How much is too much?

[Paseo Del Norte]

As I progress in my career, I find myself taking a more and more conservative stance regarding patient care during transport. It seems we are pushing for more and more modalities, yet I am not confident these modalities are all that helpful. I feel this is especially true when considering the risks of said modalities and the fact that providers may or may not be performing these modalities on a frequent basis, leading to skill degradation. Of course, one has to consider the level of overall provider education.

Some of the modalities I have potential issues with include:

Placing central lines: This is better off done by a physician in a facility and I have faster and less risky options for access such as IO devices, especially when considering placing lines in the subclavian vein.

Rapid Infusion Catheters: Again, I have other options for access and personally have never converted a peripheral line into one of these large catheters in the field.

Pericardiocentesis: This seems to be a high risk procedure with questionable benefit in the pre-hospital environment when performed by non-physician providers.

Placing Chest Tubes: This appears to be somewhat of a low yield procedure IMHO. I hear the typical arguments about long transport times and so on; however, the classic tension pneumothorax has been somewhat of a scarecrow in my pre-hospital experience.

Intubation: Hot issue right now and has already been debated.

C-section protocols: I have heard about this and what can I say?

EDIT: I should also throw in arterial lines: Again, I see little benefit and some potential risks. I am more than happy to monitor and transduce a line that has been place, I not sure there is significant efficacy related to actually placing them.

As medical directors, what do you guys think? I would love to hear the physician prospective on this issue. My personal bias is that I only want to do what needs to be done, what is well within my ability to perform and ultimately something that is high yield when compared to the risks, both physiological and legal.

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[docB]

Really interesting question and definitely an issue we will all be dealing with more and more in the future.

Each item has to be taken on a case by case basis. I agree that IOs have pretty much made prehospital central lines obsolete. The other stuff still has some applications.

I think that what we may need rather than getting rid of these modalities is to restrict them to medics with a higher level of training. This is essentially the "supermedic" concept. The idea is to have CCT-P+ providers available within a system to respond when needed by the regular crews.

Pros for this concept include the fact that training fewer people to this level is cheap enough to be feasible and that with fewer people at the top of the pyramid dividing up the procedures they should be able to stay in practice. The con would be that some of these procedures have to be done right now or not at all. It also would only really be advantageous in a rural or semi-rural area where transport times are long enough to mean that linking up with another unit is faster than transport to the ED.

 

[jwk]

As I progress in my career, I find myself taking a more and more conservative stance regarding patient care during transport. It seems we are pushing for more and more modalities, yet I am not confident these modalities are all that helpful. I feel this is especially true when considering the risks of said modalities and the fact that providers may or may not be performing these modalities on a frequent basis, leading to skill degradation. Of course, one has to consider the level of overall provider education.

Some of the modalities I have potential issues with include:

Placing central lines: This is better off done by a physician in a facility and I have faster and less risky options for access such as IO devices, especially when considering placing lines in the subclavian vein.

Rapid Infusion Catheters: Again, I have other options for access and personally have never converted a peripheral line into one of these large catheters in the field.

Pericardiocentesis: This seems to be a high risk procedure with questionable benefit in the pre-hospital environment when performed by non-physician providers.

Placing Chest Tubes: This appears to be somewhat of a low yield procedure IMHO. I hear the typical arguments about long transport times and so on; however, the classic tension pneumothorax has been somewhat of a scarecrow in my pre-hospital experience.

Intubation: Hot issue right now and has already been debated.

C-section protocols: I have heard about this and what can I say?

EDIT: I should also throw in arterial lines: Again, I see little benefit and some potential risks. I am more than happy to monitor and transduce a line that has been place, I not sure there is significant efficacy related to actually placing them.

As medical directors, what do you guys think? I would love to hear the physician prospective on this issue. My personal bias is that I only want to do what needs to be done, what is well within my ability to perform and ultimately something that is high yield when compared to the risks, both physiological and legal.

Just a few thoughts - I'm years out of EMS, but still...

CVL's anywhere are full of potential complications, and probably even moreso in the field. One big issue now - ultrasound guided placement is becoming standard of care.

Pericardiocentesis can certainly be lifesaving - it's not technically that difficult (less than CVL's IMHO), so might be reasonable in well-trained hands.

Chest tubes? Nah - needling the chest for a tension pneumo is fine for short-term.

C-Section protocols? That scares me even being mentioned. By whom?

Arterial lines have little if any value in the field, and in the patients you're going to want them (trauma/shock), they're the hardest to get because of hypotension.

Correct me if I'm wrong - I thought the trend in EMS was moving towards less "treatment" in the field, and more emphasis on quick stabilization maneuvers and rapid transport to more definitive care.

 

[Paseo Del Norte]

Just a few thoughts - I'm years out of EMS, but still...

CVL's anywhere are full of potential complications, and probably even moreso in the field. One big issue now - ultrasound guided placement is becoming standard of care.

Pericardiocentesis can certainly be lifesaving - it's not technically that difficult (less than CVL's IMHO), so might be reasonable in well-trained hands.

Chest tubes? Nah - needling the chest for a tension pneumo is fine for short-term.

C-Section protocols? That scares me even being mentioned. By whom?

Arterial lines have little if any value in the field, and in the patients you're going to want them (trauma/shock), they're the hardest to get because of hypotension.

Correct me if I'm wrong - I thought the trend in EMS was moving towards less "treatment" in the field, and more emphasis on quick stabilization maneuvers and rapid transport to more definitive care.

Pretty much how I see it. My point of view is perhaps more from the critical care transport frame of reference and perhaps more consistent with DocB's statement regarding medics that receive additional education. However, I still wonder about some of these potentially life saving procedures. Take pericardiocentesis; would we not have to perform a significant number to maintain competency? I agree it could be lifesaving, but I'm just fearful of the damage that could be caused by an overzealous or undereducated provider.

Regarding c-section protocols; this was something I overheard regarding a few services in Texas? Nothing confirmed and I know that whole paramedic-c-section incident that occurred in New Jersey back in the 1990's is commonly discussed in some EMS circles, but this is apparently something else.

I guess some of this may be related (will not confirm or deny) to new protocols that I may or may not be working under. I am not aware of significant efficacy related to many of these advanced pre-hospital procedures. Some of my co-workers see me as being too conservative, especially since I've discussed my bias against putting chest tubes out in the field and placing central lines. If good literature exists to support this, I would consider it...

I appreciate the replies and I am really curious to see this from a medical director point of view.

 

[jwk]

Pretty much how I see it. My point of view is perhaps more from the critical care transport frame of reference and perhaps more consistent with DocB's statement regarding medics that receive additional education. However, I still wonder about some of these potentially life saving procedures. Take pericardiocentesis; would we not have to perform a significant number to maintain competency? I agree it could be lifesaving, but I'm just fearful of the damage that could be caused by an overzealous or undereducated provider.

Regarding c-section protocols; this was something I overheard regarding a few services in Texas? Nothing confirmed and I know that whole paramedic-c-section incident that occurred in New Jersey back in the 1990's is commonly discussed in some EMS circles, but this is apparently something else.

I guess some of this may be related (will not confirm or deny) to new protocols that I may or may not be working under. I am not aware of significant efficacy related to many of these advanced pre-hospital procedures. Some of my co-workers see me as being too conservative, especially since I've discussed my bias against putting chest tubes out in the field and placing central lines. If good literature exists to support this, I would consider it...

I appreciate the replies and I am really curious to see this from a medical director point of view.

Wow. I did a search about the NJ medics who did the C-Section. Crazy.

 

[gro2001]

C-Section protocols? That scares me even being mentioned. By whom?
...
Correct me if I'm wrong - I thought the trend in EMS was moving towards less "treatment" in the field, and more emphasis on quick stabilization maneuvers and rapid transport to more definitive care.

(disclaimer: I have neither EMS experience/education nor familiarity with EMS literature.)

Presumably those would be post-mortem C-sections. I imagine the scenario would be something like: an obviously gravid woman clearly (and recently) dead on scene. The harm of doing a post mortem c-section in the rig seems to me to be outweighed by the potential benefit in such a scenario.

 

[FiremedicMike]

My current experience is as an urban firefighter/medic, we averaged about 5500 EMS runs each year out of our single station department, and we are about twice as busy as many of the medics around us. Our average scene to hospital time is about 30 minutes on complicated patients, more or less depending on each situation.

1. Central Lines - absolutely not. EasyIO has negated any need for this to have ever taken place, and it's far too technical of a procedure to be done once every few years.

2. Pericadiocentesis - I've worked at 1 agency that had this within the protocol, they also had IC Epi in place, and I was vocal about the fact that I would never do either. Again far too technical with too much of a risk for undesirable side effects like myocadial tear <shrug>

3. Rapid Infusion catheters, the above agency also had these in the protocol, 8.5fr to be exact. I did it once, it was fun and somewhat gimmicky, and I can tell you my 1L bolus was gone almost instantaneously (which wasn't really intended). Patient was in full arrest and was dead either way. Anyhow, I suppose they're OK, not really a bit deal either way.

4. Chest tubes - seriously? Of all the gunshot trauma's I've seen, I've needle decompressed about 4 people in my 10 years. Needle decompression works just fine until we can get them to the ED

5. Intubation - I've been saying for years that if we don't stop screwing around with tubes we're going to lose them from our protocols. We spend way too long searching for cords and refuse to pull out and give someone else a try or move to the king airway. I have been trying since the day I found out the airtraq existed to get the department to purchase them, or at least some form of a glidescope, and they hemm and haw. Aside from that, I've had great success with the king airway <shrug>

6. C-Section protocols - in the case of the emergent "mom is dead cut the viable baby out" I seriously don't see a big problem with it. It is so utterly rare that I'm not really sure why it's always blown out of proportion. It saddens me to hear the rare story of "such and such medic" who cut a viable baby out and saved it's life only to have them stripped of their certification and banned from practice. If mom is truly dead, it should at least be considered. As it is with our litigious society, I'm certain I wouldn't consider it today, which is unfortunate.

Anyways, I fully believe in simplicity of EMS. I refuse to be a cookbook medic, and I enjoy giving a full assessment to everyone, but you will never find me sitting on scene for 30-45 minutes trying to track down the exact cause and origin of anything. I'm basically a flow chart medic, and at the top of my flow chart is "is this patient sick or not".

my 2 cents, take it for what its worth.. I also hate EMS so... <shrug>
lol

 

[Apollyon]

I refuse to be a cookbook medic...I'm basically a flow chart medic, and at the top of my flow chart is "is this patient sick or not".

Hey brother..."cookbook medic" and "flow chart medic" are synonymous.

Another risk of pericardiocentesis is lacerating a coronary artery. Frying pan --> fire.

And central lines? So I can pull it out immediately on arrival in the ED, since I am very confident that it's not the cleanest line in the world, and I now have one less place to go myself? IO, indeed!

As for "cookbook medic", though...I can remember a few times when "cookbook medicine" saved me on the bus. The scariest "para-gods" were those who didn't know what they didn't know, and barreled ahead full speed.

 

[fiznat]

As for "cookbook medic", though...I can remember a few times when "cookbook medicine" saved me on the bus. The scariest "para-gods" were those who didn't know what they didn't know, and barreled ahead full speed.

QFT. Well put.

 

[FiremedicMike]

Hey brother..."cookbook medic" and "flow chart medic" are synonymous.

semantics.. In my mind a cookbook medic treats specific complaints exactly the same every time regardless of mitigating factors...

 

[Apollyon]

semantics.. In my mind a cookbook medic treats specific complaints exactly the same every time regardless of mitigating factors...

Fair enough for your interpretation. Mine differs in that, even with a cookbook recipe, one can vary a bit here and there without changing the brew too extremely.

The "plus" of cookbook medicine is that few interventions are deleterious, so something you do if you're not sure is unlikely to make things worse. Giving the Narcan by protocol isn't going to kill someone. The stuff we could have done on the bus that could kill someone weren't part of the recipe (like epi 1:1000 IV or lidocaine for idioventricular rhythms).