Accuracy of Paramedic Broselow Tape Use

Posted by Patrick Lickiss on Apr 12, 2012 in Assessment, General, Research | 4 comments

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.

Source

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.

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Differential Diagnosis: 62 year old Female – Fall

Posted by Patrick Lickiss on Mar 29, 2012 in Assessment, General, Treatment | 1 comment

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:

Yes, I know it's a picture of a man's 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?

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Are Prehospital Trauma Triage Criteria Effective?

Posted by Patrick Lickiss on Feb 8, 2012 in Assessment, General, Research, Treatment | 0 comments

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.

Pediatric Assessment Tips

Posted by Patrick Lickiss on Jan 18, 2012 in Assessment, General | 2 comments

Having a one year old at home has done more for my pediatric assessment skills than any class I could have ever taken. Pediatric patients have some very subtle changes and behaviors that can be easily over-looked. Given that kids can maintain for quite some time before deteriorating very quickly, it is important to learn to read the cues they give off. Over at Everyday EMS Tips, Greg has a great guide for comparing pediatric findings to what is “normal’ for the patient. Go take a look!

Upcoming Randomized Trial of Assessment and Referral by Paramedics

Posted by Patrick Lickiss on Aug 17, 2011 in Assessment, EMS 2.0, General, Research, Treatment | 2 comments

By far, one of the possibilities for the future of EMS which excites me the most is generally characterized as “community paramedicine”.  The idea that paramedics will be placed in a position to treat and release and treat and refer in the field, diverting patients from the local emergency rooms is an exciting one to be sure.  The first step in rolling out a system like that, however, is determining whether or not paramedics can safely determine which patients don’t actually need an ambulance transport.  Published recently in BMC Emergency Medicine (PDF link) was the study protocol for just such an experiment in Perth, Western Australia ^[1].

INCLUSION/EXCLUSION CRITERIA
Patients will be considered for the trial if they are suffering from the following conditions:

• Isolated minor injury
• Simple infection
• Hardware problem (like issues with a urinary catheter)

The exclusion criteria are:

• Younger than 16
• Third trimester pregnancy
• Not in the patient’s residence
• Residence is unsafe
• GCS < 15
• SpO2 < 95% on room air
• Heart rate > 100
• Systolic BP < 100
• Pain requiring narcotics
• Patient unable to wait four hours for further treatment

STUDY DESIGN
For patients meeting the eligibility criteria, the paramedics will call in, provide enrollment information and be told if the patient is randomized into the control arm (transport by ambulance to the ED) or the intervention arm (referral to the in-home hospital service).  Within four hours, a home hospital service nurse or nurse practitioner will respond to the patient’s residence for evaluation and treatment.  The patient might be treated and then released from the service, enrolled into ongoing care or referred to the ED.  As a side note for US readers, check out the website for Silver Chain, the home hospital service.  This is an amazing concept.

OUTCOMES
The primary outcome focus of the researchers is the proportion of patients needing unplanned medical care within 48 hours of enrollment.  The secondary outcome focuses include a variety of clinical, operational and investigatory measures.  Additionally, cost benefit and patient satisfaction data will be collected and analyzed.

ESTIMATED OUTCOMES
With an annual transport volume of approximately 100,000, researchers estimate that they can enroll roughly 10% of their total patient base in the study.  With a goal of 940 patients in both the control and intervention arms, it is estimated that patient enrollment will be completed within a year.

DISCUSSION
As I mentioned earlier, this is a truly exciting possibility.  If paramedics can be shown to safely determine whether or not a patient can be treated at home, it opens the door to diverting at least a portion of patients from overwhelmed Emergency Departments.  As the researchers note, there have been mixed messages in the literature about the ability of paramedics to safely evaluate patients for non-transport.  This study seems well designed and isn’t biting off too much at once.  By focusing on one piece at a time, the researchers appear to be approaching this type of program the right way.  I’ll keep an eye out for the completed study and will let you know the results when it is published, likely next year.

CITED ARTICLES
[1]- Arendts G, et al.: “ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home”. BMC Emergency Medicine 2011; 11:7.

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Why Should You Care About Your Patients?

Posted by Patrick Lickiss on Aug 3, 2011 in Assessment, General, Research | 0 comments

Do you care about your patients or do you approach them like an auto mechanic would a malfunctioning car?  It’s an important distinction that sometimes gets lost in the shuffle of what we do day in and day out.  A call which is routine for a skilled practitioner may be anything but routine for a frightened patient.  About a year ago, I wrote about the importance of actually listening to your patients when you ask a question.  This idea of caring falls along the same lines.

I recently came across an abstract which looked at the benefits of a “caring” assessment in an ambulance service in Sweden ^[1].  According to the researchers, one of the major findings was that understanding of the patient’s “lifeworld” was vital for a complete evaluation of the patient’s condition.  What the heck is a lifeworld?  It sounds pretty new age if you ask me.

According to Webster’s dictionary, lifeworld is “the sum total of physical surroundings and everyday experiences that make up an individual’s world”. Well that makes a little more sense.  Basically, it’s the recognition that each patient has a series of experiences which alter their perception of the situation they find themselves in.  What are the chances that “lifeworld” could impact a patient’s disease process and the medical care best suited for them?  Probably pretty good.

In fact, the researchers found that a “medical only” assessment presented an “obstacle to a full understanding of the individual, and thereby the illness per se”. ^[1] The likelihood is that you perform this “caring assessment” on a regular basis.  Think about a patient complaining of chest pain and shortness of breath.  Is your top differential diagnosis cardiac?  At the very least it should be a “must not miss” diagnosis.  Now a good practitioner would start asking the patient about when the symptoms started.  If you find out that the patient just lost her husband to a long battle with cancer and that their wedding anniversary is today, does that change your differential diagnosis?  Probably.  My hope is that all of you actually take the patient’s “lifeworld” into account when building a differential and determining treatment.  Remember to actually listen to your patient’s narrative, you can learn a lot.

In the end, the abstract for this article doesn’t include any numerical results and doesn’t quantify why one assessment is better than another.  While that would have been nice, I don’t know that it’s really necessary.  A lot of this is just common sense.  If you ask the patient about their situation and listen to the answers in a caring manner, you’re more likely to get the whole story.  If you get the whole story, you’re more likely to make the right treatment decision and the patient is more likely to feel like their suffering was reduced.  They feel this way not because you treated their symptoms, but because you connected with them and took the time to listen and understand them.  It may take a little more effort, but I think it’s worthwhile.

CITED ARTICLES
[1] - Wireklint, SB & Dahlberg, K: “Caring assessment in the Swedish ambulance service relieves suffering and enables safe decisions”. International Emergency Nursing 2011 July; 19(3): 113-9.

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