Scoop and Run

[pseudoknot]

I just read this article in JEMS:
http://www.jems.com/news_and_articles/columns/Wesley/Scoop_and_Run.html

It is a summary of a paper recently published in the Journal of Trauma where the authors looked at survival rates for penetrating trauma victims who underwent ED thoracotomies after being brought in by EMS vs police or private vehicles. They found that those brought in by EMS, despite generally being less severely injured, were half as likely to survive. They also found an increased risk associated with individual prehospital procedures such as IVs, C-spine packaging, and intubation.

I know there was a famous study performed quite a while ago at LA County+USC that had a similar result. It will be interesting to see if any systems move to minimize their on scene interventions in response to data like this. (Someday, obviously.)

The original paper:
Seamon MJ, Fisher CA, Gaughan J
"Prehospital Procedures Before Emergency Department Thoracotomy: 'Scoop and Run' Saves Lives."
Journal of Trauma. 63(1):113-120, 2007.

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[docB]

So being a big fan of EMS providers being 1. involved in research and 2. understanding research what's wrong with this study? I will assume that ost of us here don't favor the "know nothing, do nothing, drive faster" approach. If we don't want to see that happen we need to be able to critically dissect studies like this. How would you argue that this study was biased against EMS interventions?

 

[leviathan]

So being a big fan of EMS providers being 1. involved in research and 2. understanding research what's wrong with this study? I will assume that ost of us here don't favor the "know nothing, do nothing, drive faster" approach. If we don't want to see that happen we need to be able to critically dissect studies like this. How would you argue that this study was biased against EMS interventions?

This is horrible research. It's retrospective, and the patients were therefore not randomly assigned to EMS or P/PV transport. The author of this article shrugs off the fact that the patients in either group obviously were from very different populations and thus self-selected themselves into each category, for whatever various reasons.

As everyone's favourite saying goes, trauma is a surgical disease. Sitting around on scene to start IVs, apply fancy immobilization devices to patients, and intubate are really just delaying definitive treatment. Conversely, we are not going to cause harm if we perform minimum stabilization techniques onscene, start an IV en route, titrate SBP to only 80-90 mmHg, , and use less definitive airways in favour of getting them on the operating table sooner. In my area we perform all of the above, and our on-scene times for trauma patients are often only 2-3 minutes.

 

[Unlimited415]

Well, it's a bit hard to conduct a double blind study with this sort of thing, so I'm sure they were doing the best they could.

My first thought while reading the article was that patients who arrived by private vehicle were probably in better shape b/c they were ABLE to get themselves to the ER or whoever drove them deemed decided they were okay enough to drive themselves.

But the EMS patients apparently showed more "signs of life" in the field (compared to private transport in the field or in the ER?).

I think the old USC study was decent. It accounted to injury severity. Though, part of the increased survival rate might be due to being closer to hospital in the first place which is why they were transported by private vehicle?

 

[jkelly2]

Does this study operationalize "signs of life?" Also, who is assessing these signs of life on-scene? For EMS I suppose it's the EMTs. But how about for the police/private vehicle patients? It looks like these laypersons are determining what signs of life are present.

 

[leviathan]

Well, it's a bit hard to conduct a double blind study with this sort of thing, so I'm sure they were doing the best they could.

I agree that it would not be ethical to do that, but "doing the best they could" doesn't cut it when you're trying to use evidence-based medicine to direct your treatment guidelines.

 

[pseudoknot]

This is horrible research. It's retrospective, and the patients were therefore not randomly assigned to EMS or P/PV transport. The author of this article shrugs off the fact that the patients in either group obviously were from very different populations and thus self-selected themselves into each category, for whatever various reasons.

I think calling it "horrible" is a bit harsh. How do you propose to conduct a prospective randomized study of this? The 911 operator would open a little envelope for every call and depending on the contents either dispatch an RA or tell the caller that they need to arrange transport themselves? And they did make an effort to address the different populations.

As everyone's favourite saying goes, trauma is a surgical disease. Sitting around on scene to start IVs, apply fancy immobilization devices to patients, and intubate are really just delaying definitive treatment. Conversely, we are not going to cause harm if we perform minimum stabilization techniques onscene, start an IV en route, titrate SBP to only 80-90 mmHg, , and use less definitive airways in favour of getting them on the operating table sooner. In my area we perform all of the above, and our on-scene times for trauma patients are often only 2-3 minutes.

In your paragraph above you trashed the paper, but now you seem to be agreeing with it. I'm not sure what you mean by "fancy immobilization devices" vs "minimal stabilization techniques," but in the systems I've seen there was one way to do C-spine and there was only a binary decision of whether to do it or not. Incidentally, I believe that what scant evidence we have on C-spine precautions shows that they are usually not helpful and may even be harmful to patients.

An on scene time of 2-3 minutes is very impressive, but I don't think that's at all typical.

 

[pseudoknot]

I agree that it would not be ethical to do that, but "doing the best they could" doesn't cut it when you're trying to use evidence-based medicine to direct your treatment guidelines.

That's not a helpful or realistic attitude. Obviously there are many things in medicine that cannot be addressed by randomized prospective double blind experimental studies, whether due to cost, ethics, or other reasons. While it is easy as a student to sit in a classroom and complain that someone else's paper was not perfect, ultimately decisions about clinical practice have to be made. Choosing to wait for the perfect study is equivalent to using no evidence at all.

 

[leviathan]

I think calling it "horrible" is a bit harsh. How do you propose to conduct a prospective randomized study of this? The 911 operator would open a little envelope for every call and depending on the contents either dispatch an RA or tell the caller that they need to arrange transport themselves? And they did make an effort to address the different populations.

It is horrible, but that doesn't mean the people who did it had any better options. Agreeably you are severely limited in how you would research this topic, but that doesn't mean the original statement doesn't stand that it is bad research, or difficult to draw conclusions from it.

In your paragraph above you trashed the paper, but now you seem to be agreeing with it. I'm not sure what you mean by "fancy immobilization devices" vs "minimal stabilization techniques," but in the systems I've seen there was one way to do C-spine and there was only a binary decision of whether to do it or not.

"Fancy" would be strapping the patient down to a spine board, applying a collar and paying attention to the correct neutral alignment with occipital padding, taping the head down with an immobilization device (HeadBed, or otherwise), and applying lots of padding for comfort.

Minimium stabilization is a hard collar, sandbags, and on a spineboard or clamshell, and no straps except for the ones from the stretcher. This is assuming you are next to the ambulance and cot and do not have to transport them over a long distance.

An on scene time of 2-3 minutes is very impressive, but I don't think that's at all typical.

Certainly it can be delayed, but in optimal conditions with only a few interventions (eg. stabilizing bilateral femur #), I've seen it done many times. Thing speed up when you have a whole truck of firefighters helping you out.

 

[leviathan]

That's not a helpful or realistic attitude. Obviously there are many things in medicine that cannot be addressed by randomized prospective double blind experimental studies, whether due to cost, ethics, or other reasons. While it is easy as a student to sit in a classroom and complain that someone else's paper was not perfect, ultimately decisions about clinical practice have to be made. Choosing to wait for the perfect study is equivalent to using no evidence at all.

Sometimes making decisions on best clinical practice has to be done with less-than-optimal research designs, but in this case I would advise against it. Even if you do not have two randomly assigned study groups, you should still be able to say that within reason, the groups were identical in all characteristics that are important to the study. In this case, I don't see how you could draw that conclusion. I also don't see what my status as a student has to do with my ability to have that opinion.

 

[pseudoknot]

Sometimes making decisions on best clinical practice has to be done with less-than-optimal research designs, but in this case I would advise against it. Even if you do not have two randomly assigned study groups, you should still be able to say that within reason, the groups were identical in all characteristics that are important to the study. In this case, I don't see how you could draw that conclusion.

My point is that you are still advocating making a decision: in this case, the decision is in favor of the status quo. I'm not saying that drastic system changes ought to be made tomorrow, but I do think that this paper, combined with previous studies, is convincing enough to believe the issue ought to be further studied and that there may be some value to a more minimalist approach for at least the most severe trauma victims.

I also don't see what my status as a student has to do with my ability to have that opinion.

In my experience, people earlier in their training are apt to have more of a black-and-white view of research quality. There is no harsher critic of a paper than a first-year grad student who is just beginning to learn to critically read the literature and can only see the flaws in anything.

 

[docB]

So we have several good points.

It's retrospective which makes it weaker than a prospective trial. You could do a prospective trial on this, put up your hypothesis and collect data as the cases occur, but since you can't randomize it wouldn't necessarily be better than the retrospective study.

It's not double blind. True but it can't be done blinded. The patient and EMS will always know if the patient is in an ambulance or not.

"Signs of life" are assessed differently between trained EMS and whoever else is doing the assessment. This does bias against EMS in this study. Thoracotomies are only done on those who lose a pulse in the ED or immediately before they get to the ED. If a person is assessed by an untrained bystander and is described only as "not moving or breathing" on scene and they have no pulse at the ED they would likely be assumed to be down for a longer time and would not get the thoracotomy. No thoracotomy means no entry in the study. This same patient, who is clearly very sick, if assessed by EMS might be described as "not moving or breathing but having a weak pulse." That patient would get the thoracotomy and be entered in the study. Both are equally sick and both have bad outcomes but only the EMS patient and the bad outcome go into the study. That's a bias.

I would argue that the biggest bias comes from the fact that they are only looking at thoracotomy patients. Thoracotomies are done on a small minority of trauma patients. Only patients who have lost their pulse in the ED or immediately before getting to the ED are candidates for a thoracotomy. The fact that the EMS patients had worse outcomes may mean that EMS was better keeping a pulse going in sicker patients so that those patients who would have just been called on arrival were given a thoracotomy. Since those patients were sicker they would have had more problems like anoxic brain injury, tissue hypoperfusion, acidosis and so on. Consequently it makes sense that those patients would do worse. It is also possible that the EMS patients did better with the interventions given and did not code and so were not candidates for thoracotomies. If the fluids, intubation, needle decompressions and other interventions did their job then some of these patients wouldn’t get thoracotomies. The result of this bias is that the EMS patients who got thoracotomies might have been sicker than the patients delivered by PD/POV.

Choosing to wait for the perfect study is equivalent to using no evidence at all.

True, but the logical outcome of this study would be to say that EMS should adopt a “scoop and run approach” and abandon interventions that intuitively seem valuable such as C-spine immobilization, IV access and fluids, etc. I suggest that the evidence required to prompt us to abandon these interventions must be very convincing.

 

[leviathan]

My point is that you are still advocating making a decision: in this case, the decision is in favor of the status quo. I'm not saying that drastic system changes ought to be made tomorrow, but I do think that this paper, combined with previous studies, is convincing enough to believe the issue ought to be further studied and that there may be some value to a more minimalist approach for at least the most severe trauma victims.

I might not be making myself clear, so let me say I totally agree that the results of this study probably have a lot of truth to them. However, I think the best practice is doing IVs en route and minimizing time on scene doing things such as immobilization. We should scoop and run, but there's nothing stopping us from doing stuff while running. I'm intrigued that the services you have worked for do not have a "minimum stabilization" policy like we do here for unstable trauma. Is my service very unique for that, or does anyone know if this happens in other EMS systems as well?

In my experience, people earlier in their training are apt to have more of a black-and-white view of research quality. There is no harsher critic of a paper than a first-year grad student who is just beginning to learn to critically read the literature and can only see the flaws in anything.

Very true, but who said I don't have research experience? I may be a health student now, but who knows what I did before getting into paramedicine? Of course, snooping your profile I see you did a PhD before meds, so I'm sure you have much more experience than myself.

 

[howelljolly]

yeah, what docB said. The study looks at a very small cohort of patients. One huge variable thats missing is "extanded on-scene time" beyond the control of EMS (scene issues). Intuitively, those patients , if alive, will be sicker, have more intensive pre-hospital treatment, be candidates for ER thoracotomy (because they did have a pulse), and probably end up dead anyway. That would make the Mobile Intensive Care data seem spuriously lousy.

Off the top of my head, NHTSA/DOT (standard) curriculum for spinal immobilization has two categories... 1. Full C-spine (with that green thing under the bench seat... what do they call that?..... KEN....KID...TED...?) and 2. a "rapid extrication" protocol for "unstable" pt.s.

I'd guess that doing an experimental study would be impossible... Besides, you cant go back and offer the effective treatment to the untreated group.

One alternative might be not to look at overall M&M as the outcome. One can look at the individual effectiveness of each intervention. "Was the airway protected?" "Was the patient oxygenated?" "Was venous access usable?"

I really can't see how doing any less in the field can help. I really dont think that arrival times will decrease significantly. Am also pretty sure that fully immobilizing a patient with an unstable airway will do more harm than good.

 

[blotto geltaco]

Well back in the "good old days" when I was on the meat wagon we used to call it "swoop and scoop". To the above poster, it's KED - Kendrick extraction device.

 

[howelljolly]

Well back in the "good old days" when I was on the meat wagon we used to call it "swoop and scoop". To the above poster, it's KED - Kendrick extraction device.

I know. I was trying to be funny.

The only thing Ive ever used a KED for is to stabilize a R/O Hip Fx.

 

[docB]

I know. I was trying to be funny.

The only thing Ive ever used a KED for is to stabilize a R/O Hip Fx.

A KED is the green thing that you can use to place a patient in CSpine while seated in the car. It has straps that go under the legs so it would be really bad at stabilizing a hip. Are you thinking of a Hare or a Sager?

 

[beanbean]

If you turn the KED upside down and bind the chest portion around the patient's pelvis it provides pretty decent pelvic stabilization for transport if the patient is suspected of having an unstable or open book pelvis. KEDs can also be used as a pedi-immobilization device....a green papoose.

 

[tkim]

Well back in the "good old days" when I was on the meat wagon we used to call it "swoop and scoop".

We called it "scoop and screw".

 

[beanbean]

In response to the original topic of the thread, I had been involved with EMS for ~20 years as a volunteer EMT-I before making the jump to MD and EM PGY1. During that time in my region the trend has swung from "load and go" to "stay and play" and back to "load and go". The lack of good data regarding this issue forces us to set EMS medical directives based on intuition of what seems like it would be beneficial. It is also difficult to draw conclusions from the limited data which be applied to rural, suburban and urban EMS. What is best when you are 3 mins, 30 mins or 3 hrs from the level 1 trauma bay?

 

[Mark S]

Great to hear that I stirred up the pot with this paper!!!

Of course, we would like to do a randomized prospective study but its an impossibility. To have an 80% chance (power) to detect this survival difference, we would need 200pts per study arm (procedures vs. no procedures). That means if we assume a 30% error or exclusion rate (probably much better than it would be in actuality), then we would need 400/.7=571 patients. Now if we remember that only 50% of our patients are brought by EMS, that means we would need 1142 EDT patients in total. I doubt that many EDTs were performed in America last year.

Many of you are missing a fundamental point. In the end (through a multivariate logistic regression) each prehospital procedure meant the patient was 2.6x less likely to survive EDT. IT DOESN'T MATTER WHERE IN THE PREHOSPITAL PHASE THEY ARE PERFORMED. To the health student who says this is horrible research and then goes on to recommend placing IVs en route...please look up a paper by Ken Mattox (one of the true forefathers of trauma surgery) and Bickell in the New England Journal from 1994. Undeniably, resuscitating penetrating trauma patients before definitive surgical control adversely affects mortality.

I only take the time to respond because you students need to know the truth. In urban settings, prehospital procedures in penetrating trauma victims helps kill young, healthy patients.

For more info, do a pubmed search for Sampalis JS---He has done a great deal of work on this very important topic.

 

[EMTP]

..... However, I think the best practice is doing IVs en route and minimizing time on scene doing things such as immobilization. We should scoop and run, but there's nothing stopping us from doing stuff while running. I'm intrigued that the services you have worked for do not have a "minimum stabilization" policy like we do here for unstable trauma. Is my service very unique for that, or does anyone know if this happens in other EMS systems as well? ......

Minimizing scene times is always the goal in trauma and "minimum stabilization" in my area means full immobilization to a long board. PHTLS teaches a 10 minute scene time goal, with receiving facility decisions made by the paramedic enroute or on-scene in conjunction with the medical director via radio or standing orders. In my area response times can be up to 20 minutes, transport times alone can be 20 minutes if not more, flight services are dependent upon weather, and extrication can chew through scene time. The closest Lvl I trauma center is 60 minutes away via ground, 15 minutes via helicopter. We will however delay ground transport to the nearest hospital if the pt condition warrants flight to Lvl I trauma, a helicopter is already in the air and/or extrication is extensive. Due to certain conditions it can be 20-30 minutes before the pt is in the air and on the way to definitive care. Remember please, my peers operate with a very high index of suspicion based on kinematics of trauma, pattern recognition, and above all patient advocacy among other things. Our flight teams often consist of a doctor and flight nurse, and ideally will be in contact with the ground units from lift-off if possible.

Also, in my area, bilat femur fx's are cause to fly the patient. Not saying that we would in each case, just that the option is there dependent upon the scene, MOI, pt presentation and consult with med control.

 

[docB]

Great to hear that I stirred up the pot with this paper!!!

Of course, we would like to do a randomized prospective study but its an impossibility. To have an 80% chance (power) to detect this survival difference, we would need 200pts per study arm (procedures vs. no procedures). That means if we assume a 30% error or exclusion rate (probably much better than it would be in actuality), then we would need 400/.7=571 patients. Now if we remember that only 50% of our patients are brought by EMS, that means we would need 1142 EDT patients in total. I doubt that many EDTs were performed in America last year.

Many of you are missing a fundamental point. In the end (through a multivariate logistic regression) each prehospital procedure meant the patient was 2.6x less likely to survive EDT. IT DOESN'T MATTER WHERE IN THE PREHOSPITAL PHASE THEY ARE PERFORMED. To the health student who says this is horrible research and then goes on to recommend placing IVs en route...please look up a paper by Ken Mattox (one of the true forefathers of trauma surgery) and Bickell in the New England Journal from 1994. Undeniably, resuscitating penetrating trauma patients before definitive surgical control adversely affects mortality.

I only take the time to respond because you students need to know the truth. In urban settings, prehospital procedures in penetrating trauma victims helps kill young, healthy patients.

For more info, do a pubmed search for Sampalis JS---He has done a great deal of work on this very important topic.

I believe we're hearing from Dr. Mark Seamon the PI of the paper we've been discussing. This is a terrific opportunity for everyone on the board to hear some imput from someone who is changing the way EMS will be practiced. Just to make sure everyone can actually read the study here's the info and abstract. The JEMS link is a review of the paper. Since we're hearing from the actual author we should be reading the actual paper.

Seamon MJ; Fisher CA; Gaughan J; Lloyd M; Bradley KM; Santora TA; Pathak AS; Goldberg AJ
The Journal Of Trauma [J Trauma] 2007 Jul; Vol. 63 (1), pp. 113-20.

BACKGROUND: The role of prehospital healthcare personnel in the management of acutely injured patients is rapidly evolving. However, the performance of prehospital procedures on unstable, penetrating trauma patients remains controversial. The objective of this study is to test the hypothesis that survival of most critically injured penetrating trauma patients requiring emergency department thoracotomy (EDT) would be improved if procedures were restricted until arrival to the trauma bay. METHODS: A retrospective chart review on 180 consecutive penetrating trauma patients (2000-2005) who underwent EDT was performed. Patients were divided into two groups by mode of transportation and compared on the basis of demographics, clinical and physiologic parameters, prehospital procedures, and survival. RESULTS: Eighty-eight patients arrived by emergency medical services (EMS), and 92 were brought by police or private vehicle. Groups were similar with respect to demographics. Seven of 88 (8.0%) EMS-transported patients survived until hospital discharge, and 16 of 92 (17.4%) survived after police or private transportation. Overall, 137 prehospital procedures were performed in 78 of 88 (88.6%) EMS-transported patients, but no police- or private-transported patient underwent field procedures. Multivariate logistic regression analyses identified prehospital procedures as the sole independent predictor of mortality. For each procedure, patients were 2.63 times more likely to die before hospital discharge (OR = 0.38, 95% CI = 0.18-0.79, p = 0.0096). CONCLUSIONS: The performance of prehospital procedures in critical, penetrating trauma victims had a negative impact on survival after EDT in our study population. Paramedics should adhere to a minimal or "scoop and run" approach to prehospital transportation in this setting.

Now in scientific writing it's usually necessary to temper one's opinions which is why the paper notes that EMS interventions are "contraversial" and Dr. Seamons says that "EMS interventions kill young, healthy patients." Clearly, we know where Dr. Seamons stands on the issue of EMS.

I argue that while the data may be showing us that we need to look closer at what and how many interventions EMS does it is counter productive to tell EMS providers and especially students that by trying to do more they are killing people. This can only cause EMS to lose the professionalism that it has worked so hard to achieve in the past decades by making providers think they are there to "know nothing, do nothing and drive faster." If we accumulate more convincing data we would do better to tell EMS providers and students that it may be better to hold off on interventions in specific circumstances (such as short transit time to a trauma center) and to explain some of the physiologic yet counter intuitive reasoning for this such as permissive hypotension. An ALS provider can still give high level care and help their patients by knowing when to act and when to hold off.

I also argue that we should not quit teaching the interventions we currently use. Even if we get to the point where we protocol patients for no intervention transport based of some set of criteria those interventions will still be needed in situations that fall outside of the set criteria. I think that there is a significant difference between the GSW brought in from Broad and Erie (2 min transport) and those that arrive at community centers outside the golden hour.

 

[howelljolly]

I only take the time to respond because you students need to know the truth. In urban settings, prehospital procedures in penetrating trauma victims helps kill young, healthy patients.

Because "You students" (does that include docB?) need to know that "prehospital procedeures" id est, starting two large bore IVs, and securing the airway, "helps kill young, healthy patients".

And it doesnt matter when these procedeures are performed?

So, when the anesthesiologist starts the IVs and secures the aiirway, then the patient dies?

Well maybe not. Perhaps upcoming research will show that IVs and advanced airway management only kills young healthy patients when they are preformed by an ambulance driver.

DocB... Lost above was the idea that NHTSA/DOT guidelines delinieate two categories of spinal immobilization, Full (using a KED) or Rapid (directly to the board). In my expereince Ive almost never seen (or myself done) a Full spine with KED. Most opt for a Rapid whether the patient qualifies for it, or not.

Kendrick does make a Femur Fx traction device, but I was refering to having used the KED for Hip stabilization. Turn the KED upside-down, secure the waist as usual, and secure the Occipital support to the ipsilateral knee, and the hip is pretty well stabilized.

Im furious right now.

 

[docB]

Because "You students" (does that include docB?) need to know that "prehospital procedeures" id est, starting two large bore IVs, and securing the airway, "helps kill young, healthy patients".

And it doesnt matter when these procedeures are performed?

So, when the anesthesiologist starts the IVs and secures the aiirway, then the patient dies?

Well maybe not. Perhaps upcoming research will show that IVs and advanced airway management only kills young healthy patients when they are preformed by an ambulance driver.

DocB... Lost above was the idea that NHTSA/DOT guidelines delinieate two categories of spinal immobilization, Full (using a KED) or Rapid (directly to the board). In my expereince Ive almost never seen (or myself done) a Full spine with KED. Most opt for a Rapid whether the patient qualifies for it, or not.

Kendrick does make a Femur Fx traction device, but I was refering to having used the KED for Hip stabilization. Turn the KED upside-down, secure the waist as usual, and secure the Occipital support to the ipsilateral knee, and the hip is pretty well stabilized.

Im furious right now.

Good point about the NHTSA guidelines. If changes are made in EMS practice based on this type of data it is likley to be a graded change in the level of interventions based on protocol rather than a complete abandonment of ALS for all trauma patients.

You point about the difference between an anesthesiologist and a paramedic doin interventions is off the mark. We have to keep in mind that the argument being made by the non-intervention camp is that trauma stabilization can only be done by a surgeon in an OR or an ED. Therefore any delay to getting the patient to the surgeon is bad. If the anesthesiologist is doing it then surgical intervention is underway.

There are also arguments that interventions can make things worse. For example there is a body of evidence that says it's better to forego fluid resuscitation and let the patient stay hypotensive in the prehospital arena. One theory is that blood clots or areas of anatomic tamponade that result in hemostasis at a systolic of 80 will fail and start bleeding again when the systolic rises. This is the theory of "permissive hypotension" that is a part of the argument against complex EMS interventions.

Don't be furious. It's very important not to get defensive when faced with data that challenges you. I say that like I'm always able to do it and I'm not. We're all human. When faced with data that strikes you as counter intuitive you are obligated to critically examine that data, decide if it really applies the way that the researcher says it does and then, if it's convincing, to decide how to incorporate it into your practice. EMS and medicine will change over the course of your career. Studies like these will drive those changes.

Never heard of using the KED for a hip. Cool. I did use a KED to extricate a guy from a toilet once.

 

[howelljolly]

Good point. I do see that if anesthesia is doing those (in my mind, benign and basic), then a lot more hemodynamic monitoring is going on at the same time.
I suppose that its not a matter of specific interventions at all (as I was corrected on before). Maybe there is a benefit to an "all at once" approach to surgical treatment. Im not really sure what the alternative is.

But this particular case looked at thoracotomy in traumatic arrest. Where I worked as a medic, in an urban setting, our protocol for traumatic arrest was to start IVs and protect the airway, and run for the hospital. No meds, no cardioversion. I dont see how being dumped at the doorstep of the ER can be any better.

Being able to independently evaluate the claims of research well be nice. EMS and EM are both riddled with policy, and it often seems like the wrong person calls the shots. (anesthesia preventing EM from doing RSI, for example) I guess its just something I'll have to learn to work with.

Permissive Hypotension, eh? Ive heard similar thoughts on active rewarming, which reverses the compensatory peripheral vasoconstriction. I guess thats what we get for replacing our patients' blood volume with Gatorate.

 

[leviathan]

To the health student who says this is horrible research and then goes on to recommend placing IVs en route...please look up a paper by Ken Mattox (one of the true forefathers of trauma surgery) and Bickell in the New England Journal from 1994. Undeniably, resuscitating penetrating trauma patients before definitive surgical control adversely affects mortality.

First, I think I sent the wrong message by saying it is horrible research. It is decent research which tries to work within the inherent constraints of the topic it is investigating; however, what IS horrible would be to make decisions on standards of prehospital care based off of this research. I still hold the opinion that there's nothing wrong with starting lines in the field, as long as you have initiated transport. Any research I've seen which shows a negative outcome from fluid resuscitation in penetrating trauma had no mention of the paramedics maintaining the BP below ~80-90. Can you show me a study that shows a negative outcome from fluid resuscitation that is exercising permissive hypotension? I certainly have not found any out there.

At the very least, it is advantageous to start two large bore IVs in the field and run fluid in TKVO before they become any more hypotensive, and circulatory access becomes more difficult for the hospital staff to achieve.

I only take the time to respond because you students need to know the truth. In urban settings, prehospital procedures in penetrating trauma victims helps kill young, healthy patients.

I agree that staying on scene and playing with trauma patients when they need to get to an operating table is counterproductive. That is what they emphasized in our training, and I agree with it. In general, there are only a handful of MEDICAL scenarios where we will "stay and play", and everything else gets rapid transport to hospital.

 

[howelljolly]

Just a thought...

"Evidence Based Medicine" is the popular buzz-word these days. But for the life of me, I cant seem to figure out how evidence based emergency medicine is any different from non-evidence based emergency medicine.

Back in the late 90s BLS EMS improved clinical decision making by moving from a Presumptive Diagnosis based treatment, to an assessment based treatment..... I dont know if a similar paradigm shift happend in ALS, though I dont think it would be as useful. After all, all that wheezes is not asthma.

My question is, "Are the principles of Evidence Based Emergency Medicine applicable to the pre-hospital realm in a way that would improve clinical decision making?"

 

[pseudoknot]

"Evidence Based Medicine" is the popular buzz-word these days. But for the life of me, I cant seem to figure out how evidence based emergency medicine is any different from non-evidence based emergency medicine.

...

My question is, "Are the principles of Evidence Based Emergency Medicine applicable to the pre-hospital realm in a way that would improve clinical decision making?"

I don't think EBM is just a buzzword. It is the idea of using science to guide treatment decisions, rather than intuition or anecdotal experience. I'm sure there are many people in EMS who don't believe in science, but that's not really helping its status as a profession.

 

[146233]

I'm sure there are many people in EMS who don't believe in science, but that's not really helping its status as a profession.

This is a keen observation. Bledsoe wrote an article I can't find right now involving how EMS gets screwed in this arena - a large proportion of folks who are smart, motivated, and skilled often wind up going to nursing or medical school and leaving the profession. It leaves us with those without research training, stuck in the "old ways" (flushing g-tubes with Diet Coke, anyone?), and thus reinforces the reputation you mention.

 

[docB]

This brings up some really interesting questions. First is why is there relatively little EBM/research in EMS (that's if you believe that there is less which I do)? I would argue that it's because all the people interested in publishing EMS research are academic physicians there is a disconnect. So how do you fix that? Is the answer to have paramedical doctorates and the creating of a field of EMT academics? Maybe.

 

[pseudoknot]

I feel like part of that problem is the fragmented nature of the system. Most fire departments and private companies don't have protected time for research.

It actually kind of makes sense to me that academic physicians are mainly the people doing EMS research, since most research in any medical arena is done in academia, and also every EMS system has a medical director who is ultimately responsible for overseeing care. Further, the medical directors of large systems often do have academic appointments and are involved in research.

Don't you think the reason there's not as much EMS research might be partly a lack of funding, and the fact that it's hard to get good answers?

 

[docB]

I feel like part of that problem is the fragmented nature of the system. Most fire departments and private companies don't have protected time for research.

It actually kind of makes sense to me that academic physicians are mainly the people doing EMS research, since most research in any medical arena is done in academia, and also every EMS system has a medical director who is ultimately responsible for overseeing care. Further, the medical directors of large systems often do have academic appointments and are involved in research.

Don't you think the reason there's not as much EMS research might be partly a lack of funding, and the fact that it's hard to get good answers?

You are very right about the fact that EMS has no protected time (read as $$$ devoted to paying people) to do research. It speaks to the lack of funding you mention. You are also correct in noting that the fractured nature of the systems inhibit research. The number of hospital based EMS units is small. Academic hospitals are set up to do research but most EMS agencies are not.

Many EMS directors are not academics and are really more concerned with ops and QA/QC. For example, here in Vegas, which is a big city with several very active, ALS agencies, we do no EMS research.

Another problem is that by having all the research done by physicians you have people who may not have any EMS experience making assumptions and putting forth hypotheses.

 

[howelljolly]

Its the ol' EMS brain-drain... a lot of the academic minded folks get sidetracked from primary EMS research. I think, asking for doctorate programs combined with EMS, or even a GME fellowship in EMS is a bit over the top when trying to get into the research field. You're creating the people to do the research, but not the infrastructure for it to take place.

What might work, is MPH programs with an dedicated EMS concentration (with EMT-P done before or during the program). Then, these MPH/EMT-Ps need to get into jobs in public health, policy, government.... and start making EMS an issue. We need to be utilized more and be seen as a resource.

Start getting the EMS units involved in the public health system in non-emergent roles. There was some talk, years ago about creating Paramedic Practitioners (apparently a curriculum was in place in NY and was overturned by the Nursing politicals.) PPs were going to be able to take a load off from the ERs by doing Fast Track in the field, including med re-fills, wound care and ABX.... It probably wont happen any time soon, but... My point is, that if it did happen, this is something that would make a big difference.

As long as we continute to be seen as a liability, rather than an asset (even by our colleagues in trauma surgery), we wont get anywhere.
And, we need to become an indisposable asset. We aren't. Get rid of ALS, noone will say a word (as we've seen many times). Get rid of EMS, people will whine for a week, and then they'll deal. ERs might like that more, because folks that dont need to be in the ER, and cant drive themselves, cant call for an ambulance any more.

Anyway... my answer - MPH/EMT-P.... wider non-emergent use in the public health system.... indispensability

 

[leviathan]

There was some talk, years ago about creating Paramedic Practitioners (apparently a curriculum was in place in NY and was overturned by the Nursing politicals.) PPs were going to be able to take a load off from the ERs by doing Fast Track in the field, including med re-fills, wound care and ABX.... It probably wont happen any time soon, but... My point is, that if it did happen, this is something that would make a big difference.

Funny you mention that...was just talking to someone today who was in Italy and had this sort of "paramedic practitioner" show up to see her about a gastroenteritis problem.

 

[jkelly2]

What might work, is MPH programs with an dedicated EMS concentration (with EMT-P done before or during the program). Then, these MPH/EMT-Ps need to get into jobs in public health, policy, government.... and start making EMS an issue. We need to be utilized more and be seen as a resource. . .


Anyway... my answer - MPH/EMT-P.... wider non-emergent use in the public health system.... indispensability

There are graduate-level programs that offer education specifically to EMS. At UMBC the EHS Master's program offers concentrations in Administration, planning, and policy, Emergency management, Preventive medicine and epidemiology, and Education. A course in issues analysis and proposal writing is a core to the program. The program defines its purpose (http://ehs.umbc.edu/GraduateProgram/program_overview.html):

[FONT=Arial, Helvetica, sans-serif]"The UMBC Emergency Health Services graduate study programs encompass the system components listed above. The program is primarily focused on preparing professionals for leadership roles requiring skill in planning, research, development, and organizational operations. The three [sic] track curriculum is designed to provide graduate level training and education to health care providers, researchers, educators, policy makers and administrators."
.

Perhaps a step in the right direction.
​

​

 

[howelljolly]

There are graduate-level programs that offer education specifically to EMS. At UMBC the EHS Master's program offers concentrations in Administration, planning, and policy, Emergency management, Preventive medicine and epidemiology, and Education. A course in issues analysis and proposal writing is a core to the program. The program defines its purpose (http://ehs.umbc.edu/GraduateProgram/program_overview.html):

[FONT=Arial, Helvetica, sans-serif]"The UMBC Emergency Health Services graduate study programs encompass the system components listed above. The program is primarily focused on preparing professionals for leadership roles requiring skill in planning, research, development, and organizational operations. The three [sic] track curriculum is designed to provide graduate level training and education to health care providers, researchers, educators, policy makers and administrators.".​

Perhaps a step in the right direction.​

There are some EHS programs around, but I mean to say that there should be garden variety and complete programs in public health with a concurrent, separate, and supplimental EMS program.

The reason being, the programs like EHS, MS in EMS, Fire Science...., don't allow for a career in public health like an MPH does. The people that I know who have those degrees are not able to get careers in public health or policy, at best the teach paramedic school. The people that I know who are EMT-P/MPH or EMT-P/MPA do have good careers in public health and policy... however their specific roles are not focused on EMS, and they can't spearhead a grassroots advancement of EMS.

Don't get me wrong, I think programs in EHS and the like are a step in the right direction for EMS, but its not enough. Unfortunately, some of those super-specialized EMS degrees are not unlike an online-PhD.... They are bona fide academic institutions that allow the student to take their own education and experience, polish it off, repackage it, and re-sell it. We do need this to happen, to raise the bar of EMS as much as we can. However, for real changes to take place, we need to "play the game" of higher education, and not make our own game. We need to get a solid hold into the Public Health system.

 

[pseudoknot]

There's nothing stopping anyone in EMS from getting an MPH. A joint MPH/paramedic program isn't going to alter the institutional, cultural, or funding issues already mentioned. I also think that someone going into an MPH program in order to do research in EMS probably already should be a paramedic, with some experience.

 

[pseudoknot]

Start getting the EMS units involved in the public health system in non-emergent roles. There was some talk, years ago about creating Paramedic Practitioners (apparently a curriculum was in place in NY and was overturned by the Nursing politicals.) PPs were going to be able to take a load off from the ERs by doing Fast Track in the field, including med re-fills, wound care and ABX.... It probably wont happen any time soon, but... My point is, that if it did happen, this is something that would make a big difference.

Are you kidding? Whether this is even a good idea, the legal climate in this country makes that suggestion ludicrous. Moreover, what problem are you trying to solve? It's one thing to say that you think X or Y in prehospital care could be done better, but it seems a little odd and futile to just brainstorm on ways to make EMS "more important." I do think that the fragmented system and high turnover are issues, but expanding the role of EMS by encouraging its [ab]use in non-emergent roles doesn't seem likely to help with anything.

 

[pseudoknot]

Many EMS directors are not academics and are really more concerned with ops and QA/QC. For example, here in Vegas, which is a big city with several very active, ALS agencies, we do no EMS research.

Another problem is that by having all the research done by physicians you have people who may not have any EMS experience making assumptions and putting forth hypotheses.

I agree that the latter is a problem. I realize many or most EMS directors are not academics, but certainly there are many who are (I was thinking of people like Marc Eckstein). I do think that physicians who are doing EMS research ought to be currently involved in medical direction, and spend a decent amount of time on the street running calls so that they have a clear idea of what happens on the ground.

 

[leviathan]

Found this page which summarizes some of the changes in Canadian EMS towards evidence-based medicine, and a goldmine of the evidence for/against various pre-hospital procedures.

http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

 

[howelljolly]

Great find! We need more things like this. It seems like this protocol is for a multi-level Paramedic unit...

 

[leviathan]

Great find! We need more things like this. It seems like this protocol is for a multi-level Paramedic unit...

The protocols on there are indeed for multiple levels, anywhere from the primary care up to critical care paramedics. There are 4 nationally recognized levels in Canada.

 

[howelljolly]

Cool. Im moving to Canada.

Anyone.... docB, pseudoknot.... know if theres a niche for EMS in Critical Care Med (here in the states)? Since paramedic school, Ive been a pulmonary/CCM junkie.

If I go into IM/Pulm/CCM, as it's seemingly more likely than getting my Carib trained butt into an EM residency, will I be able to dabble in Critical Care/interfacility transport services, or LifeFlight?.... or is that totally run by EM docs?

HowellJolly, MD, FACP, FCCP, CCEMT-P, PhD, Esq.

Sounds nice, dont it?

 

[jkelly2]

Are you asking if the EMT-P has a role in critical care transport?

 

[howelljolly]

Are you asking if the EMT-P has a role in critical care transport?

Negative, Im asking (backwards) if Critical Care Physicians (who are most often trained in Pulmonology, not EM) have a role in medical direction of critical care transport.

Im really asking (forwards) if a Pulmonolgist/Intensivist can be involved with the medical direction of critical care transport.

 

[docB]

Yes I have heard of CC/Pulm docs doing flight work. Particularly with fixed wing IF transports.

I did a google search for "flight transport medical" and all the companies that popped up refer to their docs as "Critical Care Transport Physicians" whatever that is. I assume those could be just about anyone who deals with critical patients on a regular basis.

Of note is that they seem to refer to their physicians as "medical directors" and it looks like their transports are staffed by midlevels and RNs.

Do I think you could find a roll in this as a CC/Pulm doc. Yes. I actually think you might be better set up for than than you would be as an EP. But it looks like a fairly tight job market and you might find that the physician role is more administrative than flying.

 

[146233]

In this new article on the SDN Front Page, Dr. Seamon discusses this article further and shares a bit of what it's like being a trauma surgeon. Nice exposure for the Prehospital forum, too.

 

[howelljolly]

That was an encouraging article. This sort of research could (relatively) easily be incorporated into the existing PHTLS program, as thats already an established program by the American College of Surgeons.

On rounds the other day, we discussed the efficacy of making a (impending) cardiac arrest hypothermic (in the hospital). Apparently one of the attendings has done it successfully 4/4 times, with no neuro sequelae. That sounds like something that could be useful in the field.

 

[pseudoknot]

On rounds the other day, we discussed the efficacy of making a (impending) cardiac arrest hypothermic (in the hospital). Apparently one of the attendings has done it successfully 4/4 times, with no neuro sequelae. That sounds like something that could be useful in the field.

I believe several clinical trials are underway or will be soon on therapeutic hypothermia for cardiac arrest in the field, including one at my school. It's a pretty exciting area, and there are a lot of details on how, when, and how much to cool that remain to be worked out. There's an interesting web site (not from my school) here:
http://www.med.upenn.edu/resuscitation/hypothermia/