For those of you wondering why I haven't posted in a while, I have been a very busy man. I am attending ClinCon in Orlando next week and competing in the ALS competition for the third year in a row. I am going to be taking notes in the courses that I attend and will be posting on them shortly. Until then, enjoy catching up on the previous posts and/or whatever my coauthors decide to post in the meantime.
A study of prehospital intubation was just published. The surprising result is that in the system studied they are able to intubate 3 out of 4 patients they try to intubate.
I will write another post with more detail on this. From that study, there are some quotes worth reading.
Compliance with documentation of ETCO2 was poor.
This suggests that the medics do not understand the connection between exhaled CO2 and intubation.
Let me rephrase that. This suggests that the medical directors have been unaware of the lack of documentation of ETCO2.
The medical directors appear not to have done a good job of explaining the importance of assessing CO2 in tube placement confirmation.
There you go blaming the medical directors, again.
Yes. How do you provide oversight of paramedics and not notice that there is no documentation of, or that there is less than adequate documentation of, exhaled CO2?
I give up.
I don't know the answer to that one either, but there is good news.
Since the completion of the study, training and education on the use of capnography interpretation and documentation have been emphasized by the group of supervising EMS medical directors, and continuous-waveform capnography is now incorporated into the airway management protocol.
That is reason to celebrate!
Maybe they learned from the study, but why did it take a study to get them to notice that The Gang That Couldn't Shoot Straight needs remediation?
Why do the medics not understand the importance of capnography?
Why do the medical directors not understand the importance of capnography?
Here is one partial answer:
Our finding that EMS providers reported only 70% of attempted intubations suggests that self-reported rates of intubation may underestimate the number of intubation attempts and therefore overestimate success rates.
^ 1 A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed - in process]
All quotes are from this study.
The issue of exposing patients, and especially female patients, comes up fairly frequently on EMS forums and blogs . This post will examine the issues surrounding exposing patients, guidelines for doing so appropriately, being sensitive to various cultural considerations, and limiting your liability when you undertake to expose a patient.
I. Issues Surrounding Exposing Patients
The main issue people raise is being accused of inappropriately exposing or inappropriately touching an exposed patient. This is not an imagined threat as we will discuss in more detail below. Nonetheless, as professional providers of pre-hospital emergency care we should have a thorough understanding of when we need to expose a patient and how to properly assess the exposed patient.
First off, I feel the need to suggest we refine "exposure" into two iterations: 1. Partial Exposure and 2. Complete Exposure ((This is a construct I created for this article. I have not encountered this parsing of the concept of exposure before, however if you have, let me know so that I can give the proper attribute.)). For this article, partial exposure will refer to exposing any upper or lower extremity only, and complete exposure will refer to exposing any body surface area from the neck to the genitals alone or in conjunction with exposure of any upper or lower extremities.
When do we partially or completely expose a patient? When we need to assess or treat a body surface area that is concealed from view, restricts palpation or auscultation and/or where clothing restricts or prevents the appropriate application of interventions ((This is my definition. I have not located an official definition.)).
Let's examine two routine instances where exposure of patients is likely required.
A. Trauma Patients
The obvious situation is the trauma patient. Nearly every paramedic or emergency physician text or handbook directs the complete exposure of the trauma patient. To wit:
"Intitial evaluation of the trauma patient begins with the primary survey, part of which is the complete exposure of the patient ((An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, By Swaminatha V. Mahadevan, Gus. M. Garmel, Published by Cambridge University Press, 20057, page 102)). Failure to completely expose the patient may result in missing a serious traumatic injury ((Id. at 102))."
"Exposure is obtained by completely undressing the patient. Patients must be fully undressed to allow a complete evaluation. ((Manual of emergency medicine, By Jon L. Jenkins, G. Richard Braen
Edition: 5, Published by Lippincott Williams & Wilkins, 2004, page 33))"
"The final part of the primary survey involves a quick scan of the patient's body to note any other potentially life threatening injuries. In general, this requires removal of the patient's clothes...Injuries cannot be treated unless they are identified." ((Trauma By Ernest Eugene Moore, David V. Feliciano, Kenneth L. Mattox page 115.))
That last bit is the key: you can't treat what you can't see.
However, this does not mean that we completely expose every trauma patient. Where your assessment determines the patient's traumatic injury is limited to only an upper or lower extremity, I feel that partial exposure if the injured extremity is required to appropriately assess and treat the injury. Complete exposure in these instances may likely be unwarranted.
B. 12 Lead EKGs
Prehospital 12-lead EKG with computer analysis and transmission to the emergency department is recommended by the American Heart Association (AHA) and the National Heart Attack Alert Program (NHAAP) for patients with chest pain and possible acute myocardial infarction (AMI).
Proper electrode placement in the precordial leads is critical.
Proper and consistent placement of the precordial leads is essential for obtaining accurate ECG tracings. ((Sensible analysis of the 12-lead ECG By Kathryn Monica Lewis, Kathleen A. Handal. Published by Cengage Learning, 2000, page 12.))
Correct placement is important because the 12-lead ECGs are compared with previous ECGs. For the comparison to be reliable for identifying existing problems or highlighting the appearance of new problems, the electrodes must be placed consistently. ((NANCY CAROLINES EMERGENCY CARE IN THE STREETS By AUTOR NAO LOCALIZADO, Nancy L Caroline Published by Jones & Bartlett Publishers, 2007, page 27.65.))
V1 and V2 often times present little problem, however in the female patient or obese male patient, properly placing leads V3 through V6 may require complete exposure of the chest.
When performing 12-lead ECGs on female patients, place the electrodes for leads V3 through V6 under rather than on the breast. ((Prehospital 12-Lead ECG: What You Should Know, http://www.physio-control.com/uploadedFiles/learning/clinical-topics/Prehospital%2012-Lead%20ECG%20What%20You%20Should%20Know%203009852-000.pdf))
Can a 12-lead be properly performed with the bra unfastened, yet in place? It is likely so. Underwire bras may interfere with the electrical conductivity of the electrodes ((http://www.cigna.com/healthinfo/aa10253.html)), however I have not located any studies confirming underwire interference with 12-lead EKGs.
In any event, when performing a 12-lead EKG, complete exposure of the chest is likely warranted.
II. Guidelines for Patient Exposure
So we have identified two routine instances that may be required to expose our patients, and identified some issues surrounding the exposure. Let us focus now on some general guidelines for exposing patients.
1. Inform Your Patient You Need to Expose Them.
If your patient is conscious and alert, tell them what you need to do and why you need to do it. Be professional, and explain to the patient that as soon as you have completed your assessment/treatment/electrode placement that you will cover them up.
Remember, however, that if your assessment reveals the patient has the appropriate present mental capacity, they can refuse any or all treatments or interventions. Respect your patient's right to refuse. Improvise, adapt and overcome. Oh, and document the patient's refusal of course.
2. Limit the number of people who see the patient exposed.
While this may be difficult during a trauma scene in the middle of the street, it is not impossible. You can use screening devices such as sheets or tarps to obstruct the view of onlookers. Alternatively, you can cover the patient and expose areas systematically while keeping the bulk of the patient covered.
This is easily accomplished in the living room of a chest pain patient. Prior to exposing your patient, ensure all non-essential personnel are out of the room. I politely boot out the security guard who responded, ancillary relatives, the nosy next door neighbor, etc. Need to do a 12-lead in the bar area of a restaurant? Clear it out. Take command; it is your scene. You patients will appreciate your concern over who sees them exposed.
I know what you are thinking. "Can't we just get them in the back of the Ambulance and then do the 12-lead?" Sure we can when the situation dictates. But even then, pay attention to who is in the Ambulance and remove non-essential personnel. Keep the doors closed, and do not permit entry to or egress from the ambulance while the patient is exposed.
3. Limit the time your patient is exposed.
Don't dawdle. Expose, assess/treat/place the leads, then cover the patient up. Trauma patients should be covered anyway to prevent hypothermia and for potential of shock. Additionally, sheets, towels, and gowns definitely do NOT interfere with electrical conductivity of the EKG electrodes.
3. Use the Back of Your Hand.
When placing electrodes for V3 through V6, use the back of a gloved hand to lift a woman’s left breast AFTER informing her. It is difficult to construe this action as sexual contact versus using the front of a cupped hand. An easy alternative is to ask the female patient (or male patient with large breasts) to lift their left breast to permit you to place the electrode and wire. ((12-Lead Acquisition Training, Ontario Base Hospital Group Education Subcommittee Group, 2008, PowerPoint Presentation, slide 22.))
4. Document Your Exposure.
If you expose any patient, you should thoroughly document what body surface areas you exposed and why you exposed them. You should further include the details of your assessment of those exposed areas and the treatments or interventions applied to those exposed areas. Additionally, it may be prudent to note when and how you covered your patient after assessment/treatment of the exposed areas.
III. Recognizing Cultural Sensitivities
Our communities are more diverse than ever. Female modesty is valued in many cultures and it may be difficult for patients of different cultures to undress in front of a male health care provider. Some cultures consider the area between the waist and knees particularly private. In fact, traditional Asian physicians do not touch a woman's body except to take her pulse. Instead, the woman points to the corresponding area of a doll to indicate the site of her problem.
If you are presented with a patient whose is culturally sensitive to being exposed, even for treatment of an emergent condition, there is not much you can do except respect the patient's modesty and keep as much of the patient covered as possible. You should ensure that only procedures that are absolutely necessary should be performed.
If possible, it may be best to assign a female practitioner in such instances to limit the psychological impact on the patient. ((Caring for Patients from Different Cultures: Case Studies from American Hospitals, By Geri-Ann Galanti
Edition: 3, revised, Published by University of Pennsylvania Press, 2004, pages 102-3.))
IV. Limiting Your Liablility
Last December The Associated Press published an article entitled, "Ambulance Attendants Molesting Patients". Read it, and pay special attention to the plaintiff's lawyer's comment
"It's a dream job for a sexual predator," said Greg Kafoury, a Portland, Ore., lawyer who represents three women who were groped by a paramedic. "Everything is there: Women who are incapacitated, so they're hugely distracted. Medical cover to put your hands in places where, in any other context, a predator would be immediately recognized as such."
This is the image a good lawyer will place in the jury's mind: The defenseless patient at the mercy of the predatory paramedic.
Patients or their families may not understand our need to expose trauma patients or expose patients for 12-lead EKGs. Protect yourself by following the guidelines discussed above, namely informing your patients of the medical necessity to expose them, limiting the number of people who see them exposed, limiting the time that they are exposed, and ensuring that you fully document all patient exposures.
Our patients place their trust in us in their most dire moments of need. That is an enormous responsibility. A responsibility that we must protect, not abuse. Exposing our patients when it is medically necessary is a part of our job, but we must balance that need with the respect to actively protect our patient's dignity.
Fear of failure to identify cervical spine injury has led to extremely liberal use of radiography in patients with blunt trauma and remotely possible neck injury. A number of previous retrospective and small prospective studies have tried to address the question of whether any clinical criteria can identify patients, from among this group, at sufficiently low risk that cervical spine radiography is unnecessary. The National Emergency X-Radiography Utilization Study (NEXUS) is a very large, federally supported, multicenter, prospective study designed to define the sensitivity, for detecting significant cervical spine injury, of criteria previously shown to have high negative predictive value. Done at 23 different emergency departments across the United States and projected to enroll more than 20 times as many patients with cervical spine injury than any previous study, NEXUS should be able to answer definitively questions about the validity and reliability of clinical criteria used as a preliminary screen for cervical spine injury.
According to the NEXUS Low-Risk Criteria, cervical spine radiography is indicated for trauma patients unless they exhibit ALL of the following criteria:
1. No posterior midline cervical spine tenderness
2. No evidence of intoxication
3. Normal level of alertness
4. No focal neurological deficit
5. No painful distracting injuries
These are for purposes of clarity only. There are not precise
definitions for the individual NEXUS Criteria, which are subject
to interpretation by individual physicians.
- Midline posterior bony cervical spine tenderness is present if the patient complains of pain on palpation of the posterior midline neck from the nuchal ridge to the prominence of the first thoracic vertebra, or if the patient evinces pain with direct palpation of any cervical spinous process.
- Patients should be considered intoxicated if they have either of the following: a) a recent history by the patient or an observer of intoxication or intoxicating ingestion; or b) evidence of intoxication on physical examination such as odor of alcohol, slurred speech, ataxia, dysmetria or other cerebellar findings, or any behavior consistent with intoxication. Patients may also be considered to be intoxicated if tests of bodily secretions are positive for drugs (including but not limited to alcohol) that affect level of alertness.
- An altered level of alertness can include any of the following: a) Glasgow Coma Scale score of 14 or less; b) disorientation to person, place, time, or events; c) inability to remember 3 objects at 5 minutes; d) delayed or inappropriate response to external stimuli; or, e) other.
- Any focal neurologic complaint (by history) or finding (on motor or sensory
- No precise definition for distracting painful injury is possible. This includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury. Examples may include, but are not limited to: a) any long bone fracture; b) a visceral injury requiring surgical consultation; c) a large laceration, degloving injury, or crush injury; d) large burns: or e) any other injury producing acute functional impairment. Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.
An additional Maine EMS 2002 Spine Assessment Protocol departure from the NEXUS investigation is the direction to immobilize patients for a complaint of neck pain as well as any tenderness present in the prehospital spine assessment. This change is purposefully meant to provide an added level of concern for spine injury by increasing the “sensitivity” of the spine assessment protocol. This direction should also serve as a means for decreasing the disagreement potential between providers’ (both in and out of the hospital) assessment of individual patients.
While the NEXUS investigation applies solely to the cervical spine, large scale clinical trials evaluating clinical decision rules for thoracic, lumbar, or sacral spine injuries have yet to be performed. As a consequence, care of the entire spine generally follows cervical spine assessment and treatment principles.
The prehospital assessment of tenderness should include, but not be limited to, the palpation of the posterior midline spine. While NEXUS has emphasized the sole importance of posterior, midline spine tenderness in cervical spine assessment, the Maine EMS 2002 Spine Assessment Protocol includes consideration of any areas of spine tenderness as a means for immobilization. This decision represents another adaptation of the NEXUS rules in an attempt to improve the instrument’s sensitivity for any spine injury as well as decreasing medical provider disagreement potential.
Standards: There is insufficient evidence to support treatment standards.
Guidelines: There is insufficient evidence to support treatment guidelines.
- It is suggested that all trauma patients with a cervical spinal column injury or with a mechanism of injury having the potential to cause cervical spinal injury should be immobilized at the scene and during transport using one of several available methods.
- A combination of a rigid cervical collar and supportive blocks on a backboard with straps is very effective in limiting motion of the cervical spine and is recommended. The longstanding practice of attempted cervical spinal immobilization using sandbags and tape alone is not recommended.
The chief concern during the initial management of patients with potential cervical spinal injuries is that neurologic function may be impaired due to pathologic motion of the injured vertebrae. It is estimated that 3% to 25% of spinal cord injuries occur after the initial traumatic insult, either during transit or early in the course of management.
Where is the proof that spinal immobilization even works?-Rogue Medic
Recently, the use of spinal immobilization for all trauma patients, particularly those with a low likelihood of traumatic cervical spinal injury has been questioned. It is unlikely that all patients rescued from the scene of an accident or site of traumatic injury require spinal immobilization.
OBJECTIVE: To examine the effect of emergency immobilization on neurologic outcome of patients who have blunt traumatic spinal injuries. METHODS: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did. The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables. RESULTS: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a less than 2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34). CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.
OBJECTIVE: To determine whether EMS providers can accurately apply the clinical criteria for clearing cervical spines in trauma patients. METHODS: EMS providers completed a data form based on their initial assessments of all adult trauma patients for whom the mechanism of injury indicated immobilization. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurologic deficit; and other painful/distracting injury. After transport to the ED, emergency physicians (EPs) completed an identical data form based on their assessments. Immobilization was considered to be indicated if any one of the six criteria was present. The EPs and EMS providers were blinded to each other's assessments. Agreement between the EP and EMS assessments was analyzed using the kappa statistic. RESULTS: Five-hundred seventy-three patients were included in the study. The EP and EMS assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%) patients for whom EP assessment indicated immobilization, but the EMS assessment did not. The kappa for the individual components of the assessments ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being 0.48. The EMS providers' assessments were generally more conservative than the EPs'. CONCLUSION: EMS and EP assessments to rule out cervical spinal injury have moderate to substantial agreement. However, the authors recommend that systems allowing EMS providers to decide whether to immobilize patients should follow those patients closely to ensure appropriate care and to provide immediate feedback to the EMS providers.
OBJECTIVE: To determine whether paramedics can safely use a spinal clearance algorithm to reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting. METHODS: Paramedics were instructed in the use of a spinal clearance algorithm that prompted assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm indicated that if any of the above were present, the patient should receive full SI, and if all of the above were negative, then SI could be withheld. Paramedics completed a tracking form that included the above and followed the patient to the emergency department (ED). Data were then gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the two. To compare the trends for SI, a retrospective medical incident report (MIR) review was conducted from the previous year. MIRs were selected based on the same criteria as those used for study inclusion. RESULTS: Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in utilization of SI (95% confidence interval: 27.2%- 38.8%). CONCLUSION: An out-of-hospital spinal clearance algorithm administered by paramedics can reduce SI by one-third. Any application of a spinal clearance algorithm should be accompanied by rigorous medical supervision.
reduces spinal immobilization in the out-of-hospital setting. Pre-Hospital Emergency Care
- Its wide > 120ms
- Its fast 150bpm