Unable to gain intravenous access in a pt bleeding out, what's the next step?

[Rendar5]

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I have yet to do one in an actual emergency due to the fact that we cannot do them in the counties I interned in and worked in. I liked the IJ because (also why I like EJ) of the fact that I could remain at the head and gain access and then go to maintaining the airway, it just seemed natural.

That's absolutely crazy for a pre-hospital provider to be trained in or be allowed to perform a central line. Instead of takingg the 5-10 minutes to perform a sterile procedure in a non-sterile fashion that has a 5% complication rate even in experienced hands, they should be applying the foot to the gas, hold pressure, throw an EJ or an IO, and just get them to the hospital.

If they're honestly bleeding that fast where they need the line, then they need blood products, not saline.

EDIT: This has nothing to do with paramedic v. doc. I don't think a doc in the field should be placing a central line either. There's a lot of risk, and no benefit.

 

[Lawsonc]

That's absolutely crazy for a pre-hospital provider to be trained in or be allowed to perform a central line. Instead of takingg the 5-10 minutes to perform a sterile procedure in a non-sterile fashion that has a 5% complication rate even in experienced hands, they should be applying the foot to the gas, hold pressure, throw an EJ or an IO, and just get them to the hospital.

If they're honestly bleeding that fast where they need the line, then they need blood products, not saline.

EDIT: This has nothing to do with paramedic v. doc. I don't think a doc in the field should be placing a central line either. There's a lot of risk, and no benefit.

I don't work in a county where we can do it, we are however trained in it, as there are places where it is performed. It wouldn't be my choice, but I'm glad I know how to do it.

 

[Lawsonc]

King County- MICP Basic protocols-

I am not "100%" sure but I don't know if they use IO in the field other then handcranked for peds.

[FONT=Arial,Helvetica,Geneva,Swiss,SunSans-Regular]Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV lines), in central and peripheral veins; and monitor and administer medications through pre-existing vascular access (i.e. port-a-cath) Frequently central lines are initiated if peripheral access is unavailable.


http://www.kingcounty.gov/healthservices/health/ems/MedicOne/scope.aspx

.

 

[deleted109597]

but I'm glad I know how to do it.

Why? You shouldn't ever do it in the field. Period.

Any other things you're taught at your best medic school in the world that just so happens to be in the best medic system in the world? Do you all do thoracotomies? Selective lung ventilation? C-sections? Skin grafting? EGDT?

 

[Lawsonc]

Why? You shouldn't ever do it in the field. Period.

Any other things you're taught at your best medic school in the world that just so happens to be in the best medic system in the world? Do you all do thoracotomies? Selective lung ventilation? C-sections? Skin grafting? EGDT?

Nope, and I hope to never be in a situation where I have to do anything like that, knowledge is not a bad thing, as I hope to go to medical school one day.

 

[Lawsonc]

The original poster about the IJ/SUB CLAV was talking about the art, without ultrasound. I mentioned how we learned how to do it in the field without ultrasound, I mentioned through practice I liked the IJ for various reasons. I mentioned how I will probably never do it because where I will be working does not allow it. I mentioned how there are counties that do perform centrals in the field and provided a link to the King county protocols.

Why the hostility?

If you dont agree with it, thats fine.

I won't be held liable for not performing a central because that is not within the scope where I am. I know how to do it, in its most basic form. What is wrong with that?

 

[Rendar5]

The original poster about the IJ/SUB CLAV was talking about the art, without ultrasound. I mentioned how we learned how to do it in the field without ultrasound, I mentioned through practice I liked the IJ for various reasons. I mentioned how I will probably never do it because where I will be working does not allow it. I mentioned how there are counties that do perform centrals in the field and provided a link to the King county protocols.

Why the hostility?

If you dont agree with it, thats fine.

I won't be held liable for not performing a central because that is not within the scope where I am. I know how to do it, in its most basic form. What is wrong with that?

The problem is that it shouldn't be taught because a little knowledge can go a long way towards harming a patient. Now what you linked is pretty much the top paramedics in the country from what I understand. Even so, I don't think it's an issue of training, but an issue of what should and shouldn't be done in the field.

 

[Lawsonc]

The problem is that it shouldn't be taught because a little knowledge can go a long way towards harming a patient. Now what you linked is pretty much the top paramedics in the country from what I understand. Even so, I don't think it's an issue of training, but an issue of what should and shouldn't be done in the field.

This is where I don't understand the mentality on this board (and not you in particular Rendar5), I really thought this forum would be more open to conversation and ideas. In terms of little knowledge going a long way, I guess that is the whole point? That is why you receive the training. I am not able to operate on my own and do what I want, I have protocols set forth by the MPD. If the MPD states he wants central lines, I have received the training and I run into a patient where it is indicated, I am by standard of care mandated to perform the procedure.

There is critical thinking involved and a judgement call on when and where, but that is what education and training is for.

I know some literature states the pre-hospital conditions are not ideal for these procedures, but until my protocols and MPD change, I do my job to the scope.

EDIT- Using Central lines as an example, I however, am not working in a county that allows centrals, nor did I intern in any. Although if for whatever reason it was considered an option, that is what online medical control is for. (where we call in)

 

[Rendar5]

Not sure why you think my mentality is so negative. I just think central lines in the field is a bad idea regardless of who does it, whether it's a doctor with 200 central lines behind him or a paramedic trained in them. It is no longer a life-saving intervention when done in the field now that we have IO access, and there is a risk of line infections, pneumothoraces, arterial punctures, etc.

No benefit, known risk = don't teach it because someone may pick it over an IO for some reason.

EDIT: just so you know where I come from, I work in a county where the trained paramedics are absolutely wonderful and very-well trained. I want my paramedics intubating patients and performing other life-saving treatments on the bus.

 

[Lawsonc]

Not sure why you think my mentality is so negative. I just think central lines in the field is a bad idea regardless of who does it, whether it's a doctor with 200 central lines behind him or a paramedic trained in them. It is no longer a life-saving intervention when done in the field now that we have IO access, and there is a risk of line infections, pneumothoraces, arterial punctures, etc.

No benefit, known risk = don't teach it because someone may pick it over an IO for some reason.

EDIT: just so you know where I come from, I work in a county where the trained paramedics are absolutely wonderful and very-well trained. I want my paramedics intubating patients and performing other life-saving treatments on the bus.

Rendar5 I'm sorry if I was not clear, its the general atmosphere, not you in particular. (there were some other posts)

As far as the "mentality" we were trained in, these advanced procedures were exactly that, advanced. We learned all about statistics, infection rates, complications, contraindications, etc. However as you must know emergency medicine never goes according to plan.

What if you can't get a peripheral IV, your EZ-IO miraculously ran out of batteries, and throwing drugs down the tube just is not working on this code you are running at a burger king. Why not get on the radio/phone/etc, and ask "hey, we have XYZ can't get access, want to keep going at it, I'd like to start an IJ or Subclav?" What is the harm? Its not your front line procedure.

Same goes with RSI, Surgical airways etc. You give people the tools they need for the job. Just because they have it, strict guidelines and education should be in place to prevent abuse. Run reviews, continued education, and strict oversight by the MPD or MSO.

How many traumatic arrests have been brought back with pericardiocentesis in the field? I have heard of 2 in the region, talked about it in class. Is it something you can just jump out and do? Nope, but its good to have basic training, and the ability to consult prior to performing. Whats the worse that could happen? The patient is "dead" already.

 

[Cerberus]

Not sure why you think my mentality is so negative. I just think central lines in the field is a bad idea regardless of who does it, whether it's a doctor with 200 central lines behind him or a paramedic trained in them. It is no longer a life-saving intervention when done in the field now that we have IO access, and there is a risk of line infections, pneumothoraces, arterial punctures, etc.

No benefit, known risk = don't teach it because someone may pick it over an IO for some reason.

EDIT: just so you know where I come from, I work in a county where the trained paramedics are absolutely wonderful and very-well trained. I want my paramedics intubating patients and performing other life-saving treatments on the bus.

I agree with this. The back of an ambulance is not the place to put a central line in and if you aren't in the back of an ambulance, speeding towards the hospital, in a pt sick enough to warrant central access, you should be.

 

[Rendar5]

What's the benefit? You already have access for epi via the ET tube. It's not like pericardiocentesis where there's a clear benefit.

 

[Lawsonc]

What's the benefit? You already have access for epi via the ET tube. It's not like pericardiocentesis where there's a clear benefit.

What about the other meds that can't go down the tube?

In response to a comment about diesel therapy, dead bodies don't ride.

I'm going to play devils advocate the whole way though. Will I ever start one? Probably never, will I work in a county that allows it? Probably not. Do I like the option? I personally do, but I have a whole bunch of other tools in the box that I prefer.

Like you mentioned this is not about what level, this is about field conditions versus controlled conditions (in the hospital)

I will say, as a field personnel, I do not believe skills make the provider, but having the ability to use certain skills when indicated is undeniably beneficial.

This is also my opportunity to show humility to the fact that like it or not, if I am told by protocol that we are to perform said skill, I have to, to maintain a standard of care.

 

[deleted109597]

This is where I don't understand the mentality on this board (and not you in particular Rendar5), I really thought this forum would be more open to conversation and ideas. In terms of little knowledge going a long way, I guess that is the whole point? That is why you receive the training. I am not able to operate on my own and do what I want, I have protocols set forth by the MPD. If the MPD states he wants central lines, I have received the training and I run into a patient where it is indicated, I am by standard of care mandated to perform the procedure.

See, that's where you're wrong. You're perceiving us being against you, but in general, most of us are against the idea of medics peforming those services. Almost everyone here has much more education about emergency medicine than you. We do it every day, and many of us look at the research. There are quite a few people on here with EMS background. That being said, the literature does not support much more than diesel for most conditions. If you're sitting at Burger King putting in a central line, I bet you could have been to the hospital by the time you get it in. Sorry, but sub 60 central line times are tough when the patient is in a big room at appropriate height. I've had some that take more than 30 minutes (elective, but still).

I know some literature states the pre-hospital conditions are not ideal for these procedures, but until my protocols and MPD change, I do my job to the scope.

We aren't saying you shouldn't follow your protocols. We're saying those protocols are jacked. And it isn't some literature. It is the overwhelming majority.
Just like the literature really doesn't support aeromedical evac for most conditions. It costs a lot and kills people but doesn't save many lives. I think it has a place, but it is vastly overused. I'm happy that you're not putting CVLs in people every day, because if you were, you would be doing way too many.

 

[xaelia]

Not sure what proven lifesaving medications you critically need a central line for prior to transport. Rectal, intranasal, intramuscular, and ETT options are more than you need for a brief period.

A paramedic in the field with limited scope of practice is no substitute for the full resources of the Emergency Department. Plenty of literature supports minimizing time on scene. Scoop and run.

 

[Hamhock]

That's absolutely crazy for a pre-hospital provider to be trained in or be allowed to perform a central line. Instead of takingg the 5-10 minutes to perform a sterile procedure in a non-sterile fashion that has a 5% complication rate even in experienced hands, they should be applying the foot to the gas, hold pressure, throw an EJ or an IO, and just get them to the hospital.

If they're honestly bleeding that fast where they need the line, then they need blood products, not saline.

EDIT: This has nothing to do with paramedic v. doc. I don't think a doc in the field should be placing a central line either. There's a lot of risk, and no benefit.

👍
I couldn't agree more.
HH

 

[Hamhock]

What if you can't get a peripheral IV, your EZ-IO miraculously ran out of batteries, and throwing drugs down the tube just is not working on this code you are running at a burger king. Why not get on the radio/phone/etc, and ask "hey, we have XYZ can't get access, want to keep going at it, I'd like to start an IJ or Subclav?" What is the harm? Its not your front line procedure.

no PIV, no EZ-IO?
Compressions and Transport. That's it.
Do not waste time with drugs. They are nearly useless anyway.
If you get ROSC, then there is an arguement for hurried intravenous access - but otherwise, stop wasting time. I would argue pushing epi or anything else down the tube is a waste also and likely a distraction from compressions and maybe electricity.
HH

 

[FDNewbie]

I wanted to echo bulgethetwine's sentiment. I'm a big subclavian guy. But in the case of a hemophiliac, a compressible site is definitely #1 on my priority list = femoral introducer. If I failed for any reason on both sides (really weird anatomy etc), subclavian would be my next choice. Because I can tell ya that of the 100+ lines I've done, EASILY 90% of them are subclavians. I need ZERO prep time. While you're still trying to fetch the U/S, I can have the line in in about 30 seconds - 1 min.

I dunno about others' experiences, but I've hit the femoral artery a hell of a lot more times while doing a femoral line than I have hit the subclavian artery. As previously said, you're much more likely to get NO flash at all during a subclavian attempt than to hit the artery.

Another thing to take into account is I am completely uncomfortable doing blind IJs, as I've only done 1 or 2 in my life...and that was in med school. With the advent & availability of U/S, blind IJ technique has pretty much died...although I think it certainly has its place (in a crash situation). So that's a shortcoming I'd like to overcome one of these days. The prob is, that's a tough thing to defend if you have any complications, since you have the U/S available to you. So it's a catch-22.

Re: I/Os, what's the problem/concern with sternal I/Os? I know the medics in Fairfax County, VA routinely use them if it comes to needing a sternal I/O.

On a side note, I'm really curious who's ever done a femoral cutdown? I've seen 'em, but never did one.

 

[EMS5]

Ok, I'm in with hamhock. ET medication administration is a waste. Never had a pt come back after having to resort to flushing the meds. Aside from that, there are five primary meds you can give et (epi, atropine, lido, narcan, and I believe vasopressin)... With the advent of intranasal narcan and IO guns, or the manual if your batteries die, there is no practical reason to be giving meds down the tube.

 

[FDNewbie]

That's absolutely crazy for a pre-hospital provider to be trained in or be allowed to perform a central line.

I know the older medics in my EMS system used to perform femoral lines routinely back in the day in unstable patients. So it was definitely something they were taught.

Instead of takingg the 5-10 minutes to perform a sterile procedure in a non-sterile fashion that has a 5% complication rate even in experienced hands, they should be applying the foot to the gas, hold pressure, throw an EJ or an IO, and just get them to the hospital.

If they're honestly bleeding that fast where they need the line, then they need blood products, not saline.

EDIT: This has nothing to do with paramedic v. doc. I don't think a doc in the field should be placing a central line either. There's a lot of risk, and no benefit.

If you agree that you'd be performing a crash line in a non-sterile fashion, I can tell ya in the hands of experienced individuals, it certainly doesn't take 5-10 minutes. In my cardiac arrests brought in without IV access, 9 times outta 10, I have a crash/dirty femoral CVL in within 30 seconds of them hitting the bed. 1 minute tops, if I didn't have the line cart ready. And we can grab blood/labs to run an iStat from it, as well as push meds.

Granted, I'm not advocating delaying patient care in place of securing a central line, but a prehospital central line certainly has its place - prolonged extracations, extended transport times etc. And the Board of Emergency Medicine agrees; if you check the 2009 EMS Fellowship Draft Curriculum, it's one of the Goals & Objectives (performing prehospital placement of central venous catheters).

 

[Lawsonc]

no PIV, no EZ-IO?
Compressions and Transport. That's it.
Do not waste time with drugs. They are nearly useless anyway.
If you get ROSC, then there is an arguement for hurried intravenous access - but otherwise, stop wasting time. I would argue pushing epi or anything else down the tube is a waste also and likely a distraction from compressions and maybe electricity.
HH

Rolling dead bodies is not done in many places anymore. It is both wreckless, dangerous and pointless. You cannot do adequate compressions, and treatment while moving. This idea of medics doing procedures at 70mph is fictitious.

 

[Groove]

CVL's should never be performed in the field by a medic. EVER. I don't care what crazy county protocol link you provide, if I were on the med control line with a medic in the field, I would never under any circumstance instruct him to perform a CVL. I consider that malpractice.

Lawsonc, your attitude seems to stem from one of yearning for empowerment beyond your scope of practice, skillset, knowledge or abilities. In another thread we just heard you say..

What training do you need to intubate?

An anesthesiologist took the time to post an "lol", while we all read that statement dumfounded. You seem to think many of these procedures/interventions are analogous to learning to ride a bike or changing a tire. These are procedures that we do consistently and routinely, yet still hold them with the utmost respect in regarding potential and unforeseen complications.

You're attitude seems either reckless or the result of not being educated enough about the potential harm to the pt you are transporting.

I don't ever want you dicking around with a CVL in a 7-11 parking lot. I want you hauling ass to the ED and doing the best that you can within your scope to stabilize the pt until they get there. That's the best thing you could possibly do. The more time you take, the less their chances of survival.

If you want to do CVL's and Intubate with every RSI protocol imagineable, then go to medical school.

 

[deleted109597]

You cannot do adequate compressions, and treatment while moving.

So your area doesn't transport codes? Because almost all of them die. If you drive fast enough, they die in the ICU. Otherwise, they die on the street. I'm not saying one is better, but if you're saying you don't roll until ROSC or calling it, I think your system is seriously flawed.

 

[Lawsonc]

CVL's should never be performed in the field by a medic. EVER. I don't care what crazy county protocol link you provide, if I were on the med control line with a medic in the field, I would never under any circumstance instruct him to perform a CVL. I consider that malpractice.

Lawsonc, your attitude seems to stem from one of yearning for empowerment beyond your scope of practice, skillset, knowledge or abilities. In another thread we just heard you say.. An anesthesiologist took the time to post an "lol", while we all read that statement dumfounded. You seem to think many of these procedures/interventions are analogous to learning to ride a bike or changing a tire. These are procedures that we do consistently and routinely, yet still hold them with the utmost respect in regarding potential and unforeseen complications.

You're attitude seems either reckless or the result of not being educated enough about the potential harm to the pt you are transporting.

I don't ever want you dicking around with a CVL in a 7-11 parking lot. I want you hauling ass to the ED and doing the best that you can within your scope to stabilize the pt until they get there. That's the best thing you could possibly do. The more time you take, the less their chances of survival.

If you want to do CVL's and Intubate with every RSI protocol imagineable, then go to medical school.

I wish people would quote in context, as that little quotation does not project the whole idea I presented.

I would like to progress and go forward, and I apologize for being arrogant, seemingly wreckless and or careless. I will refrain from posting anymore, I will continue learning and providing care at my appropriate level with the patients best interest in mind. Your opinion and presentation has been noted, and I will consider all that has been said in the big picture.

Thank you for the time to write that out.

 

[Lawsonc]

So your area doesn't transport codes? Because almost all of them die. If you drive fast enough, they die in the ICU. Otherwise, they die on the street. I'm not saying one is better, but if you're saying you don't roll until ROSC or calling it, I think your system is seriously flawed.

This is not new,


http://forums.studentdoctor.net/archive/index.php/t-168739.html

 

[deleted109597]

This is not new,

http://forums.studentdoctor.net/archive/index.php/t-168739.html

While not new, the attitude of "every system that does transport codes is wrong" is at best misguided.

I suppose you are firm on your "we aren't leaving the scene until we've spent at least a half hour doing something" protocols.

You know, they make devices that perform compressions so you can continue driving without having someone straddle the chest.

 

[Lawsonc]

While not new, the attitude of "every system that does transport codes is wrong" is at best misguided.

I suppose you are firm on your "we aren't leaving the scene until we've spent at least a half hour doing something" protocols.

You know, they make devices that perform compressions so you can continue driving without having someone straddle the chest.

Not transporting codes in-progress, is more then just medicine, its public safety. Running code 3 in a 16,000 pound truck, running red lights with 2-3 in the back, is idiotic.

 

[deleted109597]

Not transporting codes in-progress, is more then just medicine, its public safety. Running code 3 in a 16,000 pound truck, running red lights with 2-3 in the back, is idiotic.

So your system doesn't run code 3 at all. For any reason. None whatsoever.


Because if it's a safety issue, it's always a safety issue. You can't pick and choose. Futile care is one thing, but often determinations of futility on scene are wrong. Exceptions are the usual "multiple body parts, exposed brain matter, hemicorpectomy, rigor mortis".

 

[EMS5]

Lawsonc, if you've ever taken an EVOC course, you would know that due caution is a major operative phrase. Experienced drivers don't go blazing through red lights with reckless disregard. If I have a crumping time critical patient who can benefit substantially from medical or surgical treatment a hospital can offer (ie blood products, central lines, chest tube), I'm going to tell my driver to "go code" all the way to the door. Accidents can and will happen, but the crew has to make that judgement call taking into consideration the risks and benefits.

Our scope as EMS providers gives us the tools and authority to initiate certain treatments that are generally not definitive. Part of our job description is that we need to be able to transfer care over to a facility that is capable of providing definitive treatment as fast as we can, and as safe as we can.

 

[Lawsonc]

Lawsonc, if you've ever taken an EVOC course, you would know that due caution is a major operative phrase. Experienced drivers don't go blazing through red lights with reckless disregard. If I have a crumping time critical patient who can benefit substantially from medical or surgical treatment a hospital can offer (ie blood products, central lines, chest tube), I'm going to tell my driver to "go code" all the way to the door. Accidents can and will happen, but the crew has to make that judgement call taking into consideration the risks and benefits.

Our scope as EMS providers gives us the tools and authority to initiate certain treatments that are generally not definitive. Part of our job description is that we need to be able to transfer care over to a facility that is capable of providing definitive treatment as fast as we can, and as safe as we can.

Not arguing any of that, I have taken EVOC, and I drove a rig for 2 years in one of the worst ranked cities for driving. Going code is used and abused, and the literature has shown that in the majority of cases it rarely makes the difference. I have a right to go home at the end of the day uninjured. This is opinion, and obviously not one agreed upon, but given the option, I am not an advocate for running codes into the hospital. Especially not now, where I will be working in a rural area and can be 30-90 minutes from a hospital.

EDIT- Re-reading that it sounded arrogant, I know many of the other folks here probably worked on rigs longer then me, but I just wanted to give my perspective after driving a rig for 2 years in a really crappy city.

 

[Apollyon]

This is where I don't understand the mentality on this board (and not you in particular Rendar5), I really thought this forum would be more open to conversation and ideas.

Not open? Really? Because people disagree with you? You sound a bit quick on the throttle, there.

I will refrain from posting anymore,

Then, this: rather absurd, because it is extreme. "Fine, I won't say anything else."

No one is arguing with you (in the sense of being oppositional with anger). Having been a paramedic for 9 years, and now an EM doc, what I know is that paramedics don't know how to read papers and studies (or, to be more clear, interpret them), and many (in my anecdotal evidence, the value of which is nil, is more than not) don't know what they don't know. A smaller amount are brazen in demonstrating that.

I have to deal with, now, senior paramedics (with at least 10 years in service, and one with more than 20) who will not immobilize elderly patients that fall - coming up with reasons not to. I've come to pointing out the error of their ways right at the time it occurs, versus passing it up the chain and waiting for remediation that may never happen.

We're not piling on. However, it just sounds like a bad idea. Rendar got to the heart of the matter - even under controlled conditions, optimal and sterile, 1/20 have a complication. That says enough for me.

And simple =/= easy. It may be "put the tube in the trachea", but the road from A to B isn't always a smooth, straight line. Remember, good BLS beats bad ALS 8 days a week.

edit: I was composing as you were.

 

[Lawsonc]

Not open? Really? Because people disagree with you? You sound a bit quick on the throttle, there.



Then, this: rather absurd, because it is extreme. "Fine, I won't say anything else."

No one is arguing with you (in the sense of being oppositional with anger). Having been a paramedic for 9 years, and now an EM doc, what I know is that paramedics don't know how to read papers and studies (or, to be more clear, interpret them), and many (in my anecdotal evidence, the value of which is nil, is more than not) don't know what they don't know. A smaller amount are brazen in demonstrating that.

I have to deal with, now, senior paramedics (with at least 10 years in service, and one with more than 20) who will not immobilize elderly patients that fall - coming up with reasons not to. I've come to pointing out the error of their ways right at the time it occurs, versus passing it up the chain and waiting for remediation that may never happen.

We're not piling on. However, it just sounds like a bad idea. Rendar got to the heart of the matter - even under controlled conditions, optimal and sterile, 1/20 have a complication. That says enough for me.

And simple =/= easy. It may be "put the tube in the trachea", but the road from A to B isn't always a smooth, straight line. Remember, good BLS beats bad ALS 8 days a week.

edit: I was composing as you were.

I appreciate the post, this makes sense. Some of my short fuse stemmed from another topic that rolled into this. My post was a question about a medication and opinions/experience, once it was answered it then turned sour quick. I know my role, I like being able to learn from others, and I know I have a long way to go as it is always a constant learning curve. I could not agree more about BLS being a vital part of patient care in the field. I hope to stick around and learn from these forums and others experiences.

Thanks

 

[pseudoknot]

Not transporting codes in-progress, is more then just medicine, its public safety. Running code 3 in a 16,000 pound truck, running red lights with 2-3 in the back, is idiotic.

You know, I've heard that argument before. And I'm fairly sympathetic to the idea that cardiac arrest ought not be a scoop and run call, as there is little that can be done in the ED that can't in the field (that will make a difference [at least that we think we know right now]).

However, code 3 transports are extremely rare to begin with in every system I've seen. Why are people so interested in transports, when we still go code 3 to almost every call? My last EMS shift I was dispatched code 3 for a homeless guy with foot pain x2 days. So if someone wants to bring in a full arrest with the lights on, OK, whatever.

 

[deleted109597]

Especially not now, where I will be working in a rural area and can be 30-90 minutes from a hospital.

That's even less of an argument. You don't get to the hospital faster if you speed but you're only 5 minutes away. However, if you're an hour away, speeding can make an appreciable dent in transport time. You also aren't running red lights in the rurals. You do have to drive on two lanes with people pulling into traffic, so I agree there is always risk. But you keep backtracking into nonsensical defensive posturing.

 

[pseudoknot]

your EZ-IO miraculously ran out of batteries

By the way, you can always just screw in the needles for the EZ-IO by hand. It's going to take longer but it will work.

 

[EMS5]

By the way, you can always just screw in the needles for the EZ-IO by hand. It's going to take longer but it will work.

Haha I pointed that out to no avail. I'm still holding ground on IO before EJ and definitely before I would consider central access even IF we were trained or allowed to do them.

As a rural provider, I am familiar with having a 45 mile ground transport to a regional trauma center. At speed limit, this run would take about 52-55 minutes.
Obviously this is a location dependent scenario, but my route out here involves a roughly 40 mile stretch of 4 lane highway. I can make this run in 30 minutes during optimal weather conditions.

If for whatever reason I can't get aviation on scene in a reasonable time, why should I not run "code 3" to the hospital? Again, it comes down to a risk vs benefit judgement call that has to be made by the crew. Sometimes speed is the best treatment.

 

[FDNewbie]

At our hospital system, we do (still) transport arrests. I know some places are moving toward the "work them in the field, and only transport for ROSC" approach. But despite us not using that approach at present (still the scoop 'n run), an arrest is never a Class I (lights & sirens, highest priority). No lights, no sirens, because outcome is typically dismal. And if they have ROSC, they're technically "stable" for now (and I use that term loosely of course), so again, they don't need Class I.

Also, I'm still not clear what you guys are talking about re: running red lights. The ONLY vehicle allowed to run red lights over here is a fire. Both police AND ambulances must treat red lights as stop signs and OBTAIN the right of way. Of course, it's easier to get through traffic with an emitter that'll change your lights to green, but not all lights have this feature, so you're still stopping at every block in the city...

 

[EMS5]

Here, any emergency vehicle can run a red light with due caution as long as we have activated emergency audio and visual signals (lights and sirens of course)...

As far as transporting a code...we are more to the stay and play style here...we still transport to the hospital unless there are obvious signs of morbidity, dnr, or the family expresses their desire for a funeral home etc to pick up the pt.

My perspective is that especially when the family is quirking out, the ED is a better place for the news to be delivered, and can be done more compassionately than in the field. Even if we as providers know that we won't get this pt back, we will go through the paces on scene more for the family than the pt, and wait until we are in the ambo to call the ED and get a termination of resuscitation order.

 

[xaelia]

Even if we as providers know that we won't get this pt back, we will go through the paces on scene more for the family than the pt, and wait until we are in the ambo to call the ED and get a termination of resuscitation order.

And then you transport the corpse to the ED? So we can deliver the bad news when the family arrives, presumably, still holding out some hope?

 

[EMS5]

And then you transport the corpse to the ED? So we can deliver the bad news when the family arrives, presumably, still holding out some hope?

Unfortunately yes. It would be much easier all around to perform the assessment on scene, call a doc and the M.E.'s office and get a DOA, but we have to transport unless we observe morbidity.

If the arrest was witnessed and the family asks, then I will tell them we are trying the best we can but we can't speculate at this point.

If the family is on the relatively calm side of things, I will tell them that things don't look good but we are doing what we can.

I'm not a fan of transporting the corpse either for the same reason you mentioned, in addition to tying up resources (an engine company and a medic at the least).

 

[docB]

Not transporting codes in-progress, is more then just medicine, its public safety. Running code 3 in a 16,000 pound truck, running red lights with 2-3 in the back, is idiotic.

I agree. I think that the EMS data will soon start to lead to restrictions on Code 3 transports.

You know, I've heard that argument before. And I'm fairly sympathetic to the idea that cardiac arrest ought not be a scoop and run call, as there is little that can be done in the ED that can't in the field (that will make a difference [at least that we think we know right now]).

However, code 3 transports are extremely rare to begin with in every system I've seen. Why are people so interested in transports, when we still go code 3 to almost every call? My last EMS shift I was dispatched code 3 for a homeless guy with foot pain x2 days. So if someone wants to bring in a full arrest with the lights on, OK, whatever.

I've seen a big increase in Code 3 transports. Several factors have lead to this. Two examples include stroke and inter facility transports. Everything that could possible be a stroke comes Code 3. That means TIAs, altered mental status, seizures, well people who say "I feel like I had a stroke." and so on. As everyone's call panels deteriorate we will have to transfer more and more patients to other facilities. Many of these such as trauma, neurosurgery, cardiology, etc. Most of those go Code 3.

A point was made about the fact that ambulances respond to everything Code 3 and that negates the argument that we should try to more appropriately triage who gets moved Code 3. I don't agree. Going to a call involves response times and therefore contracts. The fact that everyone has to go to the call Code 3 is a political issue. We need to make sure that we're doing the right things medically. So we can look at outcome data for the transports. The politicians will have to figure out that they should look at more than response times alone when evaluating contracts.

 

[EMS5]

I have read, although not in the past few months, that some EMS agencies are beginning to carry thrombolytics. I am not familiar with the protocol or specific meds, but I imagine this could spare a few minutes in CVA, MI, and TIA transports, thus reducing the total number of code transports.

Any thoughts from the docs about the use of lytics in the field, for or against?

 

[pseudoknot]

I have read, although not in the past few months, that some EMS agencies are beginning to carry thrombolytics. I am not familiar with the protocol or specific meds, but I imagine this could spare a few minutes in CVA, MI, and TIA transports, thus reducing the total number of code transports.

Any thoughts from the docs about the use of lytics in the field, for or against?

I think this is an extremely bad idea, unless your agency is serving Antarctica or someplace similarly remote. We know that outcomes are substantially better with PCI for MI. With stroke, you need to exclude hemorrhage by CT scan first (not to mention all the other stuff you need to do in order to "safely" use tPA for stroke…which I'm not entirely convinced is a good idea in the ED either). Lytics are not indicated in TIA.

 

[Cerberus]

I think this is an extremely bad idea, unless your agency is serving Antarctica or someplace similarly remote. We know that outcomes are substantially better with PCI for MI. With stroke, you need to exclude hemorrhage by CT scan first (not to mention all the other stuff you need to do in order to "safely" use tPA for stroke…which I'm not entirely convinced is a good idea in the ED either). Lytics are not indicated in TIA.

Totally agree. I personally hate pushing thrombolytics. I wouldn't push thrombolytics in a stroke case without our stroke team evaluating the patient and the only way I'd push them in an MI is if I was in bum****, and I had a pt with a clear STEMI, and no cath lab in site. Pushing thrombolytics based on the evaluation of EMS personal is reckless.

 

[turkeyjerky]

I have read, although not in the past few months, that some EMS agencies are beginning to carry thrombolytics. I am not familiar with the protocol or specific meds, but I imagine this could spare a few minutes in CVA, MI, and TIA transports, thus reducing the total number of code transports.

Any thoughts from the docs about the use of lytics in the field, for or against?

WTF. What's next, pre-hospital CABG, dialysis and ERCP?

 

[gutonc]

WTF. What's next, pre-hospital CABG, dialysis and ERCP?

I for one think that pre-hospital dialysis is a great idea. As long as that means direct transport to a dialysis center or a nephrologist's office.

 

[SLUser11]

if that doesn't work which I can't see why it wouldn't then go central line or if you wan't to be barbaric (I don't even know if they still do this in some centers) you can do a saphenous venous cut down. just land the I.O and you'll be A-OK most of the time. Good luck!

In terms of that acutely hemorrhaging patient, I'd probably try
1) EJ
2) IO
3) After either of those are in, I'd try a cordis introducer because you've bought yourself a little time with EJ or IO
4) If all those fail, cut down

US guided PIV in my experience is great for someone with good preload, but in a hemorrhagic shock I wouldn't waste my time, those veins are going to be collapsed more often than not

I'd try a femoral central line first, and a subclavian second.

I can put in either one in under 60 seconds.

Having done about 30 of these during my last deployment, I respectfully disagree. I have resuscitated many critically injured trauma patients with IOs, and I think they are absolutely amazing. 15g needles, you can pressure bag a liter through them in minutes, you can put blood in them, and they are far more stable on a helo than an EJ or other peripheral line.

I wandered in after reading the thread title.

If a patient is bleeding to death, you will want a line that is fast, secure, and reliable. I would agree with those that mentioned peripheral lines, but I think a second set of hands should be working on the CVL at the same time if the patient is unstable.

I also agree with Tired that the IO is very fast, and you can slam fluid in pretty fast if it's done correctly.

I disagree with those that consider saphenous vein cutdown barbaric or caveman. It is arguably less morbid than trying a subclavian or IJ CVL in an unstable patient. With a trained set of hands, a cutdown can be done in less than a minute, and they work great. I would recommend that everyone involved in emergency medicine become familiar with the technique for this if they are not already.

As for the comment about subclavians, I think I'm pretty good at them as well, having done a fair number, but I wouldn't ever try it in an unstable and/or coagulopathic patient. There are too many variables (pt movement, compressions, ventilations, many hands on the patient) that can lead to pneumothorax, massive hemothorax, needlestick injuries, etc. You're also blocking access to the top half of the patient's body while you try, which hinders the other people trying to save that patient's life. It's just not a good idea, especially considering how poorly this patient would tolerate a thoracic complication.

For CVLs in unstable and/or coagulopathic patients, the safest bet is almost always a femoral line. It is safer, it fails better, and it can afford multiple attempts. Also, there are less things going on down there, so the other health care workers can do their part in the resuscitation while you work.

If bilateral femoral line attempts are unsuccessful, I would probably go to the saphenous vein cutdown, but I also know how to do it. If I didn't, I would go with the IO line.

Once the patient is stabilized, the surgery resident can put in a nice clean subclavian up in the ICU.

 

[FDNewbie]

And then you transport the corpse to the ED? So we can deliver the bad news when the family arrives, presumably, still holding out some hope?

Yea that happens in a lot of places. It's very much akin to running a code well past the point that you know the patient is long gone, simply to help ease the family into the realization that we've done everything we can, and things continue to look dismal. Sometimes being humane is the right thing to do, even if it doesn't make perfect financial or resource-utilization sense.

I have read, although not in the past few months, that some EMS agencies are beginning to carry thrombolytics. I am not familiar with the protocol or specific meds, but I imagine this could spare a few minutes in CVA, MI, and TIA transports, thus reducing the total number of code transports.

Any thoughts from the docs about the use of lytics in the field, for or against?

I haven't read that info, but I'd imagine that it's ONLY for use in the case of VERY extended transport times for MIs ONLY, with clear-cut STEMIs documented on EKGs - which I would think would still require verification from a Medical Commander. I'm curious though where there's a > 90 min transport time to the closest cath lab within the US, be it by ground or air...?

I think it would be absolutely INSANE to push TPA for a suspected stroke without knowing whether it's ischemic or hemorrhagic, which can only be done via CT. Moreover, you're opening up a can of worms, because BP control becomes a big issue in stroke, with very diff BP parameters for ischemic vs. hemorrhagic strokes. But the point being is, now you need to be able to control BP which means even more meds. Too many variables, and too involved, without a definitive dx, which is a BAD idea.

 

[EMS5]

For the sakes of conversation I will try to find the source of where I read this...

My thoughts on lytics in the field is straightforward, but mostly in agreement with what has been said so far...strokes are pretty much out of the question, even with my training being well below medical school, I know a CT is a must (that may have been a lapse of memory in the previous post)...

As far as AMIs go, I think time constraints are a big issue. We should be transporting to a PCI capable facility. During that transport, I want O2, ASA, nitro, morphine, 2 EKG's showing ST elevation, and any arrythmia specific treatments that are indicated...this in itself should take up most of the transport time.

I wouldn't be down for lytics because of the lack of any available blood work...ckmb, troponin, myoglobin, GPBB...

Back soon with some links to the studies/reports

Edit:
Think SDN would publish me if I did a freelance article?

 

[Lawsonc]

Yea that happens in a lot of places. It's very much akin to running a code well past the point that you know the patient is long gone, simply to help ease the family into the realization that we've done everything we can, and things continue to look dismal. Sometimes being humane is the right thing to do, even if it doesn't make perfect financial or resource-utilization sense.

I haven't read that info, but I'd imagine that it's ONLY for use in the case of VERY extended transport times for MIs ONLY, with clear-cut STEMIs documented on EKGs - which I would think would still require verification from a Medical Commander. I'm curious though where there's a > 90 min transport time to the closest cath lab within the US, be it by ground or air...?

I think it would be absolutely INSANE to push TPA for a suspected stroke without knowing whether it's ischemic or hemorrhagic, which can only be done via CT. Moreover, you're opening up a can of worms, because BP control becomes a big issue in stroke, with very diff BP parameters for ischemic vs. hemorrhagic strokes. But the point being is, now you need to be able to control BP which means even more meds. Too many variables, and too involved, without a definitive dx, which is a BAD idea.

Eastern Oregon, Central/Eastern Washington, Parts of Idaho and Montana- To name a few places with greater then 90 minutes. We are talking hours, to a cath lab, trauma center, etc, by both air and ground.