New Series of Rants Second follow up

The last post was a response to 2 sentences by Bostonian in NY. This time he wrote a bit more, so I am alternating responses with his comments. His comments are indented and not followed by a footnote. Footnote links are at the bottom of the post.

Bostonian in NY said…

You know, I’ve come back a few times to think about this case since I rendered my hasty gut reaction. I keep coming to the same conclusion: If EITHER of his responsibilities had been successful, the patient is alive.

Maybe. When you are working in surgery, you have much more control over the way things will turn out, than EMS will. Sometimes the patient survives to the hospital in spite of what we do – not because of what we do.

Even vital signs can be misleading at times. Abdominal injuries with uncontrolled bleeding are less likely to exhibit tachycardia, than other sources of uncontrolled bleeding.^[1] There is not complete agreement on this anymore than there is in the rest of trauma.^[2]

One study stated –

CONCLUSIONS: Tachycardia is not a reliable sign of hypotension after trauma. Although tachycardia was independently associated with hypotension, its sensitivity and specificity limit its usefulness in the initial evaluation of trauma victims. Absence of tachycardia should not reassure the clinician about the absence of significant blood loss after trauma. Patients who are both hypotensive and tachycardic have an associated increased mortality and warrant careful evaluation.^[3]

It can be tempting to trivialize signs of hemorrhage, because the patient is not demonstrating the typical vital signs of major hemorrhage. In print the patient will present quite differently from in person. This is part of the problem of the Monday morning quarterbacking we are participating in, here. This is a part of the problem with the way that we are taught in EMS. This is a part of the problem with the way QA/QI/CYA (Quality assurance/Quality Improvement/Cover Your A@#) departments work.

Now, to get back to your comment about tachycardia. While he probably was tachycardic, and that does seem to be associated with worse outcome in all of the studies I mentioned above, and his death makes it quite clear that he was unstable, does that mean that an IV and a liter of 0.9% saline would have improved things? At the point of death, preferably just before, is when I think there is the least likelihood of harm from fluids. So, in his case, yes. The addition of fluid might have improved things. Does that mean he survives? If he is so low on blood, that he is on the verge of death, his problem might be more of a lack of hemoglobin, than a lack of serum. Before that point, the fluid may cause other problems, such as diluting blood to the point where it does not clot in the body.

I keep wondering what Casper’s vitals were and what he looked like. If he’s sitting there all obtunded in his barca lounger with a pulse in the 120’s and a BP in the 80’s, and a couple pints soaked into the shag carpet I’d probably want to have some IV access to dump a liter of LR in while I sit on his femoral artery for the remainder of the ride. Hell, have BLS driver guy hold hemostasis while you get the stick and then get rolling. A simple thought outside of the adrenaline rush of pre-hospital care would have saved a life.
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I believe that the blood was not making it to the floor, due to the ever increasing blob of bandages as the blood continued to soak through, but was being contained by this knee diaper. A diaper is all that it was, since a diaper does not keep the fluid from coming out, just from making an unsightly mess. Gravity was probably all that was helping to keep him alive. That and a low blood pressure – a pressure low enough to not be forcing all of the blood out through the available perforations.

Direct pressure is one method of attempting to control bleeding. It may not be successful. Running fluid into someone with uncontrolled bleeding is not, in my opinion, a good idea. What pressure to start at is debatable, but there is not good research to suggest that being aggressive is good for the patient until the pressure is lower than where we currently recommend opening the lines to high flow of saline, or whatever is the fluid of choice. Saline, and most other fluids, dilute the clotting ability, raise the pressure without necessarily improving the effectiveness of the circulation, and may force more blood out of the body – since bleeding is not yet controlled.

You suggest waiting on scene to start an IV, with the partner applying direct pressure during the IV attempt(s). The problems with this are there might not be effective control of the bleeding. The pressure may only be slowing the bleeding. If the bleeding is being controlled by the direct pressure, transport is more important than an IV and fluid through that IV, in my opinion. That is assuming the paramedic is successful with the IV. Since we do not know what the outcome will be, at that time, how do we know that the fluid is a good idea? Has the body achieved homeostasis, on its own? If PMS were assessing the patient, keeping the leg elevated, or applying direct pressure, there might be a reason to believe that PMS understands what is going on with the patient. How effective is the assessment of someone who does not believe in controlling bleeding. Even the NR (National Registry of EMTs) would not encourage putting the IV before direct pressure.

The title of the original post by ParaCynic is a reference to tourniquets. This is one situation, where the tourniquet appears to be indicated. This is something that requires judgment. I would prefer to apply a tourniquet and, if it appears to be controlling the bleeding, then attempt an IV, but I would not take time on scene with this patient to start an IV. I have had a patient, with uncontrollable bleeding from his head, where I did as you suggest. The bleeding could be slowed by direct pressure and it appeared to be something that we could stop when we were not moving. The site of bleeding was an artery under the scalp, so the pressure was not as direct as I would have liked. While the patient was still, since we were apparently able to control the bleeding, it did seem like a good time to get an IV in place – but this was a patient who presented as stable, except for the bleeding. His vital signs were not indicating significant blood loss. The bleeding appeared to be very slow when we were moving him. There appeared to be less than a pint of blood on scene, but that is a very rough estimate. I have never taken containers of blood (or something looking like blood) and measured them, then spread the blood on the ground to see what that volume really looks like. I have never had anyone measure an amount of blood and spread it on the ground to test my ability to estimate accurately. Anyway, this patient appeared to be stable, in spite of his incompletely controlled bleeding. I also contacted OLMC (On Line Medical Command) to request permission to use epinephrine on the site, if he dramatically deteriorated, as a means of helping to slow the bleeding. OLMC said OK, just don’t inject into the patient. No. I do not want to perform intracerebral epinephrine injections.

Another of the possible ways to deal with this is by keeping the leg elevated. Sometimes complicated with EMS stretchers, but there is no rule that requires the patient to be facing the normal way on the stretcher in order to raise the legs. Raising the legs is generally referred to as Trendelenburg position, which is one of the four topics ParaCynic promised to address in his post Tourniquets, Trendelenburg, Tampons, Toilet Paper. His post on Trendelenburg is Standing Trendelenburg on it’s Head. I don’t know how controversial the last two will be EMS-wise, but the first two are important and we are often taught that the good one is bad, while the bad one is good. We are taught these backwards. We are taught that tourniquets are bad – might cause damage that is insignificant compared to keeping a patient alive. We are taught that Trendelenburg is good, even though there is no evidence to support it. Ain’t EMS great?

Anyway, raising the legs can be done by using the stretcher’s Trendelenburg adjustment, which does not raise the legs very high. Another way of dealing with this patient is to turn him around on the strtcher. Trust my hunch that he does not want to sit up. Put the back of the stretcher up to keep the injured leg elevated. This is not for blood return, as Trendelenburg would be – if it worked, but this is to use elevation to prevent more loss of blood. This provides more elevation than the standard stretcher Trendelenburg setting. Or the method used by those, who might not know how the stretcher works – drug bag/box under the legs.

It is Monday morning quarterbacking, since we know what the outcome of the patient was without these interventions. We do not know what the outcome would be with any, or all, of the interventions we would have preferred. My treatment choices, in the order they would be attempted, not in the order of importance, would be:

1. Leg elevated.

2. Direct pressure.

3. Tourniquet, if the direct pressure is not working (or to allow me to free up my hands to start an IV).

4. Direct pressure in addition to the tourniquet and elevation, if the tourniquet is not controlling the bleeding.

Which to use is determined by reassessment. The IV could be added to all of these, but I think it is only something that should be considered after appropriate measure have been taken to control bleeding. The IV/fluid administration should not be a substitute for bleeding control if bleeding control is possible.

In response to your above post:

Protocols are written by people sitting in offices who know nothing of what a sick patient looks like. So are job descriptions. People who follow them to a T need to be re-educated

I am not one to make an informed statement about job description scribblers. However, it pains me to come to the defense of those, who write protocols. Generally EMS protocols are written by medical directors. They may leave the specific wording, formatting, and printing up to others, which can lead to errors of typography and translation. Medical directors should be very experienced with sick patients. I am often critical of medical directors for policies that allow bad medics to mistreat patients. A lot of medical directors did start out as EMTs/paramedics and have an idea of what EMS is like. Things have changed significantly since many were working the streets. I believe that most people working in EMS have a poor understanding of EMS, even a dangerous approach to EMS. I do not have any numbers to back this up, just my experience working and teaching EMS in 4 states, dozens of jobs, and several EMS forums. My criticisms of medical directors are of the lack of understanding, in spite of this experience (when they have EMS experience).

Too many medics, nurses, and doctors have unreasonable beliefs about the amount of benefit of EMS treatments. Benefits that are not supported by research. Some of the EMS treatments have never been studied. Some studies have only produced negative results. The studies most commonly cited in EMS often have such clear violations of the scientific method, that the results are worthless, except to suggest further research and to demonstrate the ways not to do research. Few medical directors seem to recognize this.

If I, as a physician in training, refused to put in an IV because “that’s a nurse thing”, or refused to bag a patient because “that’s a technician thing” or refused to wheel a patient around because “that’s a transport thing, or refused to hold a retractor because “there’s a big frame to do that for me” I’d be crucified on the spot. Every day in the hospital, I get to stuff my education in my back pocket and do work that is far below my capability…but the bottom line is that shit needs to get done so might as well do it yourself.

I completely agree. I think that my point was more that some paramedics will develop the attitude that their ALS treatments will be able to fix everything and that BLS treatments are not important. I certainly have encountered paramedics who have refused to do stuff that they feel is beneath them.

The attitude problem is a huge one and one that seems to exist even in places with very humble medical directors. Why Maybe they just do not believe that their people have that kind of attitude. I don’t know. I do know of plenty of basic EMTs, who go to paramedic school specifically so they do not have to waste their time on any of that EMT stuff any more.

One solution to this is improved research. Teaching research from the very beginning of EMS training. Teach the scientific method and introduce treatments, one at a time. Introduce the research that has been done on the treatment. Let the students teach themselves, with the assistance of the instructor, what works, what has not been studied well enough to come to any conclusion, and what does not work. I think this would require a dramatic remodelling of EMS education, but would produce much better providers. It is about understanding what works, more than what the current theory is. Maybe the theory will be shown to be accurate, but often we end up discarding these theories as we learn more. We may learn more form people performing research that runs counter to the accepted theories. As we learn enough to discard these bad theories, we are able to build on the confirmed theories and truly understand more.

I will write about the research on prehospital treatment of hypovolemia due to hemorrhage, but that will be another post, but these are some of the points that need to be addressed.

We are addressing a surrogate end point. This is something that we can measure, but that we cannot prove makes a difference in survival.

We need to keep the patient from becoming pulseless, but how high does the systolic BP need to be for that to happen?

I think that it will be much lower than just about everyone is comfortable with – maybe 50 to 60 systolic, with the exception of head injuries, but the research is not yet persuasive enough for any particular vital sign goal. Will the systolic pressure be the most appropriate prehospital indicator of when to start treatment? Radial pulses? Something else? Capnography?

We need good research by doctors good enough to make the study large enough and well enough controlled that the results are meaningful. Something that has been ignored too much in favor of expert opinion. I feel that this reliance on experts – who refuse to perform the necessary research – should, in Catch-22 fashion, disqualify these doctors as experts.

We need good research to improve our care. Otherwise, it is just a bunch of people making the vital signs less annoying and convincing themselves that what they are doing is making all of the difference. Surrogate end points will have to be covered in several posts. It is probably the most misunderstood aspect of research.

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Footnotes:

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^[1] Relative bradycardia in patients with traumatic hypotension.
Demetriades D, Chan LS, Bhasin P, Berne TV, Ramicone E, Huicochea F, Velmahos G, Cornwell EE, Belzberg H, Murray J, Asensio JA.
J Trauma. 1998 Sep;45(3):534-9.
PMID: 9751546 [PubMed – indexed for MEDLINE]

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^[2] Relative bradycardia in patients with isolated penetrating abdominal trauma and isolated extremity trauma.
Thompson D, Adams SL, Barrett J.
Ann Emerg Med. 1990 Mar;19(3):268-75.
PMID: 2310066 [PubMed – indexed for MEDLINE]

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^[3] Does tachycardia correlate with hypotension after trauma?
Victorino GP, Battistella FD, Wisner DH.
J Am Coll Surg. 2003 May;196(5):679-84.
PMID: 12742195 [PubMed – indexed for MEDLINE]

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