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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Evaluation of the Canadian C-Spine Rule Continues

Posted by Patrick Lickiss on Jul 27, 2011 in Assessment, General, Research, Treatment | 2 comments

In an article published in February in the BioMed Central of Emergency Medicine (an OPEN journal by the way, not charging $85/article!) a study protocol was laid out for the next phase in the evaluation of the safety of the Canadian C-Spine Rule (CCR).  The full text of the article may be found here (PDF link).

For those not familiar, the CCR is a spinal clearance tool which is basically a cross between the State of Maine and the NEXUS criteria you’ve likely seen physicians use in the ED.  There’s a nice flow chart in the article, but the basics are as follows:

• Does the patient have a high risk factor indicating immobilization?
  • Older than 64 years
  • Dangerous mechanism
  • Numbness/tingling
• Does the patient have one low risk factor?
  • Minor rear-end MVC
  • Ambulatory on scene
  • No neck pain when asked
  • No neck pain with palpation
• Can the patient rotate their own head, left and right, to 45 degrees, regardless of pain

I really like this technique because it just makes sense:  Do they have any big things to worry about?  No.  Do they have something which indicates they’re uninjured? Yes.  Can they move their head? Yes.  Fantastic, don’t c-spine!

A BRIEF HISTORY OF THE CCR
The researchers in Canada have clearly been doing their due diligence.   This project has been on going, in one form or another, for the past 10+ years.  The CCR was first written about in 2001 and was compared at the time to both the standard NEXUS exam and radiological results.  Since then, the procedure has been validated amongst physician, ED triage nurse and paramedic level practitioners.  During the phase I and II trials, the CCR demonstrated a 99.7% sensitivity ^[1].

The researchers have since implemented the protocol amongst physicians in  multiple hospitals and are studying implementation amongst ED triage nurses as well.  One line in the article really stuck in my head after reading it:  ”While we hope to demonstrate that ED triage nurses can safely remove patient’s cervical immobilization devices, it would be significantly more valuable if we could empower the paramedics to selectively forgo immobilization in the first place, and avoid great discomfort to patients.” ^[1] Simply put, I love this idea!  If we have access to a tool which can benefit our patients, why don’t we give it to everyone involved in patient care, so that we can significantly benefit our patients more often!

Additionally, I love the idea of standardizing something like ruling out spinal immobilization across all levels of care from pre-hospital to in-hospital.  The main thing holding this article/study back from being one of the most ground breaking in EMS is the actual statement that spinal immobilization is not, in fact, beneficial and actually harms our patients.  But that might be asking too much.

At any rate, check out the article and stay tuned, the idea of standardizing care across practitioner levels is an interesting one that bears more reflection.

ARTICLE CITED
[1] - Vaillancourt C, et. al: “Evaluation of the safety of C-spine clearance byparamedics: design and methodology”. BMC Emergency Medicine 2011 11:1.

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Does Real-Time Feedback During CPR Affect Outcome?

Posted by Patrick Lickiss on Jul 20, 2011 in General, Research, Treatment | 4 comments

Today’s ECG monitors are amazing pieces of equipment.  Between transmitting 12 leads over a Bluetooth connection to tracking an entire cardiac arrest from start to finish, there is little these monitors can’t do.  One recent addition (that I’ve seen on Zoll and Phillips monitors) is real-time audible and visual feedback with regard to the quality of compressions and ventilation.  At first glance, this seems like a great idea.  The more compliant the resuscitation, the more likely a positive outcome right?  Well a recent article in the British Medical Journal looks at precisely this relationship ^[1].

BACKGROUND
This study enrolled 1586 patients in cardiac arrest spread over three Resuscitation Outcomes Consortium sites.  Each site used the Philips MRx monitor with the Q-CPR software and force transducer.  Field crews were trained in a manner consistent with their local requirements and worked for three months to familiarize themselves with the monitor.

The monitor provides visual and audible feedback about the frequency, depth and release of chest compressions as well as the ventilation rate.

Philips MRx Monitor/Defibrillator with Q-CPR

DESIGN
After a period of familiarization, groups were created within the study area and were assigned to start with “feedback on” or  ”feedback off”.  All groups used the Q-CPR software and hardware to track CPR quality regardless of feedback status.  After a period of time (ranging from two to seven months) each group changed to the other arm of the study.  This rotation back and forth continued for the remainder of the study.

PATIENT POPULATION
Of the 1586 patients, 771 were enrolled into the “feedback off” group and 815 were enrolled in the “feedback on” group.  Demographic information was roughly the same for each group with about 60% of the patients being male, 10% suffering cardiac arrest witnessed by responders, 40% arresting while witnessed by bystanders and 50% receiving bystander CPR.  The most common presenting rhythm was asystole and all patients received ALS care on scene.

Patients were left out of the study if they were known to be incarcerated, pregnant, had a DNR or suffered cardiac arrest from primarily traumatic causes.

FINDINGS
The researchers began by analyzing quality of CPR provided.  When comparing the codes in each group, they found that compression rate, depth and full release were all closer to the AHA guidelines (specific values can be found in the full text (PDF link) of the article) when feedback was “on”.   There was no significant difference in ventilatory rate noted.

The study authors then looked at prehospital ROSC, presence of pulse at the ED, survival to discharge and discharge awake.  Interestingly enough, they found no difference between the group “with feedback” and “without feedback” despite the fact that the feedback group did “better” CPR.

SO WHAT?
The study authors state that improved CPR has indeed been linked to improved patient outcomes.  They also note that visual and audible feedback improved CPR performance.  So why didn’t these patients do better in the short or long term when the providers were given feedback?  The researchers suggest that perhaps the improvements in CPR noted here were not sufficient enough to improve outcomes.  Perhaps, they suggest, real-time feedback makes the most difference in situations were CPR is poor (rather than adequate) to begin with.

Another idea is that the feedback is only given by the monitor when CPR performance falls below the standard.  A better form of feedback may be goal directed, like a tone at 100 beats per minute rather than an audible feedback of “speed up” or “slow down” when quality suffers.

Ultimately, high performance CPR is what is improving our patient outcomes.  Whether real-time feedback helps accomplish that goal remains to be seen.  Does your system use real-time feedback for cardiac arrest?  What about feedback for the crew after the call during the QA/QI process?  What works?  What doesn’t?  Drop me a line in the comments.

NOTE: This article is not an endorsement or review of the Philips MRx.  This product is mentioned only because it was the specific device used by the study designers.

CITED ARTICLES
[1] - Hostler D, et al.: “Effect of real-time feedback during cardiopulmonary resuscitation outside hospital:  prospective, cluster-randomised trial”. BMJ 2011; 342: d512.

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Pediatric Poisoning Refresher

Posted by Patrick Lickiss on Jul 13, 2011 in Assessment, General, Research, Treatment | 2 comments

While browsing through recent journal articles, I came across a retrospective study published by the University of California at San Diego Emergency Medicine Department ^[1]. Looking back at eight years worth of EMS documentation (this is one of the limitations of a retrospective study) the researchers attempted to quantity particular information about pediatric poisonings in that time period.  I say that this is a limitation of a retrospective study because the validity of the research relies on the quality of documentation performed before the study was designed.  This can prove to be time consuming and may not yield useful results.

THE FINDINGS

There were more than 40,000 paramedic transport calls for patients 5 years and younger over the study period; 996 (2.5%) of these calls had the chief complaint of poisoning. Of the calls classified as poisonings, 38% involved a 1-year-old and 35% involved a 2-year-old. Fifty-six percent of these poisonings involved either prescription or over-the-counter medications. An additional 16% were due to household cleaners. Eighty-eight percent of all calls were classified as mild in acuity, with 13% of poisoning calls for children under a year of age classified as moderate or acute; 50% of moderate or acute poisoning calls were to children 2 years of age. July and March were the months with the highest incidence of poisoning calls. The fewest calls were received on Saturdays and Sundays^[1].

There are a few items of interest in these findings.  First of all, the vast majority (over 70%) of poisonings take place with patients 2 years old and younger.  It seems like a lot of presentations in that population should including poisoning as a potential differential diagnosis, particularly if you are struggling to find a cause for the symptoms.  Next, the majority of poisoning calls for pediatrics involve medications.  Keep in mind that therapeutic effects in adults are potentially fatal in pediatrics.  This is especially true with regards to medications targeted at the cardiovascular system like digoxin and beta-blockers.  Finally, “moderate” or “acute” poisonings were more likely to occur with patients two years of age.  This is logical as these patients are becoming more active and mobile.  When responding to patients in this age group (for other calls, not for poisonings) take a quick look around on scene and see if there are medications or household cleaners in easy reach of children.  This is the perfect opportunity to provide some education to the family, particularly if you’re not the primary caregiver.

NATIONAL STATISTICS
According to the American Association of Poison Control Centers,  over 52% of poisonings in 2009 occurred in patients aged 0-5 years.  Since 2006, the pediatric ingestion of analgesics has seen a particularly marked increase ^[2].  According to the CDC, children are twice as likely to be seen in the Emergency Department for medication poisoning as they are for poisonings from household cleaners ^[3].

ACTIONS WE CAN TAKE
We discussed earlier about maintaining an elevated index of suspicion for poisoning in pediatric patients.  We also discussed gently providing education to caregivers when an unsafe situation is discovered on scene (though not necessarily during a response for poisoning).  What about treatment options?  Poison Control is a valuable resource and every EMS practitioner should have the number in his or her cell phone.  Poison Control is staffed by medical providers who are able to provide you with valuable information, even if you do not know the exact toxin which has been ingestion.  Often, the individual answering the phone will be able to determine the substance based on partial labels, color, uses, etc.  I have had excellent luck with identifying myself as a paramedic on scene of a 911 call after the line is answered.  I am often transferred to a pharmacist right away and have been able to get treatment suggestions as well as findings (including ECG changes) to watch out for.  After that, it’s as easy as contacting my base hospital, letting them know that I contacted poison control and getting an order to treat as suggested by the pharmacist.

I encourage everyone reading this to stop for a moment and put the following number in your phone:  (800)222-1222.  You can call that number from anywhere in the U.S. and you will be connected to your local poison control center.

So how about it?  Have you used Poison Control on duty?  What about off duty?  What was your experience like?  Are you taught about using Poison Control during annual training?  Let me know in the comments.

CITED ARTICLES
[1] - Vilke GM: “Pediatric Poisonings in Children Younger than Five Years Responded to by Paramedics”. J Emerg Med 2011 Jan 5, [Epub ahead of print].

[2] – American Association of Poison Control Centers – 2009 Detailed Statistics (PDF Link)

[3] – Centers for Disease Control and Prevention – Poisoning Factsheet

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The Prehospital Shock Index

Posted by Patrick Lickiss on Jun 8, 2011 in Assessment, Research, Treatment | 1 comment

The body is an amazing piece of machinery.  There are compensatory mechanisms and back up compensatory mechanisms, all designed to maintain homeostasis in the event something goes wrong.  Prehospital providers are likely familiar with the response the body exhibits to blood loss.  After experiencing a traumatic event, say a ruptured spleen from a motorcycle accident, the circulating blood volume begins to drop as uncontrolled internal hemorrhage continues.  During this early stage of shock, the body takes steps to compensate for the blood loss, most notably (and measurable) an increase in heart rate.  As shock progresses, and the body begins to decompensate, the heart rate gradually drops and blood pressure soon follows.

In the case of the ruptured spleen (obviously a serious injury requiring surgery and likely a blood transfusion) early recognition of the severity of the patient could guide destination or more rapid transport. In some cases, waiting until the patient becomes hypotensive may be too late to make a proper treatment or transport decision.

THE PREHOSPITAL SHOCK INDEX
In an article published in February of this year^[1], researchers suggested a method to predict the need for large-scale blood transfusion (more than 10 units of red blood cells in the first 24 hours) based on dividing the heart rate by the systolic blood pressure.  The new CDC Field Triage Criteria focus on blood pressure but not heart rate.  Perhaps including heart rate could prevent undertriage of these potential serious, though compensated patients.

DO WE NEED ANOTHER SCALE?
As I discussed in the stroke series, I think that all too often, scales and assessment tools are given to EMS practitioners and can be used, incorrectly, as a substitute for actual learning.  That being said, if you’re interested in the article, the abstract can be found here.  What I find more useful than adding another “tool” to our tool box is to look at the pathphysiology behind the tool.  In this case, the concept is pretty straight forward.

To review:

• Compensated shock: a state where the body uses methods to maintain circulation despite volume loss.  These can include, increased heart rate, constriction of the vasculature and decreased urinary output.
• Decompensated shock: a state where the mechanisms the body uses to maintain perfusion begin to fail.  Includes dropping heart rate, blood pressure and circulation to vital organs.

Obviously the goal is to figure out when the patient is in compensated shock and to do something before he moves to decompensated shick.  Knowing that the mechanisms used to compensate for shock include tachycardia, we should be paying particular attention to all of the vital signs of patients who “should be” hypotensive.

Take our ruptured spleen for example.   The patient walks up to your ambulance complaining of left lateral abdominal pain after a solo motorcycle accident.  The location of the call is far from your normal response zone so it took 25-30 to arrive on scene.  The patient appears agitated.  After performing a rapid trauma exam, you note that the patient is experiencing tenderness with palpation to his left upper abdominal quadrant.  His blood pressure is 138/80, heart rate is 130 and respiratory rate is 26.  Are you concerned about this patient?  Is his heart rate due to stress from his accident or is he in compensated shock?  Is his respiratory rate due to anxiety or is he trying to maintain oxygenation with a diminished circulating blood volume?

What the decision comes down to is this:  Do you have an index of suspicion that this patient experienced an injury which left him volume depleted?  Could this patient’s vital signs be the result of that volume depletion?  Hopefully you don’t need another scale or assessment tool to answer those questions.

CONCLUSION
Interestingly enough, however, the researchers found that patients with a Shock Index of 0.9 or higher (basically patients with a  heart rate near to or greater than systolic blood pressure) where 1.5 times more likely to need significant blood transfusion.  What common sense tells us is a “big sick” trauma patient based on mechanism, assessment and vital signs turns out, in this study at least, to actually be a “big stick” trauma patient.  Score one for common sense in EMS!

CITED ARTICLES
[1] - Vandromme MJ, et. al: “Identifying risk for massive transfusion in the relatively normotensive patient:  utility of the prehospital shock index”. J Trauma 2011 Feb; 70(2): 384-8.

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