There’s an interesting video that has been making the rounds on the Internet that provides a first hand account of what it’s like to suffer from carbon monoxide poisoning. The backstory is that the driver (patient) is a recreational racer who is driving a mid-engine vehicle. His car has a carbon monoxide leak which is filling up the passenger compartment with the products of combustion (CO and soot among others). He has conveniently been videotaping his race. Over time, you can start to see his level of confusion increase and his coordination become delayed. He starts to exhibit rambling speech. Additionally, you can see the buildup of soot on the glass of his roof. Important to note is that for a large portion of time after he claims not to remember, he still appears conscious. Check out the video for yourself:
If you read through the comments on YouTube (something I try not to do often) you’ll see that there is a lot of criticism reserved for the response crew. While that may be a valid conversation to have I think it’s more important to focus on the driver’s presentation. Most recreational racing leagues use volunteers (some with little or no training) to work as safety staff. Many of these leagues also discourage doing damage to drivers’ vehicles (like breaking out a window). Cut them a little slack.
Have you ever run a CO poisoning call? How did the patient present? What was their outcome?
As we talked about last week, the Glasgow Coma Scale is a useful assessment and triage tool in patients presenting with illness and injury. An article in the Emergency Medicine Journal looks at the ability of Australian paramedic students to correctly determine the GCS of several patients on a video test.
Here’s the abstract from PubMed:
Emerg Med J. 2012 Apr 13. [Epub ahead of print]
Should an alternative to the Glasgow Coma Scale be taught to paramedic students?
Winship C, Williams B, Boyle MJ.
Monash University, Department of Community Emergency Health and Paramedic Practice, Victoria, Australia.
Background The accurate assessment of a patient’s conscious state using the Glasgow Coma Scale (GCS) is an important skill for paramedics as it may determine the patient’s initial and ongoing management. The objective of this study was to determine if undergraduate paramedic students from a large Australian University were able to accurately interpret a variety of conscious states.
Methods A prospective double-blinded observational pilot study requiring students to interpret the conscious state of four adult patients using the GCS by viewing a simulation DVD package.
Results There were 137 students who participated in the study, of whom 65% (n=87) were female students. The results demonstrated that undergraduate paramedic students were unable to accurately interpret a number of patient conscious states with only 20% and 37% of students able to accurately identify the GCS of patients 2 (GCS=12) and 3 (GCS=7). The motor component of the GCS appeared to be the component where the least accurate interpretation occurred, with only 47% of students being able to accurately identify the criteria that patient 3 displayed. Participants were however able to accurately interpret the GCS of both patient 1 (GCS=14) (86%) and patient 4 (GCS=15) (92%).
Conclusion This pilot study demonstrates that undergraduate paramedic students from an Australian university were unable to accurately interpret a patient’s conscious state if their GCS score was <14. These findings have provided academic staff with important information for considering alternative teaching and learning strategies and approaches in conscious state assessment in current paramedic curricula.
Obviously there are some short falls in the performance of the students. I find it interesting, however, that the title of the article discusses finding an alternative to GCS. For better or worse, the Glasgow Coma Scale is a standard measurement. If the students aren’t able to utilize it properly, perhaps a different method of teaching is warranted. If an entirely different assessment technique is taught, those students would just have to learn GCS after getting into the field.
What do you think?
I’ve written before about the CDC Field Triage criteria. There has been a lot of talk since the guidelines were released about whether mechanism of injury is a worthy criteria to use when deciding about whether to trauma activate a patient or not. Though mechanism is questioned, the physiologic criteria are generally accepted as effective criteria. The question is: how effective are they? Is a patient meeting those criteria more likely to die and therefore may have a benefit from going to a trauma center? A study published in Prehospital Emergency Care looks to answer that question for traumatic brain injury (TBI) patients.
Let’s look at the abstract from PubMed:
Prehosp Emerg Care. 2012 May 1. [Epub ahead of print]
A Review of Traumatic Brain Injury Trauma Center Visits Meeting Physiologic Criteria from the American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines.
Pearson WS, Ovalle F Jr, Faul M, Sasser SM.
From the Division of Injury Response, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (WSP, FO, MF, SMS) , Atlanta , Georgia ; Vanderbilt University School of Medicine (FO) , Nashville , Tennessee ; and the Department of Emergency Medicine, Emory University (SMS) , Atlanta , Georgia .
Background. Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient.
Objectives. This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population.
Methods. The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling.
Results. The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7-28.3). Other physiologic criteria also demonstrated significant odds of death.
Conclusions. These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.
Well would look at that? Physiologic changes, particularly those measured by GCS are linked to increased mortality. I suppose we did know that, but think about the flip side. This means that a patient with a GCS of 14 or 15 is 17 times less likely to die than a patient with a GCS of 13 or less. Maybe we can consider a basic ED for those patients or transporting them without lights and sirens.
What do you think? Does your system use the CDC criteria? What do you do with patients that don’t meet physiologic or anatomic criteria but might meet mechanism criteria? Let me know in the comments.
Image via Flickr
The medical community has a love-hate relationship with the Broselow tape. If you ask five providers, regardless of level of training, how accurate the device is, you are bound to get six answers. The most recent report of the accuracy (or not) of the Broselow tape in estimating the weight of pediatric patients was e-published this month in the journal Prehospital Emergency Care. Check out the abstract below:
Prehosp Emerg Care. 2012 Mar 23. [Epub ahead of print]
Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting.
Heyming T, Bosson N, Kurobe A, Kaji AH, Gausche-Hill M.
From the Department of Emergency Medicine, Harbor-UCLA Medical Center (TH, NB, AHK, MG-H) , Torrance , California ; St. Joseph’s Medical Center (TH) , Orange , California ; Los Angeles Biomedical Research Institute at Harbor-UCLA (TH, NB, AK, AHK) , Torrance , California ; Department of Medicine, David Geffen School of Medicine at UCLA (NB, AHK) , Los Angeles , California ; and University of California Irvine (AK) , Irvine , California .
Background: The Broselow tape is widely used to rapidly estimate weight and facilitate proper medication dosing in pediatric patients.
Objective: We aimed to determine the accuracy of prehospital use of the Broselow tape.
Methods: We prospectively enrolled a consecutive sample of pediatric patients transported to the emergency department (ED) at Harbor-UCLA Medical Center from February 2008 to January 2009. Eligible subjects arrived via ambulance and were less than 145 cm tall, the upper limit of height for Broselow measurements. Subjects were excluded if they had a medical condition preventing proper measurement (e.g., contractures). Per Los Angeles County protocol, paramedics obtained a Broselow weight on all pediatric patients. The paramedic Broselow weight was compared with the ED Broselow weight and the ED scale weight, which was obtained unless mobilization was contraindicated. Accuracy was determined by assessing Bland-Altman plots and the Pearson correlation coefficient. As part of a sensitivity analysis, multiple imputation was used to account for missing data.
Results: There were 572 subjects enrolled. The median age was 24 months (interquartile range [IQR] 10 to 49 months); 316 (55%) of the subjects were male. The weighted Cohen’s kappa assessing agreement between the paramedic and ED Broselow colors was 0.74 (95% confidence interval [CI] 0.68 to 0.79). The median difference between the paramedic Broselow weight and the scale weight was -0.10 kg (IQR -1.7 to 0.7). The accuracy of the paramedic Broselow weight when compared with the ED scale weight and the ED Broselow weight as defined by Pearson’s correlation coefficient was 0.92 (95% CI 0.90 to 0.93) and 0.97 (95% CI 0.97 to 0.98), respectively. Multiple imputation for missing data did not alter the results.
Conclusion: Paramedic Broselow weight correlates well with scale weight and ED Broselow weight. Paramedics can use the Broselow tape to accurately determine weight for pediatric patients in the prehospital setting.
This appears to be a fairly well designed study. Comparing paramedic Broselow weights to those obtained both from the hospital scale and the hospital Broselow allows both the technique used by the prehospital providers as well as the accuracy of the tape itself to be analyzed.
Do you routinely use the Broselow in your practice? Do you have a different technique for estimating the weight of pediatric patients? Any tips or tricks? Let me know in the comments.
Image via Flickr
You are dispatched Code 2 (no lights and sirens) to a report an elderly female who fell on the steps of the library. It rained recently and has been cold out. There have been several slip-and-falls responded to around the city this morning.
As you pull up on scene, you find that your patient is still leaning up against the steps and has been covered with a blanket by a bystander. The patient tracks you visually when you walk up and appears to be in obvious pain. Witnesses report that the patient was walking down the ice-covered steps and fell. Both the patient and bystanders state that she did not have a loss of consciousness nor did she strike her head.
As you begin to assess the patient, she reports that she only has pain to her right knee. She denies feeling dizzy or weak before the fall. She has a history of hypertension and is currently taking Atenolol. She reports an allergy to aspirin. Enlisting the help of bystanders, you move the patient to the gurney and into the ambulance out of the cold. You now have an opportunity to directly visualize her knee:
There is obvious deformity to the knee joint and swelling to the back of the knee. The patient has good circulation, sensory and motor distal to the injury site. She is in significant pain.
What are your potential differential diagnoses? What is your treatment? What hospital services do you anticipate that she will need? Anything else?
Image via MedScape
Chances are, the system you work in has a list of trauma criteria. Patients meeting such criteria are transported to specific trauma hospitals where advanced services are available. Some systems present their trauma criteria as guidelines while others are set in stone. Some systems mandate that certain criteria be activated while others are left to the discretion of the paramedics. The real question is: do these criteria even work?
Before answering that question, we need to decide what makes up an effective trauma triage system. In my opinion, an effective trauma system doesn’t miss severe life-threatening injuries and exhibits a minimum level of over-triage.
Why not just activate every trauma patient regardless of severity? A more thorough assessment is better right?
Yes and no. Well, actually no. Thorough assessment is good, unnecessary assessment isn’t. Think about what happens when you bring in a trauma patient. Depending on the hospital there are up to 15 or so people in the room or immediately on stand-by. This includes physicians, nurses, lab technicians, radiology technicians, respiratory therapists, social workers (my favorite!) and many more. When dedicated to your patient, at least initially, they are unavailable to respond to another patient.
Now think about what happens to your patient: labs, x-rays, CT scans and countless other diagnostics. Each time a vein is punctured, there is a risk of infection. Every x-ray and CT scan involves exposing your patient to radiation which has additive effects over time. In the end, a trauma system should be judged both on catching serious injuries and not activating patients unnecessarily.
Imagine my pleasure at reading the following excerpt from an Australian study published last year in Injury:
Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.
Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.
Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.
Strategy & Planning Department, Ambulance Victoria, Australia. Shelley.Cox@ambulance.vic.gov.au
BACKGROUND: There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines (‘potential major trauma’) with trauma patients who are identified as ‘confirmed major trauma patients’ at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.
METHODS: For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as ‘confirmed major trauma patients’ and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the ‘potential major trauma’ group. Non-major trauma patients (N=27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.
RESULTS: The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.
CONCLUSIONS: While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.
There are a few reasons I like this study, not the least of which is that the following ad campaign came out of Australia:
But I digress. Basically, I think this study takes a pretty realistic look at what works and what doesn’t in their system. According to the study authors, their triage criteria (and associated paramedic discretion) catch about 80% of confirmed traumas. This is respectable sensitivity (ability to identify positive results). The authors admit, however, that strict adherence to triage criteria would result in unacceptably high over-triage.
With no evidence to back this up, my gut reaction is that most trauma systems suffer from similar over triage, or at least the potential for over triage.
What about your system? Have you done anything to reduce the amount of over triage for trauma patients? Are the study authors totally off base? Let me know in the comments.