Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study


Why treat hypoglycemia with 10% dextrose (D10), rather than the more expensive, potentially more harmful, and less available, but traditional treatment of 50% dextrose (D50)? Why not? The only benefit of 50% dextrose appears to be that it is what people are used to using, but aren’t we used to starting IVs (IntraVenous lines) and running fluids through the IVs?

We should be much more familiar with running in fluid, than in pushing boluses of syrup.

What happens when we have temporary shortages of 50% dextrose? Do we stop treating hypoglycemia? Are we supposed to panic, because we can no longer follow tradition? No. We give the more appropriate, and lower, dose of the much lower concentration of dextrose. We provide better care because of our need.

Despite the traditional use of D50, there is a minimal amount of data to support it as the standard of care.[1]


Is 10% dextrose the perfect treatment for hypoglycemia? No, but it does appear to be less likely to cause harm than the current overtreatment with 50% dextrose.

Seven patients had a drop in blood glucose after D10 administration, all of 10 mg/dL or less except for one patient with a drop of 19 mg/dL who had an insulin pump infusing that was not removed by EMS personnel during D10 infusion.[1]


Is that any different from what happens with 50% dextrose? If this is different from D50, how does the potential harm from giving too much dextrose to most hypoglycemic patients compare to the potential harm of giving a first that is too small to fewer than 1% of hypoglycemia patients?

There were no reported adverse events related to dextrose infusion. Six patients who received intravenous D10 were pronounced dead in the field during the period of study. On investigator review, all patients had altered level of arousal or were in cardiac arrest prior to arrival of EMS personnel and their deaths were deemed to be unrelated to dextrose administration.[1]


Dextrose does not reverse death, so there is no reason to expect a better outcome for dead patients with a higher concentration of a drug that does not reverse death. Go read the excellent review of the evidence on hypoglycemia, death, and the potential of dextrose to improve outcomes from death.[2]

But is 10% really better? We don’t have any good research, but is there any good reason to give all 25 grams of dextrose in a syringe of 50% dextrose if the patient wakes up before the full dose has been administered? Would we continue to give the entire syringe of morphine, or fentanyl, or most of the other drugs that we give, if our assessment shows that the patient no longer meets the protocol criteria for administration of the drug?


76% of patients received only 10 grams of dextrose, rather than the usual 25 grams. While it is not known if any of these patients required any further dextrose, or oral glucose, while in the hospital, they should have been awake enough to take any further dextrose orally, as they would the rest of the time.

23% of patients received only 20 grams of dextrose, rather than the usual 25 grams.

Fewer than 1% of hypoglycemia patients received a dose as large as we traditionally give.

We do not appear to be concerned with harm from administering more aggressive treatment than is justified by the evidence.

We do appear to be concerned about our anxiety of deviating from the traditional too much is not enough approach to hypoglycemia.


[1] D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study.
Hern HG, Kiefer M, Louie D, Barger J, Alter HJ.
Prehosp Emerg Care. 2017 Jan-Feb;21(1):63-67. doi: 10.1080/10903127.2016.1189637. Epub 2016 Dec 5.
PMID: 27918858

Of the 1,323 patients administered D10 during the study period, the 452 patients excluded from the study cohort for the aforementioned reasons were similar demographically to the study cohort. The median initial blood glucose was the same at 37 mg/dL and the median age was also 66. There were slightly more women at 229 (51%) in the excluded group compared to the cohort.


[2] Using Dextrose in Cardiac Arrest
Wednesday, March 14, 2012
Mill Hill Ave Command
Dr. Brooks Walsh

Hern, H., Kiefer, M., Louie, D., Barger, J., & Alter, H. (2016). D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study Prehospital Emergency Care, 21 (1), 63-67 DOI: 10.1080/10903127.2016.1189637


Management of prehospital seizure patients by paramedics


Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

Why look at seizures?

In a 2001 multicenter study, patients presenting with seizures or complaints related to seizures represented 1.2% of all ED visits.1 The majority of these patients (71%) utilized emergency medical services (EMS) for transport and care. An even greater number (84%) had interventions during EMS transport or in the ED that included airway attention, establishing intravenous (IV) access, and medication administration, and 55% received antiepileptic medications.[1]

It does seem as if seizures are over-represented in EMS and it seems that seizures require some very aggressive care.

The secondary objective was to identify other characteristics related to these cases that would help to ascertain the utility of specific ALS procedures.[1]

Of all of those interventions, such as 55% received antiepileptic medications, which ones are most important and why?

500 consecutive adult seizure patients over a period of 9 months produced only 97 patients for analysis. Seizures are frequent. One of the advantages of research is that it allows us to acquire some of the experience of much more frequent patient contact than we would in a busy career. 97 seizure patients is not a lot. If I only see one seizure patient a month, this is 8 years of experience, but does one seizure patient a month reflect your system? Would one a week be more like it? At one a week, this is only 2 years experience.

Why do I spend time explaining this?

These patients represent a heterogeneous group of patients including those with generalized seizures, focal seizures, and pseudo-seizures.[1]

With a very varied group, small numbers can be expected to produce results that are not representative of a much larger population. The idea is right, but the numbers are not. 500, or a thousand, would be much better for averaging the many variables. If your experience does not match what is described, here, don’t get upset. This does not match my experience, either.

You can click on the tables for larger versions.

That seems normal. I do not recall a lot of patients who are confused or who remain confused for more than a few minutes after arrival on scene.

Six patients had glucose levels (BGLs) less than 80 mg/dL (range 68–79 mg/dL), which was the protocol cutoff for treatment with dextrose or glucagon; blood glucose values at this level are herein referred to as hypoglycemia. All of these patients had an IV line attempted, though only one (BGL = 69 mg/dL) received dextrose and none received glucagon. However, only one of the untreated patients had a BGL less than 70 mg/dL (BGL = 68 mg/dL) and was in an alert, conscious state. The patient who did receive dextrose and one of two hypoglycemic patients with an unsuccessful IV attempt (BGL = 76 mg/dL) had recurrence of seizure activity in the prehospital setting.[1]

There is so much about this that raises questions, rather than answering questions. Were the seizures of any of these patients attributed to the hypoglycemia? Did any of these patients have a history of seizures due to hypoglycemia? What was learned about them in the hospital?

2/6 hypoglycemic patients (33.3%) had repeat seizures, but overall 28/97 patients (28.9%) had repeat seizures, only 17 of them (17.5%) out of the hospital.

Should we compare the hypoglycemic patients with the overall seizure patients? With only 6 hypoglycemic patients, and only 56 had BGL measured (64.4%), changes of just a single patient will completely change the apparent significance. What if, instead of 2 hypoglycemic patients having seizures, only 1 did (16.7%)? Or what if 3 did (50%)? Or what if 4 did (66.7%)? Or what if none of them did (0.0%)? And how many of the patients, who did not have BGL measured, had repeat seizures and hypoglycemia?

The hospital data are not helpful for learning more about the hypoglycemic patients. Did the hospital check BGL on every patient? Probably. Go to an ED (Emergency Department) for anything non-traumatic and expect to have a blood sugar checked.

Does that mean that we should make every medical EMS call ALS, just to check BGL?

This could be the Mechanism Of Idiocy Injury that could help minor medical calls leapfrog past trauma in ALS over-triage.

Just stop thinking and start making everything ALS, because what if we miss one?

If it saves just one life (even though maybe a dozen who would otherwise have lived will now die), it’s worth it! Go ALS!

Or we could fly all of these patients, just in case, because What if . . . ?

Anyway, back in the real world, we just don’t know what to do with the data on hypoglycemia. What about the data on repeat seizures? Some seize. Based on this study, are we able to predict which patients will have repeat seizures? No. Are we able to tell which patients have pseudo-seizures? No. Are we able to tell which patients need ALS, based on this study? No.

All but one of the 10 patients who were treated with diazepam had a less-than-alert level of consciousness (n = 7), additional prehospital seizure activity (n = 7), or both (n = 5).[1]

Maybe, we do have a good hypothesis for another study. Does the alert patient benefit from ALS?

Even if the repeat seizure patient has the full ALS workup of IV, ECG, and BGL before the repeat seizure, does it make any difference in outcome? Would any of this really prevent a seizure?

Overall, instead of revealing inappropriate care, this review emphasized the difficulty with creating a homogeneous protocol for such a diverse group of patients.[1]

That does appear to be the case.

We recommend further study with emphasis on concrete outcome measures to determine the impact that specific ALS interventions have on this group of patients.[1]

That is a good idea.

What is the right treatment for a seizure? This may be the wrong question. Maybe we should ask what the right treatment should be for a patient with no history of seizures and a decreased level of consciousness? Or what is the right treatment for a patient with a focal seizure that has been evaluated in the ED several times before? Et cetera.


[1] Management of prehospital seizure patients by paramedics.
Martin-Gill C, Hostler D, Callaway CW, Prunty H, Roth RN.
Prehosp Emerg Care. 2009 Apr-Jun;13(2):179-84.
PMID: 19291554 [PubMed – indexed for MEDLINE]

Martin-Gill, C., Hostler, D., Callaway, C., Prunty, H., & Roth, R. (2009). Management of Prehospital Seizure Patients by Paramedics Prehospital Emergency Care, 13 (2), 179-184 DOI: 10.1080/10903120802706229


Comment on ALS is Oxygen, IV, Monitor, and Transport – Part II

Continued from Part I.

Image credit.

I agree with a lot of what I read here. However, why is anyone going to give a medic with 18 months of technical school freedoms that ED docs with 8 years of medical education can’t always handle?

Because well trained medics have demonstrated that they do make good patient care decisions in the several limited areas that medics treat aggressively.

What medics do is very limited, but still cannot fit into any group of protocols, no matter how detailed.

We need to hold medics to high standards, not pretend that restrictive protocols make incompetent medics safe.

According to Joe Paczkowski (EMT-Medical Student), one of the 4 Phrases That Should Never Be Said on an Ambulance is –

We’re not doctors.

. . .

Is it any wonder that there are so many problems in EMS when EMS is one of the few, if any, fields that actively teaches their students to not think about what they’re doing past the cookbook? After all, why question any of the care you’re providing if you’re “not a doctor?”

He is going to medical school, but he does not seem to think that those who do not go to medical school should not think.

Unless you work for a service that practices “different rules for different medics”, you’re going to have to stay within protocol – not necessarily throw the protocols at every patient, but at least remain within them, or know enough to convince a reasonable doctor to agree with you.

Which is exactly what I am stating. In my response to MOE Medic, I explained a practical way to deal with protocol deviations. Why should we let paramedics make decisions about whether protocol deviations are appropriate?

I am all for taking it to the medical director. I used to make these calls about once a week to explain each deviation I made from our protocols.

I had doctors in the local emergency departments who were willing to listen.

I had even more doctors in the university hospital emergency departments willing to listen.

I also had medical directors willing to listen.

What they cared about was whether I was taking care of the patient appropriately, not whether I was taking care of the protocol appropriately.

The doctors are not usually the ones opposed to having paramedics think. This objection seems to come from the paramedics.

As in, Stop making the rest of us look bad!

I’m willing to give up some freedoms that I might be able to handle so they won’t be abused by a lazier or less proficient medic, and call med control. It’s all about doing the greatest amount of good for the largest amount of people, not stroking our ego by allowing us to declare C/P non-cardiac or do sutures.

We need to remediate, or teminate, the lazier or less proficient medics.

We do not need to dumb down the system to whatever level deceives people into believing that they are protecting patients from the lazier or less proficient medics.

Punishing patients in order to avoid remediating, or terminating, the lazier or less proficient medics is dangerous management.

Punishing patients in order to avoid remediating, or terminating, the lazier or less proficient medics is probably one of the reasons so many competent medics leave EMS.


There is no protocol that can make a lazy and/or incompetent medic safe.


There is no drug that is safe in the hands of a lazy and/or incompetent medic.


Making the protocols safe for the incompetent is the wrong approach.

1. It is guaranteed to fail.

2. What kind of Luddites are we that we oppose progress and oppose thinking?

Am I happy about that – no, but I didn’t go to medical school or do an internship either.

If you want to be a doctor, you should go to medical school and you should think.

If you want to be a paramedic, you should go to paramedic school and you should think.


Thinking is within the paramedic scope of practice.


Thinking is an essential part of the paramedic scope of practice.


This is not about what makes medics happy.

This is about what is best for patients.

To be continued later in Part III.


Comment on ALS is Oxygen, IV, Monitor, and Transport – Part I

In response to my post, ALS is Oxygen, IV, Monitor, and Transport, there is a comment from Prmedc.

Quite a few of the problems I see in the local ED come from the ED doc “practicing medicine”. Hey, I’m a doctor! Let’s just drop ten of Versed on this patient and try to intubate, instead of following my well established RSI protocol developed by ACEP.

There are appropriate reasons to deviate from any protocol – even one written by an ACEP committee.

There are many different RSI (Raped Sequence Induction/Intubation) protocols. One protocol does not fit all patients.

The 10 mg midazolam decision does not appear to make sense, but there may be legitimate reasons for using midazolam alone. It would be a mistake to assume that just because research has consistently shown that midazolam alone leads to worse outcomes, midazolam alone is never appropriate.

This is why protocol deviations should be reviewed afterward, rather than automatically punished.

Or, hey, I’m a doctor! Let’s shock sinus tach at 140 instead of giving fluids and pain meds for that fractured femur!




Image source.


Plus this –


Image source.


Is NOT an example of THINKING!


Anyone who thinks that shocking sinus tachycardia is a good idea should not be a doctor, should not be a nurse, and should not be a medic.

Sinus tachycardia is a symptom, rather than an arrhythmia to treat. We treat sinus tachycardia by treating the underlying cause(s) – the underlying cause(s) could be hypovolemia, fever, pain, inappropriate vasodilation, stimulant medication, physical exertion, et cetera.

Shocking sinus tachycardia seems to be an example of not thinking.

Shocking sinus tachycardia seems to be an example of trying to make the protocol fit the patient.

Thinking should prevent this.

We should not be memorizing faulty and nonsensical rules, such as over 150 cannot be sinus tachycardia. Or that over the maximum calculated heart rate cannot be sinus tachycardia.

These overly simplified tachycardia rules are neat, plausible, and wrong, but they are to be expected of some EMS cardioversion protocols.

Someone who thinks should not make this mistake. Someone who thinks should not obey such a protocol.

The protocol monkey does not know what to think.

The protocol monkey follows the dumbed down protocols that say to shock whatever is too fast.

The protocol monkey cannot be trusted to do anything else.

We “require” ED docs to think,

Yet you give an example of a doctor not thinking as a reason to prohibit medics from thinking.

“requiring” medics to think won’t fix the legal system or increase our knowledge base or skill level.

Let’s take a look at these suggestions:


1a. Will requiring medics to think fix the legal system?


No. Why would anyone think that it would? Medics do not run the legal system. Requiring medics to think will also not fix the banking system.


1b. Will preventing medics from thinking fix the legal system?


Of course not. This is not relevant to what I wrote.


2a. Will requiring medics to think increase our knowledge base?


Requiring medics to think can be expected to force medic programs to do a better job of teaching, which should increase our knowledge base.


2b. Will preventing medics from thinking increase our knowledge base?


No. I believe that it has the opposite effect in the places where medics are prohibited from thinking.


3a. Will requiring medics to think increase our skill level?


Probably. As medical directors have seen the ability of competent medics to handle several limited emergency conditions, they have generally expanded what paramedics are permitted to do and the medical directors have increased what paramedics are permitted to do on standing orders.

The medical directors most involved in EMS keep showing us that they want us to think.

What kind of medical director is foolish enough to prohibit medics from thinking?


3b. Will prohibiting medics from thinking increase our skill level?



Why would these medics, who are prohibited from thinking, need any skills other than skill at not thinking?

To be continued later in Part II and even later in Part III.


ALS is Oxygen, IV, Monitor, and Transport

In response to a question about a complicated ECG strip, someone responded that Oxygen, IV, Monitor, and Transport are all that is needed. Perhaps this was meant sarcastically. Perhaps not.

I do know people in EMS who think this way.

I also know people who think about people in EMS this way.

If Oxygen, IV, Monitor, and Transport define ALS in EMS, we are in trouble.

Why isn’t this blood pressure, along with the rest of the vital signs, enough?

I rarely give oxygen.

We should be giving drugs only for a specific effect.

We should not be giving drugs just to satisfy a protocol.

We should not be giving drugs to satisfy a mnemonic.

A mnemonic is a memory aid.

A mnemonic is not a standing order.

How often do we give anything other than a flush through an IV, or a saline lock?

If we are only using it to make the mnemonics Nazis happy, are we helping our patients?

Does an asthmatic need an IV to receive a bronchodilator?

What about getting an ECG for every ALS patient?

Let’s consider that the origin of this post was a comment that medics do not need to be able to interpret complex rhythms, because we just do Oxygen, IV, Monitor, and Transport.

If the medic cannot figure out what the rhythm is, why hook the patient up to the monitor? Satisfying billing? Satisfying QA/QI/CYA gnomes? Something else?

Should we transport every ALS patient?

What if this conflicts with informed consent?

What if we insist that patients agree to transport in order to receive treatment?

What about ALS treatment requires transport?

In other words, Oxygen, IV, Monitor, and Transport are not essential to ALS in EMS.

Is a doctor required to give oxygen for treatment to be ALS?

Is a doctor required to have an IV for treatment to be ALS?

Is a doctor required to have an ECG for treatment to be ALS?

Maybe we need to allow medics to think.

Maybe we need to encourage medics to think.

Maybe we need to require medics to think.


Dealing with Grief

In the comments to On the Clock: Dead, there are some great thoughts, but one is an idea that many people ignore. ERP, of ER Stories, points out:

I remember when I first was able to just put this sadness out of my mind and get back to work. I was an intern and have to say, it was pretty weird. Strange how you can just adapt to these feelings and push them aside in order to be functional.

A long time ago, in a life far, far away, I was experiencing a bit of grief. Not the first time. Won’t be the last time. I was just driving along, and not at all crying, because I am much too manly for that. Anyway, there I was, minding my own business, when all of a sudden these two cars collide in front of me.
A K-car full of little old ladies, apparently driven by one with poor depth perception, turned in front of me. I, being an experienced driver, used the middle pedal to decelerate quickly and avoid pointing out this driving flaw. The driver of the minivan next to me was less tactful. Sumdood was not driving. The driver was a very distraught soccer mom.
One LOL received some serious head trauma. The others did not appear to have any serious injuries, but did have exacerbations of underlying medical conditions. Particularly the driver with chest pain. I was off duty, but did what I could to help. Eventually, about 40 minutes after the collision, the head injured passenger was transported by helicopter. We were only about 10 minutes from a trauma center, but the medic needed to follow all of the protocols that might be relevant. 
The patient also had her chest decompressed – after the medic spent over 5 minutes off scene on the phone with medical command for permission to perform something that I doubt she needed. Of course permission was granted. It is the stuff that might actually help the patient that is turned down. I wasn’t involved in her care at that point, since I don’t know what her vital signs were, but the EMT bagging her did not seem to be experiencing difficulty and the patient did seem to tolerate the delay. 10 minutes from the trauma center and extrication of less than 5 minutes, but a scene time of close to 40 minutes (the medic was not there at the time of the crash). EMS at its finest.
Well, after the medic transferred care of the head injured patient to the helicopter crew, he was getting ready to leave. I asked him what he intended to do about the driver with chest pain, the passenger feeling weak, and the other passenger with arm pain. He seemed to blame me for his lack of awareness of the other patients in the car, even though I had updated him on them earlier. He called for more ambulances and suggested that I not make his day any more pleasant.
I gave my information to the police, in case they needed anything for their report. I returned to my vehicle and considered the question that kept returning to Leonard in Memento

Now… where was I?

Well, as I mentioned, I was just driving along, and not at all crying, because I am much too manly for that. Anyway, there I was, minding my own business, . . . . Pleased to be moving to a different state. Maybe EMS is not the same everywhere.
It is pretty amazing how easily we can put aside grief in order to do what needs to be done. The grief isn’t gone. Grief doesn’t ever seem to completely go away, just to diminish with time. Maybe it is replaced with more painful grief. Maybe it is overshadowed by joy. Maybe it just begins to fade. It does not control our lives, even though it may seem to. It sure does interfere with our lives, but we do not give up control to the grief or we would not be able to function in times like this.

On the Clock: Hole

On the Clock: Hole

With all of the recent discussion of the research and the pathophysiology of massive hemorrhage, Medic61 at On The Clock does a great job of making it real and showing how the ALS personnel can easily get caught up in things that cause them to ignore more direct methods to control the bleeding. A manual blood pressure cuff is a tourniquet – one that is often overlooked.

A blood pressure cuff, the fancy name is sphygmomanometer, works by blocking the arterial flow of blood. It allows for the slow release of the pressure applied, usually to the brachial artery, so that the return of arterial blood flow can be observed as the systolic blood pressure. If it were not an effective tourniquet, it would not be effective at measuring the systolic blood pressure.

Or, as the often used saying states –

Paramedics save lives.

EMTs save paramedics.

At some point everybody ignores the basics. If we are lucky, we have someone with more sense around. If we are even luckier, they remind us gently.

If we are unlucky, really the patient is the unlucky one, we have more certification than sense and this is not challenged by anyone around.

On The Clock is a great blog for putting patient care into a well written narrative, not something that is easy to do or easy to find.

Here are a bunch of recent posts on tourniquets, Trendelenburg, bleeding control, and hubris.


Tourniquets, Trendelenburg, Tampons, Toilet Paper

Standing Trendelenburg on it’s Head

Too Old To Work, Too Young To Retire:


And my own posts:

New Series of Rants – ParaCynic

New Series of Rants follow up

New Series of Rants Second follow up


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.

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.


[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]

[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]

[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]