitting in the captain's chair one day thinking, "I've a ship's company of almost 3000. Some of them are barely capable of keeping their drool in the mouth. How do I go about proticolizing the sticking of large, sharp pieces of metal into an already profoundly sick person's chest?" Then the answer is probably, "when its painfully obvious that its needed".
When it comes to trauma, I think EMS providers are not responsible for a majority of blame from lack of knowledge or ability.
Trauma is an extremely broad and complicated medical topic. Rather than spend the time this topic deserves most providers (including non EMS trauma providers) are often given some very basic procedures to follow rather than have them start weighing decisions.
US EMS, not only because of educational time components, but because of the system philopsophy, really gets short changed to basically "just drive." They also face the complication of not having dedicated rotation time at a major trauma facility.
So they are basically set up to fail. If you don't regularly see major trauma, even minor stuff looks very severe to you. It is set up for the error of overtreatment.
As far as I recall, in the US, paramedics are expected to diagnose and treat tention pneumo. Implying there is already tension present.
They are not expected to decompress simple pneumo because if it is not major, (usually accepted as greater than 16%) watchful waiting to see if it self limits is a valid treatment. It doesn't automatically equate to a chest tube.
Of course when a chest tube is required, its utility is undisputed.
h34r:
