One of the measurements that many EMS systems use to determine if they are “doing it right” is their survival rate for cardiac arrest patients. These numbers are broken down in many different ways but the accepted “standard” seems to be witnessed arrest with a shockable rhythm (ventricular fibrillation or ventricular tachycardia). In other words, the patients with the best possible chance at survival.
One of my current tasks in my system is entering all of our data into the CARES registry so that our patients can be matched with their hospital outcome and our system performance can be tracked for cardiac arrests. Typical of most quality improvement projects, part of this one involves figuring out how to do what we do better.
Over at MedicSBK, there’s a post entitled “Doing it Better” that looks at precisely this idea. In this post, Scott contrasts his system with that of Wake County in North Carolina. I have been lucky enough to hear Brett Myers speak about cardiac arrest care and the approach that his system takes is revolutionary and it works. By performing CPR only on scene and packaging a patient for transport only after sustained return of circulation, they are locking their crews into focusing on high quality chest compressions. This, along with defibrillation, is the only treatment that has been PROVEN to help cardiac arrest victims. I say good for them!
I recently began analyzing the quality of compressions that our crews perform in conjunction with our first response agencies. A quick Twitter poll leads me to believe that many EMS systems are not performing detailed analysis of this important component of care. Our findings have mirrored Dr. Myers views on when and where to treat these patients: despite the best efforts of everyone involved, CPR quality suffers during transport and lengthy pauses in CPR are not uncommon. The conclusion? We should not be transporting under CPR! Treat these patient where they drop.
I’m lucky in that my crews have the latitude to remain on scene during resuscitation. We transport very few of our cardiac arrest patients and usually only after regaining pulses. Thanks to Scott for bringing this up about his system. I hope that we can all move towards treatment algorithms that closely mimic Wake County and that allow us to provide optimal care in the optimal setting.
What about your system? Do you routinely transport during CPR? Do you wait for a certain length of ROSC before transporting? Let me know in the comments.
Unfortunately no, but this story had me going. Turns out that EMS agencies in Portland, Oregon are going to be studying “whether cardiac arrest drugs help or hinder”. That headline gave me hope that we were finally studying if all the ACLS drugs benefited or harmed patients when looking at neurological outcomes. Turns out we’re not. We’re studying whether Amiodarone, Lidocaine, or a placebo results in better outcomes. Now don’t get me wrong, this is a step in the right direction. Now that being said, the article references the fact that research has already shown Amiodarone to be no more effective than a placebo. But, if memory serves, that study looked at ROSC, not neurologically intact outcome. That being the case, this study IS moving in the right direction.
My question remains, however, why can’t we do the same study with epinephrine? On the face of it, this study protocol appears to be one which could be easily transferred to epinephrine. Using syringes marked only with a barcode so that researcher can later link a certain medication or a placebo to a given patient. When I started reading the article comments, however, I realized why we can’t study epinephrine. We haven’t bothered to teach the public. Heck, we haven’t even bothered to teach the medical community. Many of the comments, including some from those who identified as medical professionals, launched into tirades about lawsuits resulting from withholding “standard care”. The fact is, as long as people (both those in the public and the medical community) assume that our “standard” treatments are based on facts, our hands will be tied. This dedication to tradition for tradition’s sake may be killing our patients.
We are forced to follow outdated modes of treatment because we haven’t taken the time to educate our own communities about what those treatments are based on. While there will always be a subset of the population unwilling to participate is these types of programs, aggressive public (and medical) education campaigns may help to mitigate some of those issues. Researchers are offering the public free “No Study” bracelets if they want to opt out. It will be interesting to see, when all things are said and done, how many took them up on that offer and if they have trouble getting an acceptable sample size.
What do you think? What would be the most effective design for a study looking at the benefit or harm of ACLS drugs? Should patients or family have to consent for this type of study? How can we effectively educate the public about why and how we treat them? Do you work for one of the agencies in this study? Let me know in the comments.
EMS seems to have a “technological imperative” when it comes to our allotted “monkey skills”. The day they put a new toy on your rig is the day you suddenly find a need for it. Venous access is no exception. Now granted, starting IVs is not a new addition to the EMS scope of practice, we’ve been doing that for years. And the ability to start them isn’t the only driving factor. Crews that I’ve spoken to often reference the appreciation of the hospital staff for starting an IV. Other crews reference complaints by the hospital staff that an IV wasn’t started. Call it a healthy mix of availability and peer pressure.
In a 2011 article published in the Journal of Vascular Access (did you know there was one of those?) authors review a cohort of patients transported to a single emergency room and evaluate whether IVs were actually used after they were placed. Here’s the abstract:
J Vasc Access. 2011 Jul-Sep;12(3):193-9. doi: 10.5301/JVA.2010.5967.
Indication and usage of peripheral venous catheters inserted in adult patients during emergency care.
Göransson KE, Johansson E.
Department of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden. firstname.lastname@example.org
PURPOSE: The aim of this study was to identify the underlying decisions taken regarding the insertion of prehospital peripheral venous catheters in adult patients and, additionally, to ascertain peripheral venous catheter insertion rate and explore prehospital and hospital (within 24 hours of insertion) pharmaceutical treatment via peripheral venous catheters.
METHOD: This cross-sectional study gathered data through a study-specific questionnaire and patient record auditing. We distributed a study-specific questionnaire to be completed by ambulance crews, and carried out patient record auditing for 345 patients (median age 64 years, range 18-97 years) arriving at the emergency department at a Swedish level-1 trauma center in October 2008.
RESULTS: Of 135 patients (39%) arriving at the emergency department with a peripheral venous catheter, 94 (70%) had received the device because the ambulance crews intended to use it for intravenous therapeutics (of which analgesics, intravenous fluids, and psycholeptics were most frequently used). In 30 patients (22%), the prehospital inserted device was not used by the ambulance crews or at hospital within 24 hours. The corresponding rate of unused peripheral venous catheters inserted in patients after arrival at the hospital was 35%.
CONCLUSIONS: We found that the main reason for the ambulance staff to insert a peripheral venous catheter in a prehospital setting was that they intended to use the device. Further, the rate of unused peripheral venous catheters was lower among prehospital peripheral venous catheters than hospital.
The results pretty well speak for themselves. It should be noted that this analysis only took place at one hospital. I also know that compared to my system, 39% of patients receiving an IV is relatively low. The important thing to remember is that an IV is an invasive procedure. Simply starting one because you can or because “someone might use it later” may not be the best thing for your patient. Every IV increases the risk for healthcare-acquired infections.
What about you? Do you routinely start prophylactic IVs? Why or why not? Let me know in the comments.
There is a huge body of evidence that therapeutic hypothermia can improve neurological outcomes in the post-cardiac arrest patient. The questions becomes, how best to cool that patient? Options in the EMS systems I’ve worked in have ranged from ice packs in the groin and axillae to helicopter transport with chilled normal saline and micro-fiber cooling blankets and everything in between. Most ambulances do not have refrigerators or freezers so keeping chilled saline around is difficult…or is it?
In an article published in the American Journal of Emergency Medicine, authors tested the ability to maintain chilled saline with coolers and ice packs. Here’s the abstract:
Am J Emerg Med. 2012 Jan 2. [Epub ahead of print]
A simple method of maintaining chilled saline in the prehospital setting.
Isenberg DL, Pasirstein MJ.
Department of Emergency Medicine, Mercy Catholic Medical Center, Philadelphia PA 19143.
OBJECTIVE: Mild therapeutic hypothermia has been shown to improve neurologic outcomes after sudden cardiac arrest. Therapeutic hypothermia should be started as soon as return of spontaneous circulation occurs. However, saline is difficult to keep chilled in the prehospital environment. We sought to determine whether a cooler and ice packs could keep saline cold under prehospital conditions.
METHODS: In phase 1 of the experiment, two 1000-mL bags of prechilled 0.9% normal saline were placed in a cooler with 3 ice packs. An additional bag of 1000-mL 0.9% normal saline remained outside the cooler as a control. Over 9 consecutive days, we measured the ambient air temperature and the temperature of each bag of saline every 4 hours. In phase 2 of the experiment, the cooler was kept sealed, and the temperature of the saline was measured after 24 hours.
RESULTS: The mean temperatures over 24 hours ranged as follows: ambient temperature, 24°C to 27.2°C; bottom bag, 0.6°C to 3.5°C; top bag, 1.4°C to 5.7°C; and control bag, 9.8°C to 26.8°C. A t test was used to compare the chilled saline against the control bag. Statistical significance (P < .05) was achieved at all times. In phase 2 of the experiment, after 24 hours, 100% of the bottom bags and 93% of the top bags were less than 6°C.
CONCLUSIONS: Our data demonstrate that saline can be kept chilled in ambulances for 24 hours using ice packs and coolers. The estimated cost is less than $50.00 per ambulance. Using coolers and ice packs is an inexpensive way for emergency medical service agencies to initiate prehospital hypothermia.
Since few ambulances are away from a station for greater than 24 hours, this seems like a reasonable method to maintain the ability to provide therapeutic hypothermia in the prehospital environment.
Does your system use therapeutic hypothermia? With what method? Do your vehicles have refrigerators on board? Let me know in the comments.
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.
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