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Prehospital care

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plank

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I am a fourth year student doing an emergency medicine elective at SUNY Downstate. As part of the elective, they require that we have an "EMS experience." When I called the EMS base to set up the appointment, the man on the phone asked if my ridealong was for ALS or BLS. I paused (having no idea what that meant) and again informed him that I am a medical student doing an ER elective at Downstate. He sighed in frustration and asked again if it was for ALS or BLS. I responded with a prolonged, "uhhh." He then said, "are you supposed to be with an EMT or a paramedic?" I said something along the lines of, "our packet mentions working with an EMT a couple more times than it mentions working with a paramedic, so I guess EMT." He was not pleased.

What my much-too-involved story is saying is that I am going to be a resident in the ER next year, and I know absolutely nothing about what happens before patients get to the hospital. Does anyone here know of any basic informational websites or books that could help me get an idea of what's going on? Or would anyone like to educate the whole forum with some basic definitions (e.g., EMT vs. paramedic, ALS vs. BLS)? I know there are some ex-EMTs out there, so I apologize in advance for my ignorance. Don't hate me.
 

docB

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He's got a point though. There are lots of people who start looking at EM and at this forum and must get really lost. I suggest checking the definitions and checking out the prehospital forum on SDN. Do some searches (once the search is back up) and then ask for clarification on the stuff that's still hazy.
 

carn311

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plank said:
I am a fourth year student doing an emergency medicine elective at SUNY Downstate. As part of the elective, they require that we have an "EMS experience." When I called the EMS base to set up the appointment, the man on the phone asked if my ridealong was for ALS or BLS. I paused (having no idea what that meant) and again informed him that I am a medical student doing an ER elective at Downstate. He sighed in frustration and asked again if it was for ALS or BLS. I responded with a prolonged, "uhhh." He then said, "are you supposed to be with an EMT or a paramedic?" I said something along the lines of, "our packet mentions working with an EMT a couple more times than it mentions working with a paramedic, so I guess EMT." He was not pleased.

What my much-too-involved story is saying is that I am going to be a resident in the ER next year, and I know absolutely nothing about what happens before patients get to the hospital. Does anyone here know of any basic informational websites or books that could help me get an idea of what's going on? Or would anyone like to educate the whole forum with some basic definitions (e.g., EMT vs. paramedic, ALS vs. BLS)? I know there are some ex-EMTs out there, so I apologize in advance for my ignorance. Don't hate me.


ALS= Advanced Life Support (paramedic's standard of care)
BLS= Basic Life Support (EMT's standard of care...little more than cpr & 02)

Try this site for starters. And make sure you go ALS...you don't want to wind up doing transports all night. Enjoy! EMS is a blast!
 

DropkickMurphy

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I highly recommend the link that CARN311 recommended. It's a good site with lots of really good, honest and very experienced prehospital providers on it. :thumbup:
 

leviathan

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carn311 said:
ALS= Advanced Life Support (paramedic's standard of care)
BLS= Basic Life Support (EMT's standard of care...little more than cpr & 02)
I believe there would be quite a lot of people that would disagree with your statement about EMTs. Of course, I'm not very familiar with the standard of care of BLS in the US, so maybe I'm mistaken.
 

OSUdoc08

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leviathan said:
I believe there would be quite a lot of people that would disagree with your statement about EMTs. Of course, I'm not very familiar with the standard of care of BLS in the US, so maybe I'm mistaken.

BLS is never used for 911 care unless it is the only ambulance service available.

They cannot transport patients that require EKG's, IV's, advanced airway support, defibrillation/cardioversion, medication administration, cricothyrotomy, needle thoracostomy, et. al.

As a result, you will not be seeing ANY advanced care on a BLS ambulance. In many cases the ambulance does not even carry the proper equipment for YOU to use anyway.

An EMT is simply 1 month-1 semester of training, and these people serve mainly as the ambulance driver on ALS units.

(I was an EMT for 3 years, by the way.)
 

southerndoc

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OSUdoc08 said:
BLS is never used for 911 care unless it is the only ambulance service available.

They cannot transport patients that require EKG's, IV's, advanced airway support, defibrillation/cardioversion, medication administration, cricothyrotomy, needle thoracostomy, et. al.

As a result, you will not be seeing ANY advanced care on a BLS ambulance. In many cases the ambulance does not even carry the proper equipment for YOU to use anyway.

An EMT is simply 1 month-1 semester of training, and these people serve mainly as the ambulance driver on ALS units.

(I was an EMT for 3 years, by the way.)
You'll definitely see much more on an ALS unit. As OSUdoc points out, ALS units are usually sent to the more serious calls (chest pain, shortness of breath, etc.).

Some places do not send BLS units on ANY 9-1-1 call. We are rather aggressive with our BLS units and send them as the primary responders for all MVC's, abdominal pains, "bleeding," and other calls where there is a low likelihood (<10%) of an ALS intervention.
 

OSUdoc08

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southerndoc said:
You'll definitely see much more on an ALS unit. As OSUdoc points out, ALS units are usually sent to the more serious calls (chest pain, shortness of breath, etc.).

Some places do not send BLS units on ANY 9-1-1 call. We are rather aggressive with our BLS units and send them as the primary responders for all MVC's, abdominal pains, "bleeding," and other calls where there is a low likelihood (<10%) of an ALS intervention.

Also note that a large percentage of fire departments are EMT's and above, and thus are BLS first responders for the ALS & MICU units that may have a longer response time.
 

Hawk22

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For those looking for more in-depth information about EMS and all the great things that they do, I highly recommend the newest edition of Principles of EMS Systems by Brennan and Krohmer. I have a background as an EMT basic and I am doing alot more EMS focused work and research this year, so I picked up a copy at ACEP at the DC meeting. I'm about 1/3 of the way through it so far and I think it provides a great general overview of EMS, with lots of references to more in-depth reading.

Its published by ACEP, but is a little pricey. Here's the link for those interested:
http://www2.acep.org/bookstore/index.cfm?go=product.detail&id=10248
 

leviathan

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Ahhh, I see I see.

Up here it's a 1 year program to be a primary care paramedic (basic life support), so that's probably why I thought people would take offense. And PCPs can do IV therapy along with basic drugs (dextrose, narcan, entonox, nitro, etc) and are trained in a lot of pathophysiology...Advancd care paramedics then go to take another ~6-12 months of training to become certified as ACPs for all the ALS techniques aforementioned by yourself. I'm surprised they let people operate in EMS after only a month of training, but if they aren't doing 9-1-1 calls then it makes more sense.


OSUdoc08 said:
BLS is never used for 911 care unless it is the only ambulance service available.

They cannot transport patients that require EKG's, IV's, advanced airway support, defibrillation/cardioversion, medication administration, cricothyrotomy, needle thoracostomy, et. al.

As a result, you will not be seeing ANY advanced care on a BLS ambulance. In many cases the ambulance does not even carry the proper equipment for YOU to use anyway.

An EMT is simply 1 month-1 semester of training, and these people serve mainly as the ambulance driver on ALS units.

(I was an EMT for 3 years, by the way.)
 

carn311

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leviathan said:
Ahhh, I see I see.

Up here it's a 1 year program to be a primary care paramedic (basic life support), so that's probably why I thought people would take offense. And PCPs can do IV therapy along with basic drugs (dextrose, narcan, entonox, nitro, etc) and are trained in a lot of pathophysiology...Advancd care paramedics then go to take another ~6-12 months of training to become certified as ACPs for all the ALS techniques aforementioned by yourself. I'm surprised they let people operate in EMS after only a month of training, but if they aren't doing 9-1-1 calls then it makes more sense.

I'm an EMT-B (BLS provider) and I ride 911 calls with only an untrained driver along with me. The closest ALS support is 20 minutes away. This is a great opportunity for me as a premed because I have to push myself to delever the best care possible in less than ideal circumstances. While I agree that ALS care is something that our squad (volunteer) should be looking toward in the near future so as not to continue to do our patients a disservice; just remember: in EMS "you need good BLS in order to have good ALS". We are, as EMT-B's, limited in our scope of practice but don't discount our competancy or our drive to be the most effective providers we can be.
 

southerndoc

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OSUdoc08 said:
Also note that a large percentage of fire departments are EMT's and above, and thus are BLS first responders for the ALS & MICU units that may have a longer response time.
Just to clarify, I was stating that BLS transport companies are the primary responders/transporters with no ALS transport unit dispatched unless called for by a first responder or the BLS ambulance when it arrives on scene for MVC's, "bleeding," abdominal pain, etc.
 

OSUdoc08

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southerndoc said:
Just to clarify, I was stating that BLS transport companies are the primary responders/transporters with no ALS transport unit dispatched unless called for by a first responder or the BLS ambulance when it arrives on scene for MVC's, "bleeding," abdominal pain, etc.

That seems to be a substandard level of care to me. Wouldn't a critical patient have an undue delayed call-to-advanced care response time?

I suppose this is a necessary evil in areas with limited coverage, but this wouldn't seem appropriate in higher population areas.
 

leviathan

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carn311 said:
I'm an EMT-B (BLS provider) and I ride 911 calls with only an untrained driver along with me. The closest ALS support is 20 minutes away. This is a great opportunity for me as a premed because I have to push myself to delever the best care possible in less than ideal circumstances. While I agree that ALS care is something that our squad (volunteer) should be looking toward in the near future so as not to continue to do our patients a disservice; just remember: in EMS "you need good BLS in order to have good ALS". We are, as EMT-B's, limited in our scope of practice but don't discount our competancy or our drive to be the most effective providers we can be.

Hey, I'm a BLS pre-med as well, but I'm not familiar with your system and was just going off what was said ("only CPR and oxygen"). I'm sure that was an understatement! :)
 

southerndoc

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OSUdoc08 said:
That seems to be a substandard level of care to me. Wouldn't a critical patient have an undue delayed call-to-advanced care response time?

I suppose this is a necessary evil in areas with limited coverage, but this wouldn't seem appropriate in higher population areas.
No, it's not substandard care when very few of these patients were receiving ALS interventions when ALS units were responding.

Besides, the OPALS studies seem to suggest paramedic interventions have limited changes in outcome.
 

OSUdoc08

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southerndoc said:
No, it's not substandard care when very few of these patients were receiving ALS interventions when ALS units were responding.

Besides, the OPALS studies seem to suggest paramedic interventions have limited changes in outcome.

Surely this study is excluding patients with lethal arrythmias or shock, right?
I'd hate to be bleeding all over the ground with a systolic of 60 and have 2 EMT's show up to save me.

I suppose I can understand BLS units in a rural area, with an "on-call" paramedic, since that is they style of service I worked for when I was an EMT at first. The service was "BLS with MICU capability." We would most commonly have an EMT-Intermediate there if a paramedic was not available, however. Sometimes all they could get for coverage was EMT's since it was a volunteer unit, and if no paramedics were available to be "on-call," the supervisor had to do it.
 

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leviathan said:
Hey, I'm a BLS pre-med as well, but I'm not familiar with your system and was just going off what was said ("only CPR and oxygen"). I'm sure that was an understatement! :)
Hey, I'm an EMT-B from Minnesota, and we have a whole FIVE drugs we can administer.

One of them is oxygen. None of them are IV. One is "Hey, guy, I can help you administer your inhaler, if you need a hand." :rolleyes:

So I'm not offended in the least at the suggestion that Basics are limited. We should be, really. But for the most common complaints, we're suitable. In the city, the hospital runs two-Paramedic crews, the private 911-response companies tend to go one EMT and one medic, and the transport companies use two EMTs. Seems to work out well.
 

hakksar

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OSUdoc08 said:
Surely this study is excluding patients with lethal arrythmias or shock, right?
I'd hate to be bleeding all over the ground with a systolic of 60 and have 2 EMT's show up to save me.

I suppose I can understand BLS units in a rural area, with an "on-call" paramedic, since that is they style of service I worked for when I was an EMT at first. The service was "BLS with MICU capability." We would most commonly have an EMT-Intermediate there if a paramedic was not available, however. Sometimes all they could get for coverage was EMT's since it was a volunteer unit, and if no paramedics were available to be "on-call," the supervisor had to do it.

There is actually quite a bit of evidence coming out that ALS provides no real advantage for trauma patients. That being said for medical patients and in particular cardiac patients I think paramedics offer an advantage (although with the increasing use of AED's even by bystanders this might not be as true as it once was). I am too lazy and busy studying for Pharm to look up the studies right now but I know I have read 2 or 3 articles in either Annals of EM or Academic EM in the last year or so looking at ALS vs BLS in trauma. However, for the op it makes sense for a med student to ride on an ALS ambulance over a BLS just for the advanced capabilities and because a lot of systems use only ALS for 911 calls.

edit: In Colorado where I worked as an EMT-B we could administer IV's for fluid replacement, D-50, O2, Asprin, oral glucose, Activated Charcoal that we carried and Nitro, Epi-pen, and Albuterol inhaler if the patient had it. However, a lot of that had to be online direction . . . the scope for EMT's is very state and system dependent.
 

leviathan

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Febrifuge said:
Hey, I'm an EMT-B from Minnesota, and we have a whole FIVE drugs we can administer.
I know you are an EMT, Feb. :)

One of them is oxygen. None of them are IV. One is "Hey, guy, I can help you administer your inhaler, if you need a hand." :rolleyes:

So I'm not offended in the least at the suggestion that Basics are limited. We should be, really. But for the most common complaints, we're suitable. In the city, the hospital runs two-Paramedic crews, the private 911-response companies tend to go one EMT and one medic, and the transport companies use two EMTs. Seems to work out well.
Don't they give you permission to use Entonox or Nitro as a Basic?
 

southerndoc

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OSUdoc08 said:
Surely this study is excluding patients with lethal arrythmias or shock, right?
I'd hate to be bleeding all over the ground with a systolic of 60 and have 2 EMT's show up to save me.

No, it did not exclude patients in shock. Our BLS units carry AED's.

We do not send BLS units to chest pain patients, shortness of breath, or any call where an ALS intervention might be likely. However, if <10% of a certain type of call is receiving an ALS intervention, then why send an ALS unit?
 

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southerndoc said:
No, it did not exclude patients in shock. Our BLS units carry AED's.

We do not send BLS units to chest pain patients, shortness of breath, or any call where an ALS intervention might be likely. However, if <10% of a certain type of call is receiving an ALS intervention, then why send an ALS unit?

So, patients in hypovolemic shock don't have an improvement in mortality rates with IV administration in the field?
 

OSUdoc08

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southerndoc said:

So I guess there is not need to start an IV on any trauma patient in the field then, right?

If so, why is this the standard?
 

WestcoastMedicine

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I rode as an EMT-B in New Jersey and Pennsylvania for 4 years and BLS is sent to every call, our ALS does not transport patients. They couldn't even if they wanted to because they respond in tahoes or suburbans and have no cots. If it is chest pain or some other obvious call where ALS intervention is likely they are also dispatched the same time BLS is. Otherwise it is up the BLS providers to contact dispatch for an ALS unit. Wow, I didn't realize how different some parts of the country handle their medical 911 calls.
 

OSUdoc08

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LHUEMT911 said:
I rode as an EMT-B in New Jersey and Pennsylvania for 4 years and BLS is sent to every call, our ALS does not transport patients. They couldn't even if they wanted to because they respond in tahoes or suburbans and have no cots. If it is chest pain or some other obvious call where ALS intervention is likely they are also dispatched the same time BLS is. Otherwise it is up the BLS providers to contact dispatch for an ALS unit. Wow, I didn't realize how different some parts of the country handle their medical 911 calls.

All major cities in Texas and Oklahoma have a paramedic on EVERY ambulance that responds to 911 calls. In fact, a large majority have ONLY paramedics on the ambulance, since most fire departments do EMS (i.e. Dallas/Ft. Worth, Houston, San Antonio). Those that have private EMS services independent of fire will often have a mixed crew with a medic and either an EMT-I or EMT-B (i.e. Austin, Oklahoma City, Tulsa). The fire department first responds in all cases, and a large majority are ECA/EMT certified, with several also being EMT-I/paramedics.

I only find that BLS units respond in rural areas, where ALS is "on call" or a supervisor responder. Unfortunately, in these areas, there is a longer transport time, with a greater need for ALS. Short transports in large cities (notwithstanding traffic) where the hospital is nearby may not require as much ALS care urgently.
 

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Having an EMS background is an incredible advantage when going into EM, at least in my opinion. I started as an EMT-basic, then became an EMT-CT in Virginia, and finally a Nationally Registered paramedic (Gold patch). You medics know what I mean.

It gave me an incredible amount of confidence to remain calm and collected during stressful encounters, and it carried me through PA school and later now medical school. I'll graduate near the top of my class and with top board scores and I believe I owe it all to my EMS roots. That said, you cannot learn EMS lingo and culture in a book. But as a resident you will do lots of EMS ride alongs and flights so don't stress over it in the slightest.

OSUdoc,
Southern doc is correct. Trauma studies now show that the single best thing for a trauma patient is to get moving with them. ALS providers have a bad habit of staying on scene too long to do lines and stuff, and now we are not even sure if isotonic fluids even really help all that much in hypovolemic shock. After all, there is no oxygen carrying capacity in lactated ringers, and perhaps it does more harm. And blood on the shelf longer than days has no real oxygen carrying capacity either because of its inactivated 2,3 DPG. As a medic with years of experience and hundreds of calls, I firmly believe that ALS care is invaluable for medical calls, but that trauma is not an ALS issue. I believe the standard of care for airway control should be LMA's or ET's down to the EMT basic level.
 

12R34Y

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OSUdoc08 said:
All major cities in Texas and Oklahoma have a paramedic on EVERY ambulance that responds to 911 calls. In fact, a large majority have ONLY paramedics on the ambulance, since most fire departments do EMS (i.e. Dallas/Ft. Worth, Houston, San Antonio). Those that have private EMS services independent of fire will often have a mixed crew with a medic and either an EMT-I or EMT-B (i.e. Austin, Oklahoma City, Tulsa). The fire department first responds in all cases, and a large majority are ECA/EMT certified, with several also being EMT-I/paramedics.

I only find that BLS units respond in rural areas, where ALS is "on call" or a supervisor responder. Unfortunately, in these areas, there is a longer transport time, with a greater need for ALS. Short transports in large cities (notwithstanding traffic) where the hospital is nearby may not require as much ALS care urgently.

Multicenter Canadian Study of Prehospital Trauma Care.
Annals of Surgery. 237(2):153-160, February 2003.
Liberman, Moishe MD *+; Mulder, David MD *; Lavoie, Andre PhD ++; Denis, Ronald MD ; Sampalis, John S. PhD [//]
Abstract:
Objective: To evaluate whether the type of on-site care a trauma patient receives affects outcome.

Summary Background Data: The controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients.

Methods: This prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge.

Results: The overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%.

Conclusions: In urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients.

There is a fair amount more where this came from showing the same thing. OPALS is of course huge, but there are numerous smaller studies all showing one thing..........ALS and trauma does NOT equal better survivability.

later
 

hakksar

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corpsmanUP said:
I believe the standard of care for airway control should be LMA's or ET's down to the EMT basic level.

Although, definitive airway is often important, there is substantial evidence that it is not that important in the prehospital environment for trauma:

J Trauma. 2005 May;58(5):933-9.

The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury.

Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F, Eastman AB, Velky T, Hoyt DB.

Department of Emergency Medicine, School of Medicine, University of California, San Diego, 92103-8676, USA. [email protected]

BACKGROUND: Although early intubation to prevent the mortality that accompanies hypoxia is considered the standard of care for severe traumatic brain injury (TBI), the efficacy of this approach remains unproven. METHODS: Patients with moderate to severe TBI (Head/Neck Abbreviated Injury Scale [AIS] score 3+) were identified from our county trauma registry. Logistic regression was used to explore the impact of prehospital intubation on outcome, controlling for age, gender, mechanism, Glasgow Coma Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension. Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation. RESULTS: A total of 13,625 patients from five trauma centers were included; overall mortality was 22.9%, and 19.3% underwent prehospital intubation. Logistic regression revealed an increase in mortality with prehospital intubation (odds ratio, 0.36; 95% confidence interval, 0.32-0.42; p < 0.001). This was true for all patients, for those with severe TBI (Head/Neck AIS score 4+ and/or Glasgow Coma Scale score of 3-8), and with exclusion of patients transported by aeromedical crews. Patients intubated in the field versus the emergency department had worse outcomes. Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation. CONCLUSION: Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively.

also see:

J Trauma. 2003 Feb;54(2):307-11.

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury.

Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM.

R Adams Cowley Shock Trauma Center and University of Maryland Medical School, Baltimore, 21201, USA. [email protected]

OBJECTIVES: There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS: Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS: Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION: Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.

I also know I saw a study in Annals of EM in the last year where head trauma patients intubated with RSI in the field by flight nurses did best, followed by BLS techniques, with intubations without RSI by Paramedics doing the worst even after statistical analysis eliminating injury score and transport time as factors.
 

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OSUdoc08 said:
So I guess there is not need to start an IV on any trauma patient in the field then, right?

If so, why is this the standard?

True, there is no evidence that starting an IV on a trauma patient provides any benefit. This is the standard of care for the same reason lots of things are: it seemed to make sense that it would be helpful but no studies were done to prove it (similar to the old belief that administering post-menopausal women HRT would decrease mortality which we all know is not true now, or the old belief that it was important to backboard any patient with mechanism even if they had no complaints, no distracting injuries, and no neurotrauma or intoxication because there might be an occult cervical fx . . . which has also been shown to be a false assumption).

However, prehospital IV's for trauma patients might become warranted depending on what the Polyheme trial finds . . . but as of now, Prehospital Crystalloid IV's really do not improve the chances of trauma survival.
 

corpsmanUP

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The UCSD study on intubation is a bit skewed. First of all, what alternative exists for not providing an airway to a patient who is either apneic or AMS and hypoxic? As you know, 6-8 minutes without supplemental oxygen in this situation causes irreversible brain death. What alternative would you advocate? I challenge anyone to try and drop an OP and bag someone solo or with a partner for miles in the back of the bus. It won't work. Its hard enough to do on the OR table with the patient paralyzed. There simply is no other option and to me a study like this makes no sense.
 

southerndoc

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OSUdoc08 said:
So I guess there is not need to start an IV on any trauma patient in the field then, right?

If so, why is this the standard?
No, there is no need to start an IV in the field for trauma patients.

Trauma patients need a surgeon, not an IV. There is evidence that suggests that trauma patients who are aggressively fluid resuscitated in the field have worse outcome when compared to those who receive no pre-hospital IV fluids.
 

southerndoc

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OSUdoc08 said:
All major cities in Texas and Oklahoma have a paramedic on EVERY ambulance that responds to 911 calls. In fact, a large majority have ONLY paramedics on the ambulance, since most fire departments do EMS (i.e. Dallas/Ft. Worth, Houston, San Antonio). Those that have private EMS services independent of fire will often have a mixed crew with a medic and either an EMT-I or EMT-B (i.e. Austin, Oklahoma City, Tulsa). The fire department first responds in all cases, and a large majority are ECA/EMT certified, with several also being EMT-I/paramedics.

Just because a city has an all ALS system doesn't make it the standard of care. The top systems in the world -- Boston, Seattle, etc. -- use tiered response. It is a waste of resources to be sending paramedics on every 9-1-1 call. If there is <10% likelihood of ALS interventions, then ALS response is not needed.

Too many paramedics can be detrimental. Ask Lincoln, NE that. Their increase in paramedics caused a dilution in procedures, which caused their intubation success rates to drop dramatically.
 

hakksar

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corpsmanUP said:
The UCSD study on intubation is a bit skewed. First of all, what alternative exists for not providing an airway to a patient who is either apneic or AMS and hypoxic? As you know, 6-8 minutes without supplemental oxygen in this situation causes irreversible brain death. What alternative would you advocate? I challenge anyone to try and drop an OP and bag someone solo or with a partner for miles in the back of the bus. It won't work. Its hard enough to do on the OR table with the patient paralyzed. There simply is no other option and to me a study like this makes no sense.

Well considering that the study below in its text (but not its abstract) found that when aeromedical flight nurses intubated using RSI they had a better result than either BLS or ALS units and they hypothesized that this was either due to a neuroprotective effect of RSI or (in my opinion less likely) a higher level of skill by the flight nurses I would suggest we wait and see what the studies of EMT-P's using RSI shows (this is controversial I know since there are also several studies in Ann of EM that have found worse outcomes with Paramedic RSI as well). However, the fact remains that the studies have repeatedly shown that Head Trauma patients do worse with Paramedic Intubation than BLS techniques.

Ann Emerg Med. 2004 Nov;44(5):439-50.

Out-of-hospital endotracheal intubation and outcome after traumatic brain injury.

Wang HE, Peitzman AB, Cassidy LD, Adelson PD, Yealy DM.

Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA. [email protected]

STUDY OBJECTIVE: Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury. METHODS: From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage). RESULTS: There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52). CONCLUSION: Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.
 
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