Sick Kid Part 3

Shaggy | 11:48 PM | , | 5 comments

Photo Courtesy measurelife.com
Finally, here is Part 3 of Sick Kid, following up on Part 1 and Part 2. Here we will discuss the treatment of this pediatric patient in DKA, in the field and what will be started in the ED. You may be thinking, this should be easy; the kid is acidotic, so give Sodium Bicarbonate (NaHCO3); he is vomiting, give Zofran; he is dehydrated, so give lots of fluids; and he is hyperglycemic-he needs insulin and the local ED has that. The hospital can also treat the hypekalemia you may see on the monitor as well. Right? Not quite. All are correct, but most can be wrong too. The body is very complex and reacts in diverse ways. This is the reason for the reliance on evidence based medicine as opposed to that which is based upon expert opinion we traditionally have been used to in EMS. The treatment plan is obviously based upon the clinical presentation of the child. Is the child protecting his airway? Is the child hypoxic? Is the child in hypovolemic shock? Is the child currently vomiting? These are some questions that will guide our decisions.
The A, B, Cs-Airway
Let’s start at the beginning. Obviously our first priority is the A, B, Cs, right. Of course. If the kid starts to lose consciousness, we may want to consider intubation. I say consider as I admit our pediatric intubation skills are most usually attributed to practicing on a manikin once or twice a year. It depends on good clinical thinking in what is really best for the patient, considering how long it is from the appropriate hospital. We can find patients in DKA who are severe enough to be unconscious. Some parents just are not bright enough to ensure their kids get their needed insulin. If the trip to the appropriate facility is far, intubation may be warranted, but if it is close, monitoring the airway and BVM may be all that is needed, as well as an NG tube if that is within your scope.


Breathing-Oxygen
The kid will need some oxygen. How much? Enough to keep O2 saturations as close to 100% as possible. Since the SaO2 is in the high 90s and the patient is hyperventilating in this particular case, we can be sure that the patient is capable of exhaling CO2 and large concentrations of O2 are not necessary unless we see other signs of hypoxia. In this case, a nasal cannula should be enough. Some expert literature advocates using O2 via mask, implying high concentrations. There really is not much evidence to show high concentrations of O2 are needed here and some evidence may even question if it is safe. I would also give a cannula since the patient is vomiting for obvious reasons. If the child is showing signs of hypovolemic shock, perhaps increasing the FiO2 via mask would be warranted even if the patient is not showing signs of hypoxia, but increasing fluids is the key, which leads us to circulation.


Circulation-IV Access
Now for circulation; This is where things really get tricky. We know the patient is acidotic, hyperglycemic and dehydrated, and possibly hyperkalemic. We have to take care in how we address these issues. But one thing is for sure, the child needs an IV, preferably two of them. Why two IVs? This is a seriously sick kid as anyone in DKA would be. We always get two IVs for traumas and arrests, but we rarely do it for other seriously ill patients. We should be getting two IVs in AMIs, acute Strokes or any other seriously ill patient. Well, for one reason, this kid will probably be receiving many medications later, including insulin, and later potassium and if acidotic enough, possibly HCO3, often simultaneously, so two lines will be necessary. Another important reason is to have a good line to draw serial labs while the other line can be used for fluids and medication infusions. My suggestion is in this kid is to first get the best IV you can to start fluids, even if it is a small bore IV. You can then have time to look for better access afterward, but this is just my opinion, so feel free to debate it. Don’t forget about considering an IO if you feel the kid is sick enough. This kid is sick enough to warrant it, especially in hypovolemic shock.Though I am one to often preach a 20g IV is usually the biggest you need to get on most of your patients, obtain an IV large enough to draw labs, if you can.


Blood Draw and Fluids
Though I am one to often preach a 20g IV is usually the biggest you need to get on most of your patients, obtain an IV large enough to draw labs, if you can. If you routinely draw labs for your hospitals, then draw the “rainbow”. The most important will be the chemistries (various-light green to tan). Important labs from this will be electrolytes such as Na+, K+, HCO3 and Phosphate (P-) which tend to be depleted. I did not mention P- in part 2 but a deficit shifts the oxyhemaglobin curve to the left reducing O2 delivery. Other labs from this tube will the anion gap and BUN, (as I mentioned in part 2), serum osmolality and obviously serum ketones (β-hydroxybutyrate) and glucose.


photo courtesy of yzmedical.en.alibaba.com


A CBC (purple top) is always ordered as well as this checks H/H and platelets but most importantly WBCs. Why does the ED MD care about WBCs? Viral infections, and bacterial infections, especially in kids less than 3 years old are the precipitating factors of DKA. Infections are physiological stressors that can result in sympathetic nervous system response; releasing hormones like epinephrine and cortisol counteract the effects of insulin. An important goal for an ED MD would be to not only identify the infection or any other trigger and treat it. Other useful tubes may be a clear redtop in which to draw a venous blood gas, but this is often drawn in the ED. We draw the rainbow because the ED attending will often order off the wall labs and it is often hard to predict with what the attending will order. If the hospital does not accept your labs, then don’t waste time drawing them, obviously. And don’t feel bad if you don’t have time to draw them because if you have a good line to draw from, the ED will only take less than a minute or two to draw them. That is why it is nice to bring your DKA patient in with two lines, one big enough for labs.
Blood tube order:

So, as soon as we have vascular access, we need to run some fluids. Despite a hyperosmolar state of the blood, we want to run our isotonic fluids like normal saline or ringers lactate. This will keep fluid in the vascular spaces longer, but will decrease counterregulatory hormones and lower the blood glucose level. How much do we run? Well, that depends. Is our patient in hypovolemic shock? We all should know the signs and symptoms so I won’t go over them. If so we need to correct this first by restoring extracellular fluid by running the routine 20cc/kg bolus as we learned in PALS, with one caveat. It should not be run wide but should be run over 30 minutes to an hour. Many other sources recommend over 1-2 hours. How fast should depend on how hypotensive they are. Either way, the fluids should NOT be run wide open, as we would in an adult, where would dump 1-3 liters in an hour. Ideally it should be run by a pump, programming in the volume to be infused and the time being set for 30 minutes to an hour. How many ambulances carry pumps? Too bad. If not, you have to consider the tubing drip factor and count the drips. Some experts recommend the use of microdrips for more careful control.

If the patient is not hypotensive, we still know the child is dehydrated, so we will give 10-20cc/kg over 1-2 hours, initially. The ultimate goal in IV therapy is correcting fluid deficits, which in children is usually 60-100 ml/kg of body weight, or 7-10% of body weight. The deficit can be figured out by multiplying the percentage, say 0.10 (10%) by the body weight in kg. This fluid deficit is replenished over 24-48 hours, depending on the guidelines of the facility. Some may want 36 hours. Of course, if you gave a fluid bolus to correct hypotension, it would be deducted from the calculated total fluid replacement. This is why it is important to tell the receiving facility how much fluid you administered.


Photo courtesy of www.indiamart.com

Once the first bolus has been administered, the guidelines recommend switching 0.9% NSS to 0.45 NSS (“half-normal”), though most ambulances don’t have this fluid. Unless you are doing an interfacility transfer of this kid, you won’t have to worry about that anyway. However, there is a good chance you may be the transferring service. If that is the case, this child should be on a maintenance fluid. These will be set by the referring facility and since you will not usually be expected to initiate them. Just be sure the ordered rate is in fact the rate that is running on the pump or drip set. If there is a question of the rate set by the referring hospital, consult your medical command or Children’s Hospital consult MD. Remember, many referring facilities are not confident or competent to treat seriously ill pediatric patients appropriately.This is one reason STAT Medivac and other HEMS/MICU services consult a Children's Hospital MD on interfacility transfers involving pediatric medical patients.


Photo courtesy of www.choa.org

Cerebral Edema

So why the difference in fluid therapy between pediatrics and adults? The higher basal metabolic rate and large surface area relative to total body mass in kids requires greater precision in delivering fluids and electrolyte. We are also a little worried about Cerebral edema. There is some evidence that aggressive fluid therapy increases the risks or aggravates existing cerebral edema, (though recent evidence does not support this). Cerebral edema leads to increased intracranial pressure and then to herniation. Some sources state cerebral edema is normally present to some degree in all DKA patients due to idiogenic osmoles in the CNS that causes the accumulation of fluid. The exact cause is not really known and it is almost exclusively a pediatric problem, rarely seen in adults. Though severe cerebral edema is uncommon in pediatric DKA patients, with only 1-3%, it is the main cause of death in kids with DKA with a mortality rate of about 21% and a morbidity rate of 27% of kids having permanent neurological deficits.


courtesy of emedicine.medscape.com


Children’s brains have higher oxygen requirements than adults and the hypophosphatemia I mentioned above only decreases O2 delivery and hypoxia leads to cerebral edema. We also see studies that show the lower the pH, as well as low Na+ (during rehydration) and even arterial PCO2 levels, the greater prevalence of cerebral edema as well as increased BUN, indicating dehydration, being a significant risk factor. Cerebral and other autoregulatory systems do not develop well until later childhood and with these other risk factors, can predispose a child to cerebral edema. There is conflicting evidence regarding whether increasing fluid administration is a significant risk factor. It appears the fluid rates are not a primary contributor. However, since there was evidence showing some correlation between large fluid rates and cerebral edema, we still remain careful with the fluids.
What if you are transferring this child from a local facility to a children’s hospital and he shows clinical signs of cerebral edema. What are the clinical signs?
• Sudden or persistent drop in heart rate
• Altered mental status, increased drowsiness, irritability and restlessness
• Severe headache
• Emesis
• Seizures
If you see these signs, stop the infusion and raise the head of your patient 30 degrees and be sure to notify the receiving facility. Some sources recommend hyperventilating to reverse it. Most sources however, as we know, recommend against it, especially since that decreases cerebral perfusion. Manitol is the drug of choice, or other hypertonic colloid, but most services don’t carry it.


Courtesy of rn.modernmedicine.com


By the way, though rare, children with DKA have been known to develop thrombotic strokes, so this is another reason we also keep an eye on the patient's neuro status.
Have we forgotten about the nausea and vomiting? No? Good. This kid needs that addressed, too. Ondansetron (Zofran) is ideal, dosed at 0.1 mg/kg IM/IV, but in some regions, like here in Pa., you need medical command authorization. There is no consistency in prehospital anti-emetics, so use whatever you have as long as you understand the pediatric dosage. I know there are more side effects with Phenergan (promethazine), especially in pediatrics.


Potassium started in the ED
If you are doing an interfacility transfer of this kiddo, don’t be surprised if he is not receiving KCl added to the fluids. Why would that be if he was hyperkalemic? Well the potassium leaves the cells and enters the bloodstream, causing the hyperkalemia, but the fluids tend to wash it out. The cells are already lacking potassium and there won’t be any in the blood stream to draw from when the potassium is excreted in the urine. Therefore, after the first hour or two of fluids, the goal is to administer potassium via the fluids. With this see-saw balance of potassium, it is important to monitor this kid during transport to detect any arrhythmias.



Photo courtesy http://www.usza.us/

Insulin Drip in the ED

So, our patient is hyperglycemic. Isn’t large amounts of insulin the key? No. The fluids do a good job of diluting the blood and helping to excrete the glucose. The child does need insulin to normalize the blood glucose and suppress lipolysis and ketogenesis, but low dose IV insulin is the key. It is to be started after the first fluid bolus-after the first hour or two. However, most EMS services do not give insulin. Why am I bringing it up then? You may be transferring a pediatric patient on insulin as part of a MICU team. Remember that referring facilities often don’t know the current pediatric DKA treatment guidelines and may give too much. Either way, when you do a transfer of a DKA patient, you need to check the glucose. When the glucose level gets down to 300 mg/dl, IV D5 1/2 or D5 NSS should be started. If you are transporting the patient and the patient is on D5NSS, and you are wondering why, it is because between the insulin and fluids, the sugar levels drop fast. The 5% dextrose will help prevent hypoglycemia but the insulin will still continue to run to continue treating the DKA.




Photo courtesy of http://www.cvs.com/

Treating Acidosis

Now the kid is acidotic, so we should treat that with bicarb, right? No. At least not in the field. The ideal treatment is fluid replacement, especially in the field. The fluids will decrease the serum ketones, which in turn will decrease the acidosis. The ED may start bicarb if the pH is low enough and critical, but since EMS currently is not doing field ABGs and generally don’t have patients too long, there is no need for field administration of bicarb. Studies show no significant in improvement in patients in DKA and in fact, bicarb administration may in fact exacerbate cerebral edema, according to some studies.




Photo courtesy http://www.dixieems.com/

Transport

Now where does this child get transported to? The local hospital? Sure, if the local hospital is appropriate or the appropriate hospital is over an hour away. Well, what is the appropriate hospital? For one, a hospital that has pediatric endocrinology with written guidelines for pediatric DKA, and one with a laboratory for frequent and timely evaluation of lab results. And that is just for the more stable kids. Those with severe symptoms (kussmaul respirations, acetone breath, large ketones on urine dip stick), like this particular case I gave, would need to go to a Pediatric Intensive Care Unit (PICU). If you are not sure of the severity, and this is very difficult just on clinical presentation alone, err on the side of assuming this kid will need a PICU admission. Therefore, transport the child to a Children’s hospital or one that has a PICU. EMS providers seem to have a problem with transporting patients to the appropriate facilities and often don’t know the capabilities of the hospitals in their region. I suggest that should be one of the first things learned or taught during field training.






Children's Hospital of Pittsburgh, before it opened this year.

Summary

Here is a sample DKA ALS protocol.
So, to summarize, this kid will need O2 to keep sats as close to 100% as possible, Two IVs with labs drawn and IV NSS started to run at 20cc/kg run over an hour or two, unless the kid is in shock. In that case, run the fluids twice as fast perfusion is improved. Treat nausea and vomiting with an anti-emetic, and just as important: transport to the appropriate facility; one that has a PICU. Here is that boring but informative doctor again to summarize medical treatment for DKA:

References:

Brandis, K., “8.2.5 Management of DKA, Acid-Base Physiology”, http://www.anaesthesiaMCQ.com, November 2008

Chansky Michael E, Lubkin Cary L, "Chapter 211. Diabetic Ketoacidosis" (Chapter). Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM: Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 6e: http://www.accessmedicine.com/content.aspx?aID=606036.



Chiasson J, Aris-Jilwan N, Bèlanger R, Bertrand S, Beauregard H, Ekoè, J, Fournier, H, Havrankova, “Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state”, CMAJ. 2003 April 1; 168(7): 859–866.



Children with Diabetes Website, “Treatment of DKA”, 6 August 2006



Crandall, J., “Diabetic Ketoacidosis (DKA)”, The Merk Manual, May 2007



Finberg, Laurence, Appropriate Therapy Can Prevent Cerebral Swelling in Diabetic Ketoacidosis, The Journal of Clinical Endocrinology and Metabolism. - San Francisco : [s.n.], 2000 . - No. 2 508-509 : Vol. Vol. 85.



Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N; “Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics., Predicting cerebral edema during diabetic ketoacidosis”. N Engl J Med. 2001 Jan 25;344(4):264-9.



Green SM; Rothrock SG; Ho JD; Gallant RD; Borger R; Thomas TL; Zimmerman GJ, “Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis”. Annals of Emergency Medicine. 1998; 31(1):41-8



Ho Josephine , Pacaud Danièle, Hill Michael D., Ross Catherine, Hamiwka Lorie, and Mah Jean K. “Diabetic ketoacidosis and pediatric stroke” CMAJ. 2005 February 1; 172(3): 327–328.



Hopley L, Schalkwyk, J., “Diabetic ketoacidosis: pathophysiology”, jo2@anaesthestist.com, 2006



Kane E., “Diabetic Ketoacidosis and Cerebral Edema”, pedsccm.org, November 6, 1996



Kitabchi A, Wall B., “Management of Diabetic Ketoacidosis, American Family Physician”, August 1999



Kravitz J, “Diabetic Ketoacidosis: Still Serious After All These Years”, Emergency Medicine 39(11):10, 2007



McNally, P, “Aggressive Fluid Resuscitation in Initial Treatment of Children Presenting in DKA May Cause Herniation”, Michigan Department of Pediatrics Evidence-Based Pediatrics Web Site



Moran, Tony, “GUIDELINES FOR THE TREATMENT OF PEDIATRIC
DIABETIC KETOACIDOSIS”, University of Minnesota Department of Pediatrics Division of Endocrinology, 2003



Morris, A, Olshan, J., “CRITICAL CARE GUIDELINE FOR THE MANAGEMENT OF DIABETIC KETOACIDOSIS (DKA) IN THE PEDIATRIC PATIENT” at the Barbara Bush Children’s Hospital, March 2005



Munk, M, “Pediatric DKA: The presentation, assessment & prehospital management of diabetic ketoacidosis in children”, JEMS June 2006 Vol. 31 Issue 6 2006 Jun 1



Pischke M., “Diabetic Ketoacidosis”, Physician Assistant, Volume 25, Number 11, 2001



Wolfsdorf J, Glaser N, Sperling M., “Diabetic Ketoacidosis in Infants, Children, and Adolescents: A consensus statement from the American Diabetes Association, Diabetes Care” May 2006 vol. 29 no. 5 1150-1159

Advances in Resuscitation - CCR, if you're not doing it now, you will be

Ckemtp | 3:53 PM | , , | 4 comments

Allow me to introduce myself. My name is Chris Kaiser, or Ckemtp, and I write the EMS blog http://www.lifeunderthelights.com/ - I am a Nationally Registered Paramedic holding licensure in Illinois, Iowa, and also in Wisconsin. A few months ago I was asked to become a contributor to write for this blog and I jumped at the chance to intermingle my stuff with the venerable names here. Unfortunately, it has taken me a while to get something up here with the work needed to move from my old site to the new site. Today I'm fixing that and I would like to repost this article here with a few updates. I hope you find it educational.

Visitors to my blog probably know that at my ambulance service we tend to bring back a lot of codes. I talk about it a lot. Back in 2004 our medical director, Dr. Michael Kellum, got us involved in a “Demonstration Project” to bring Continuous Compression CPR or Cardiocerebral resuscitation to a rural area. Since that time, the results have been more than dramatic. Depending on what statistics you look at, we may be “Saving” almost 50% of witnessed arrests found to be in ventricular fibrillation.

It’s all explained at http://www.callandpump.org/, but if you want to go right to the whitepaper that explains what we do, why we do it, and how it’s done then you want to go here: http://callandpump.org/assets/Proposal_Current.pdf – This link is explains the demonstration project initiated by Dr. Kellum et al. in the two county area that I work in. This paper was published in 2004 at the beginning of the project.

This is a link to the results published in the Annals of Emergenc Medicine in 2008 – http://www.ncbi.nlm.nih.gov/pubmed/18374452?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

You may be interested in this part:

“RESULTS: In the 3 years preceding the change in protocol, there were 92 witnessed arrests with an initially shockable rhythm. Eighteen patients survived (20%) and 14 (15%) were neurologically intact. During the 3 years after implementation of the new protocol, there were 89 such patients. Forty-two (47%) survived and 35 (39%) were neurologically intact. CONCLUSION: In adult patients with a witnessed cardiac arrest and an initially shockable rhythm, implementation of an out-of-hospital treatment protocol based on the principles of cardiocerebral resuscitation was associated with a dramatic improvement in neurologically intact survival.”
This is good stuff. Remember, the above is only reflective of those included in the study, who are “Witnessed arrest(s) with an initially shockable rhythm”. Anecdotally, I’ve personally attended those that were not in a shockable rhythm and witnessed greater effectiveness as well.

Here’s the short version of our protocols for Witnessed V-Fib Arrest: (and for those of you who want more, email me at: proems1@yahoo.com and I will be happy to send you a copy of the protocols)

We follow an acronym called MCMAID in our resuscitation protocols, it stands for:

Metronome – We carry a metronome in our monitor/defibrillator bags that clicks out at 100 beats per minute. We are to compress at 100bpm. No more, no less. This metronome keeps us on rhythm and reminds us to be on the chest.

Compressions – 100 compressions per minute. Do not stop. Initially, we are to administer 200 compressions (2 minutes) before our first shock. We are to limit any interruptions in compressions absolutely as much as possible, charging our defibrillators while compressions are ongoing and recognizing V-fib through the compressions if possible. Compress hard and deep, completely releasing tension on the chest upon recoil to maximize the compression and decompression of the chest.

Monitor – Place the monitor on the patient using fast patches. Do not stop the 200 compression cycles to determine the rhythm. Shock at max joules biphasic. If you can anticipate V-Fib, charge the defib during the compressions and only stop long enough to clear for the shock. Don’t check the pulse, get right back to compressions.

Airway – Initially, a BLS airway will be placed in the patient and a non-rebreather oxygen mask will be placed on the patient. If the airway must be controlled by more advanced means to protect and ensure a patent airway, now is the time to do so.

Intravenous Access – Most of the time, this is accomplished through the means of the Ez-IO drill that we carry and love. (See: Alternative Circulatory Access Strategies – Hi Ho IO) This can also be obtained through peripheral or EJ IV access.

Drugs – Epinephrine 1:10,000 1mg IVasopression 40 IU, Amiodarone 300mg, then Epinephrine 1:10,000 1mg q 3-5min. If refractory, we may give an additional 150mg Amiodarone IV.

To see the full MCMAID CCR protocol (I put it up in a post) you can see it by clicking here.

Dr. Kellum came down again for our monthly training recently and let us know the latest breakthroughs and orders in the project. He is stressing the importance of End-Tidal CO2 (ETCO2) monitoring and states that no pulse check is necessary without a spontaneous increase in ETCO2. He expects every intubated (or combitubed) patient to have ETCO2 monitoring in place.

He also expects that we will monitor ETCO2 readings as a way to prove effectiveness of compressions. Rescuers who cannot get ETCO2 readings consistent with other personnel when providing compressions shouldn’t be doing compressions.

Rescuers should switch off compressions EVERY ONE MINUTE whenever possible. This is providing some fantastic results in preliminary trials.

He also stated that the effectiveness of the CCR protocols are showing a marked increase in refractory V-fib. He hinted that the protocols might soon show a need for thrombolytic use in treatment of refractory V-Fib.

Stay tuned folks, I am happy as heck to be included in this. I will bring updates, with permission, as many times as I get them. You can find more information on this on http://www.lifeunderthelights.com/. It's truly exciting stuff.

Blue Babies

Adam Thompson, EMT-P | 2:35 PM | , , | 3 comments

Blue Babies




I am not an expert when it comes to pediatric emergencies. The mean age of most of my patients is over 50, and the kid calls are far and few between... well usually. In the past two shifts I have had two unstable kids. When it comes to cardiac or adult respiratory calls, I am top notch. My comfort level doesn't go far below the age of 16. I handled the calls efficiently of coarse, but with an added sense of pucker. This has initiated a need for further education.

So let me provide some information on the two congenital conditions these kids suffered from.


Hypoplastic Left Heart Syndrome


In a child with Hypoplastic Left Heart Syndrome, all of the structures on the left side of the heart (the side which receives oxygen-rich blood from the lungs and pumps it out to the body) are severely underdeveloped.

The mitral and aortic valves are either completely "atretic" (closed), or they are very small. The left ventricle itself is tiny, and the first part of the aorta is very small, often only a few millimeters in diameter.

This results in a situation where the left side of the heart is completely unable to support the circulation needed by the body's organs, though the right side of the heart (the side that delivers blood to the lungs) is typically normally developed.

What will we see in the prehospital environment?
Chronic hypoxia. Most-likely, your patient will already be diagnosed, and hopefully receiving the needed treatments.

What is the definitive treatment?
The management of the newborn with Hypoplastic Left Heart Syndrome can be divided into the initial stabilization period and the operative / post-operative period.

Even while diagnostic tests may be going on, the rapid stabilization of infants with Hypoplastic Left Heart Syndrome must begin as soon as the diagnosis is suspected.

Catheters are placed, usually in the umbilical blood vessels, which allow medications to be given and blood to be obtained for testing. An infusion of prostaglandin, a medication that prevents the patent ductus arteriosus from closing, is begun, thus maintaining the pathway for blood to reach the body from the right ventricle.

Even though the infant may have low oxygen saturations, supplemental oxygen is avoided since it tends to promote more blood flow to the lungs which may steal blood flow from the body and place excessive demands on the already stressed single right ventricle.

Manipulations of medications and respiratory treatments (including possible mechanical ventilation) are performed to optimally balance the flow of blood to the body and the flow of blood to the lungs.

Close monitoring is essential to detect any organ dysfunction and maintain cardiopulmonary stability because infants with this anomaly may be very unpredictable and undergo quite sudden changes.

There are essentially three treatment options that have been proposed for children with Hypoplastic Left Heart Syndrome.

In the past, due to poor outcomes with available treatments at that time, no treatment was often recommended. Today it is rare that a family may choose not to treat a child with Hypoplastic Left Heart Syndrome, though in cases when the infant is unable to be satisfactorily stabilized no treatment may be advised.

Cardiac transplantation in the newborn period is performed as primary treatment for Hypoplastic Left Heart Syndrome at some centers in this country. While transplantation has the advantage of replacing the very abnormal heart of a child with Hypoplastic Left Heart Syndrome with one of normal structure, this treatment is limited by the scarcity of newborn organs available for transplantation and the life-long need for anti-rejection therapy. Additionally, although outcomes for transplantation continue to improve, and the incidence of rejection is lowest in patients transplanted as newborns, the average life span of the transplanted heart is limited (currently less than 15 years).

The most commonly pursued treatment for Hypoplastic Left Heart Syndrome is "staged reconstruction" in which a series of operations, usually three, are performed to reconfigure the child's cardiovascular system to be as efficient as possible despite the lack of an adequate left ventricle. These surgeries do not correct the lesion, and are instead considered "palliative".

The first operation in the staged approach is known as the Norwood operation and is typically performed in the first week of life. With the Norwood operation, the right ventricle become the systemic or main ventricle pumping to the body. A "new" or "neo" aorta is made from part of the pulmonary artery and the original, tiny aorta, which is reconstructed / enlarged to provide blood flow to the body. Finally, to provide blood flow to the lungs, a small tube graft is placed either from an artery to the lung vessels (called a modified Blalock-Taussig shunt) or from the right ventricle to the lung vessels (called a Sano modification). Because of the extensive reconstruction of the aorta that must be done, this operation is one of the most challenging heart surgeries in pediatrics.

The subsequent operations in the staged reconstruction plan are the bi-directional Glenn procedure, typically done at 3 to 6 months of age, and the Fontan operation, typically done in children older than 2 or 3 years. These operations are described in more detail in the Heart Encyclopedia chapter on "Single Ventricle Cardiac Anomalies."
"Blue Baby Syndrome"

The first heart surgery ever done was on a blue baby at Johns Hopkins. There is a great movie about this Something The Lord Made, which I highly recommend.

Hypoplastic Left Heart Syndrome is a form of "Blue Baby Syndrome" as well as the following:

Tetralogy of Fallot - Pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy.

Dextro-Transposition of the Great Arteries (d-TGA) - With d-TGA, blue blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, bypassing the lungs altogether, while the left heart pumps red blood continuously back into the lungs through the pulmonary artery.

Tricuspid Atresia - Complete absence of the tricuspid valve.




Most information and images courtesy of Wikipedia.

EMS 2.0: Critical Thinking in Prehospital Training

Rogue Medic | 3:16 AM | , , , , | 2 comments





Even though EMS 2.0 may not be any more successful at changing EMS than previous efforts at improving patient care, it does seem to be getting more attention. One place is EMS1.com. The names do not share etymology beyond the letters EMS, although both have been wise enough to get Kelly Grayson to contribute. Kelly is also the author behind A Day In the Life of An Ambulance Driver.

Kelly wrote an article called EMS 2.0: Critical Thinking in Prehospital Training. In the article, he does make reference to my blog, but that is not the reason for this post. Although, he does summarize many of my points very nicely.

He also mentions a debate on paramedic-initiated refusals. A debate that I have not commented on, because I have not been able to sit down and read through enough comments to get caught up to the current comments. This is a debate that has also taken place many times before.

Here is an example of the commentary -


"We've got 12-lead EKGs and capnography, and if we had I-Stats to do point-of-care labs, think of how many unnecessary transports we could avoid!" they gushed.

And that statement exposes the gaping hole in their logic while simultaneously demonstrating the flaws in the EMS mindset:

We focus on the things we can do, rather than what we know.



This is the essence of the problem. Too many people still believe that the right technology will produce a foolproofTM paramedic/nurse/doctor/et cetera.

Too many people still believe that the right technology will produce a foolproofTM human.





This completely ignores the Law of Unintended Consequences.TM This law is far too important and entertaining to ignore.

In another article on EMS1.com, Stop Talking, Dan White suggests that providing continuous transmissions of all of the information we are looking at in the ambulance - ECG, SpO2, EtCO2, BP, et cetera - will lead to more concise communication with the ED. While he means well, I think that he is overlooking the probability that the Unintended Consequence gremlins are just waiting to pounce. As Kelly writes -


All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools.



Many places have made pulse oximetry a BLS skill. How many of them use it appropriately? Nursing homes regularly send patients to the ED because of a low sat.

The fancy equipment does not lead to better care. It often only leads to toggle switch care. Sat of X or less = emergency. Sat of more than X = no problem. There is nothing in between. Everything is either an emergency, or does not meet treatment criteria.

Less than 8 - intubate. More than 8 - procrastinate.





Or should our patients receive airway management from someone who has an understanding of airway managment that goes beyond a nursery school rhyme?






Kelly continues with -

EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal.



Adding to the EMS scope of practice presumes that we are already good at what is in our scope of practice. The debate about paramedic-initiated refusals is an example of this. How many paramedic schools spend any time on education about which patients do not need to go to the ED? It is not really something we receive training to do, so it is no surprise that when we arrogantly do what we are not trained to do, we provide many examples of incompetence.

At one place where I used to work, they kept track of what happened to patients who refused or were triaged to BLS after being assessed by paramedics. Their main criterion was whether the patient ended up in the ICU. Unless something changes dramatically in the patient presentation, none of these patients should end up in the ICU. Yes, some stubborn refusals will, but the chart should reflect that the paramedic saw the potential for significant complications and did not just say, OK. Sign here.

I have seen refusals, where the full narrative is - Medical command consents to refusal. Patient signed AMA form. Available at XX:xx. Indicating a total scene time - leaving the vehicle, assessing the patient, contacting medical comand, getting a signature from the patient, and notifyinging dispatch that the medic is available - of less than 5 minutes. The medic is only surpassed by the medical director in lack of attention to the problem.


Some of you may argue that things aren't that bad. You may know of EMS educational programs that excel at turning out capable EMTs.



There are excellent programs. These excellent programs exist in spite of the National Registry's No Paramedic Left Behind dog and pony show.

The National Registry does not just share responsibility with the bad EMS programs for the pathetic state of EMS education, the National Registry pushes the envelope to the point where stupid, dangerous, and irresponsible all begin to sound like compliments.


But for the most part, those medics are as good as they are in spite of their EMS education and not because of it, and it's not those superior medics that we should use as measure of the effectiveness of EMS education. They are, by definition, outliers.



Sad, but true.


It's when the rank-and-file, average medic in an EMS system can make those decisions and get those tubes that we'll know that EMS education is where it should be. And likely as not, when we get there, those medics are going to know enough to realize that they need to do very little for most of their patients.



There are many, who suggest that all we need to do is to require more education to improve EMS. All it takes is a degree to make EMS a respectable profession. As long as we keep doing things the same way, does it matter if we require 3 months of misinformation?

What if we require 6 months of misinformation?

What if we require 1 year of misinformation?

What if we require an Associate's degree in Misinformation?

What if we require a Bachelor's degree in Misinformation?

What if we require a Master's degree in Misinformation?

Should we just pile it higher and deeper?

Until we get rid of the misinformation in EMS education, it does not matter how much time we spend making students memorize misinformation - we are not providing a useful education. We are not protecting patients.

There are schools that do a good job. We need to find out what they are doing well. We should not be telling everyone that more of the same is the solution to bad education.


For some other perspectives on this, Unconventional Thoughts On Emergency Services by Steve Whitehead at The EMT Spot. Not really an education post, but all of his posts are education posts. Nice clear posts that get us to look at things differently.

And I’m Hangin’ Up My AHA Spurs by Buckman at Gomerville. Great writing and he tells a story as well as Kelly does, which is no small achievement.






^ TM Unintended Consequence
Wikipedia
Like Murphy's law, again a humorous expression rather than an actual law of nature, this law is a warning against the hubristic belief that humans can fully control the world around them.
Article

Possible causes of unintended consequences include the world's inherent complexity (parts of a system responding to changes in the environment), perverse incentives, human stupidity, self-deception, failure to account for human nature or other cognitive or emotional biases. As a sub-component of complexity (in the scientific sense), the chaotic nature of the universe – and especially its quality of having small, apparently insignificant changes with far-reaching effects (e.g., the Butterfly effect) – applies.

Robert K. Merton listed five possible causes of unanticipated consequences:[8]
Ignorance (It is impossible to anticipate everything, thereby leading to incomplete analysis)
Error (Incorrect analysis of the problem or following habits that worked in the past but may not apply to the current situation)
Immediate interest, which may override long-term interests
Basic values may require or prohibit certain actions even if the long-term result might be unfavorable (these long-term consequences may eventually cause changes in basic values)
Self-defeating prophecy (Fear of some consequence drives people to find solutions before the problem occurs, thus the non-occurrence of the problem is unanticipated)

The Relevance paradox where decision makers think they know the areas of ignorance about an issue, and go and obtain the necessary information to fill the ignorance, but neglect certain other areas of ignorance, because, due to not having the information, its relevance is not obvious, is also cited as a cause.


.

Second comment from Anonymous on Teaching Airway - Part I

Rogue Medic | 3:09 PM | , , | 0 comments





There is also a thoughtful analysis of airway management and intubation in Airways and ET tubes... at 9-Echo-1.

In the comments to Teaching Airway - Part I - comment from Anonymous, Anonymous writes -


Hi, me again...Nothing brings out a good post from you better than BS. Your best posts come from you when you're challenged.



Thank you.


So I get to respond to your post...

Science shows us what works. Anecdote can show us areas to examine scientifically, but basing treatment on anecdote is bad patient care. We need to base treatments on science.


Yes, but studies can't be started and performed without anecdotal evidence to steer research. We have to do a few things wrong to figure out what's right.



I agree. Although there may be some research that is begun without some anecdotal evidence to support it, that is probably rare.

We do have to do a few things wrong to figure out what's right. We spend too much time on punishing mistakes, rather than looking for ways to avoid those mistakes. We are taking the wrong approach to figuring out what is right.

I see this as a reflection of insecurity and ignorance by those in charge. Those in charge are insecure because of their ignorance. Maybe they just do not know how to do things well, but they do not seem to be doing the right things to learn how to do things well. One easy way to learn how to do things well. Find somebody doing it well, and ask them for some ideas. In Too Many Medics? comment from Anonymous, I included the abstracts from 2 systems that demonstrate excellence at intubation.

One of our big problems is that we do not look at bad outcomes as opportunities to learn how not to keep making the same mistake. We look at bad outcomes as an excuse to punish somebody. Why learn from our mistakes, when we can deny that we made a mistake, and punish someone else for our mistake? Win - Win? Right?


That has never been my position. I want medics to use the right tool to accomplish the job. The job is patient care.


I know and I really don't expect anything less from you. I'm not doing this for the check.



I need the paycheck, but I could probably make more in a different line of work. If I had gone into a different line of work, I would have less debt at the end of the month.


There are some medics, that I do not want to be allowed to intubate. Those are the medics, who do not intubate competently. According to the studies of prehospital intubation, there are a lot of these medics out there.


I agree 100%, but how do you sort them out, in a city wide system, with poor medical command, that sometimes barely has a budget to even staff trucks.



That is probably the thing that is going to have the greatest effect on who should intubate. A system, like the one you describe, will have a lot of horrible medics, but do nothing to get rid of them. Or just a little more than nothing.

A system that gets rid of maybe one bad medic a year, but has a couple dozen bad medics, and has them training new medics, is not likely to stop getting worse. That is a system that is not getting better, but getting much worse. Everybody sees that the bad medics are tolerated. Sure they sacrifice one every year, or maybe every other year, just so they can say that they do something about bad quality. They make it seem as if they are doing something significant, but what they really are doing is telling everyone that they are not serious, or that they really are too stupid to understand.

Who are they?

They are the medical director, the chief, the CEO, the City Manager, the QA/QI/CYA department, the union, and all of their accomplices.

Anyone, who has one of those jobs is responsible for eliminating bad patient care. All of them have that responsibility, but few seem to do anything significant to eliminate bad patient care.


The same medics that keep the CPAP (Continuous Positive Airway Pressure) stuffed under the seat because "we're right down the street from the hospital, we'll just use meds" attitude. I've seen it and it's scary.

I'm NOT supporting these systems, but how do you change it?



That is a good question. There needs to be somebody who just insists that patient care be the priority. That needs to come from the top. When the bosses get on camera and defend horrible care, there is no reason to expect things to change until that boss is gone, and probably some others, too.


I have no problem with competent medics intubating when it is appropriate. We are learning that intubation may not be appropriate for some patients, who used to be routinely intubated. We need to learn more about when intubation is appropriate.


Yes, again I agree, in fact I use CPAP, NTG (NiTroGlycerine), and Ace inhibitors on a regular basis and I don't drop a tube, in fact most, are turned around at the hospital. The CHF I described carried down on the Reeves was unresponsive and wasn't going to fit in a stairchair, so yes, my partner bagged, I put in a line, NTG paste w/3 sprays in a foamy mouth (no IV NTG), Lasix (which I rarely give because CPAP works so well), and Captopril 125. Then I suctioned the pt and tubed while waiting for fire to help carry out my pt. The pt waited to long. Indicated for intubation. I saw that pt again, alive, and good for them. You've had that pt before, most medics have.

Was that pt saved by the tube? No idea, yep, no idea. Would CPAP work, no. Would a KingLT which we carry work, maybe, no idea, didn't use it. I saw need for a tube and did it because it was indicated, could I have just bagged that pt, sure, would have been a bitch, but it could be done. I have even used the ramp on the KingLT to place a successful tube, it's was pretty cool actually. The problem is these patients are still presenting while science and training catch up or figure out what's best for the patient and when you FINALLY get people comfortable the rules change. Little and large systems seems to continue to fail, and most likely to "follow the dollar" where other systems seem to always be on top of things.



There are patients like that. Sometimes they do not have time to call, because the onset is so rapid. The train wrecks will not necessarily be any better, regardless of what we do. Positive pressure ventilation (CPAP) is probably the most important treatment for this patient. Next most important is high dose NTG. 10, 20, 50, 100 NTG sprays - whatever it takes. As long as the blood pressure does not dramatically drop. I have given over 50 NTG sprays and still not had the systolic pressure drop to even 200, in some patients. We are unnecessarily afraid of NTG. Hypertensive CHF patients tend to be resistant very resistant to the effects of NTG. The only reason not to be giving 3 to 5 sprays/tabs at a time to hypertensive CHF patients is having a bad protocol.

The NTG paste makes no sense. You are applying it to the skin to be absorbed by the circulation to the skin, but the patients skin signs indicate that the circulation to the skin is just not there.

Pale - due to a lack of hemoglobin reaching the skin.

Cool - due to a lack of the warmth from blood reaching the skin.

Diaphoretic Sweaty - due to the large amounts of adrenaline being released by a body in hypoxic panic. The adrenaline shunts the circulation away from the skin.

The circulation needs to pick up the NTG from the paste on the skin to take it to where it is needed in the pulmonary circulation. It is not needed on the outside of the skin, unless we are looking for ways to accidentally expose our coworkers to NTG.

A great example of this is when someone is suturing a laceration and injects lidocaine with epinephrine (epinephrine is adrenaline). The skin around the injection site becomes more pale, as you are watching. This is what is going on to all of the skin on the pale, cool, sweaty patient. This is one reason that it does not make sense to use NTG paste. The other reason is that the low dose of the NTG paste is like trying to make the tide rise by urinating in the ocean. With precise enough tools, we may be able to measure a minuscule difference, but it does not make any noticeable difference. The epinephrine is shunting the blood away from the skin, not the lidocaine. The lidocaine is for pain relief. The epinephrine is to minimize bleeding during suturing.


As far as educating residents and stopping them from pulling my KingLT, the second you find an answer to that then post it immediately, I'm up for anything with that.



The best way to educate the residents is to educate the attendings. Maybe I have been spoiled, but I have found that the attendings are willing to look at different ways of doing things, if you present it to them in a way that makes sense. You may find that it takes several years to get them to actually change things, but I have found that they are willing to listen. Then it becomes a matter of politics. How do you identify the attending most likely to do something about it? Doctors are more likely to listen to other doctors. Good reasons coming from a medic are less likely to persuade a bunch of doctors, than the same reasons coming from another doctor.


If you are worried about the resident being able to do something that you might not be permitted to do, then there is an excellent way to frustrate them.


I get that secret smile when I turned the pt prior to arrival also.



You lost me on that one.


As I have repeatedly stated, I do not wish to remove intubation from the paramedic scope of practice. However, I definitely do not want dangerous medics intubating.


I really do know that, and I agree. I have family that I really wouldn't want some of these medics even touching them.



I kind of figured that.


Maybe we should use the term alternative paramedic for those not capable of maintaining adequate intubation skills.


True, but I have seen a few attendings reach for a LMA because they couldn't get an ETT placed. What is their standard for maintaining skills? Are they are judge? I've taken many ACLS classes over the years and every ED doc shows up but shows no initiative and participates. Here's your card doc, oh and did I mention your codes, run like 1998.



The hospital decides what their rules are. Some restrict some skills to only certain doctors, while others may not have any restrictions for any doctor, as long as the doctor maintains a state license and malpractice insurance. Most are probably somewhere in between these extremes. It has been my experience that some ED attendings, board certified in EM, are scary at intubation and airway management in general. Others are great. I have sat in the parking lot to intubate some patients, because they were not responding to medical treatment, I knew that they would be intubated soon, and I knew who was the on duty attending. Why subject the patient to that doctors obligatory 2 or 3 failed intubation attempts, followed by a call to anesthesia and a waltz-by intubation, when they could come in with a tube in place and have less iatrogenic harm?

Some doctors just do not seem to get airway management. We all have our blind spots. I keep trying to minimize mine.


As we have learned more about airway management, we have come to realize that the Gold Standard is not intubation. We old timers were taught that intubation is the Gold Standard, but we were taught a lot of other things that are just plain wrong. The Gold Standard is what is best for the patient. The gold Standard is excellent patient care.


I'm not that old, and would NEVER disagree with that statement.



:-)


Where is the evidence that prehospital intubation is better patient care than prehospital alternative airway use?


I've got none, and I'm not going to claim it, they are really new prehospital, around here anyway. LMA's have been around for awhile but as far as I know no squad, at least in my area ever carried them. However I'm sure your reply will have a stat.



I will have to follow up with some posts on prehospital LMAs. There are services using them. There has been research on prehospital LMA use, but it is going to take a while to go through it and come up with something thorough.


Maybe research will end up showing that replacing the alternative airway is indicated some of the time, but not indicated other times. We do not currently have research to determine which is better.


Agreed



After all, anesthesia seems to be leading the way in airway management, and they are increasing their use of LMAs. That may be where the rest of in-hospital airway management is headed.


You do not appear to be familiar with ICU care. Patients with the need for long term ventilation will have the endotracheal tube replaced by a tracheotomy tube. Apparently, the doctors do not consider your endotracheal tube to be permanent.


I've suctioned enough of them, I am aware for long term, in my head I was focusing on pt's that should have turned around and are only on a vent for a few days to a week. The patient that I knew would probably turn around if we were all aggressive on in the beginning, the CHF pt who was just to weak, but after being medicated, tubed, and cleared out, would allow the tube to be pulled assuming all the ABG values looked good.



Even that may change. VAP (Ventilator Associated Pneumonia) is a big concern in hospitals. It seems to fall into the never event category. As Ambulance Driver mentioned, hospitals are paying attention to the cost of care. They are going to try to cut down on costs, so I expect that we will see a lot more use of LMAs in the hospital, even if they don't improve outcomes or expenses, but because they might and hospitals are all about saving money.


No waveform, then the tube is pulled, PERIOD.


Yeah, even I slapped myself for that statement, I got out of control. Let me explain what I was thinking. If I place a blind tube and don't see a good waveform then the tube is pulled. This is on a patient that should show an ETCO2 reading. I could expand on it more but I think you get the jist.



Please send video of you slapping yourself. I am not above cheap sensationalist publicity. ;-)

As I understand it, unless there are conflicting assessments, if there is no good wave form, the tube should be pulled. At least, that is the way I approach confirmation, and I get the impression that we agree.


Again, I do not wish to remove intubation from the paramedic scope of practice. More important is that, I definitely do not want dangerous medics intubating.


Again, how do we fix it?



I think the first thing is that we need agreement on what should be minimum standards, but that has to come mostly from the medical directors.

We need research to show what the differences are between places that intubate well and those that, even though the service may have some people who are great at intubation, the service overall does a horrible job of intubating patients. To do that we need well done research, which you get into below.

We need very well done research in places that intubate well, that are large enough to show what conditions are likely to benefit from intubation. There will always be good reasons for deviating from the typical treatment, but we do not even have research to clearly show that intubation does not cause harm.

We probably need a separate designation for medics permitted to intubate. I don't know if it should be like the EMT-D add on for defibrillation, or whether it should be something like the critical care paramedic certification, with an broader scope of practice than whatever the regular paramedic would be. There are many ways of handling this.

I think this would be an important part of what Ckemtp is trying to do with EMS 2.0 over at Life Under the lights. My initial impression was that this is just going to be another passing fad, but I think he might be on to something. We need to transform EMS from a trade to a profession. Airway management is one of the areas, where EMS really needs to push the doctors to improve. We do not have the authority to change the rules, but I don't see any reason to let that stop me. EMS 2.0 is also covered in Ckemtp, EMS 2.0 – Momentum Building, Happy Medic, Medic999, Too Old To Work, Too Young To Retire, Ambulance Driver, and even The Fire Critic and Firegeezer.


Waveform capnography?

EMS - Yes, usually. In Pennsylvania, it is mandatory for ALS.

ED - No. Some places have it, but most do not seem to use it.


One-on-one observation of patients for heavy sedation/aggressive pain management?

EMS - Yes, what are we going to do, leave?

ED - No, this requires rearranging staffing and will be done, if necessary, but is certainly not the baseline level of care. Generally, each ED nurse has 3 patients, or more.

These are just a couple of examples of ways EMS should be pushing patient care forward. As I wrote in EMS Needs to Be a Separate Medical Specialty - Now - Part I.


cont still...damn restrictions...

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)


Scary stats, but failed why? Attempted but unable to place or, attempted and misplaced. That's a big difference. If I miss a tube and I can't get it, if I'm still able to oxygenate the pt to keep the stats up then it's still successful, I just may not be able to move on to additional treatments. It sucks but it happens. If I misplace a tube then I'm killing my patient and think I'm helping. If I stick a blade in the patients mouth, it's an attempt if I try to tube or not, even if it's to suction to even clear an airway. If I have to do this on 5 of 10 patients then I'm at a 75% success/failure attempt rate. Data can be manipulated to favor for or against. It all looks bad on a pie chart, something we all learned in statistics at college.



I think there are plenty of problems with the data from Miami, but nobody has come out and provided documentation of these flaws. There is one very interesting rumor that I have heard. I do not like dealing in rumors, but I am hoping that somebody reading this will be able to document this, or get the medical director(s) involved to set the record straight, at least if the rumor is true.

The rumor is that in at least one of the services studied, the medical director strongly encouraged the use of alternative airways as true alternatives to intubation, rather than as back up airways, for airway management. However, the way the success/failure of intubation was determined was based on just two things. Was there any kind of airway intervention - BVM, CombiTube, LMA, crichothyrotomy, endotracheal tube, unrecognized esophageal tube. If any of those methods of airway management were being used, but there was not a properly placed endotracheal tube, this was considered a failed intubation.


After two ETI attempts, placement of a Combitube is considered as a rescue airway measure.


For this study, members of the Department of Anesthesiology assessed the airways of patients at their admission to the trauma bay. We defined prehospital airway management as paramedics having had an active role in managing the patient’s airway through a variety of approaches, including ETI, laryngeal mask airway (LMA), and Combitube and/or cricothyroidotomy.We defined a failed PHI as the improper localization of an endotracheal tube (ETT) on arrival at the trauma center or the need to use alternative rescue devices for airway management after intubation attempts.


Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]



If the CombiTube is used as an initial airway measure, it is definitely not a rescue airway measure. If the doctors assessing the intubations were not familiar the way that airway management was being performed, then their determination of all CombiTubes as failed intubation attempts would be wrong.

From the way I read the study, if a CombiTube, or LMA, salesperson happened to stop at an accident scene and placed an airway, but the patient was transported by a BLS ambulance (no endotracheal tubes anywhere on the ambulance), this might have been classified as a failed endotracheal tube attempt. They might have presumed that paramedics were involved in the management of the airway, since they consider the ConbiTube to be only a rescue airway, rather than an alternative airway. I don't think they would have done the same for a BLS crew transporting with just BVM airway managment if no ALS was available. From the system design, it is possible that all 911 ambulances have a medic on board. Still, there is no good reason why a BLS interfacility transport ambulance could not arrive on scene, deliver excellent care, realize that the closest ALS is at the hospital, and transport. BVM only. No possibility of endotracheal tube. According to the study, it might be classified as a failed intubation attempt.

Well, that is the thing that bothers me the most. Is the rumor true?

If the rumor is true, how many patients classified as having missed endotracheal tube attempts, never had any endotracheal tube attempts?

If the rumor is true, how can the researchers publish this without disclosing that variable? A variable that should have been controlled for, but if the rumor is true, a variable that was not controlled for.


You claim that you know that it is necessary. How do you know?


Only by experience, discussions with our command doc, and in my training and education I've receive to date that I'm acting in the best interest of my pt.



This is one of the reasons we need to have good research. It is unfortunate, but apparently medical school does not do a good job of preparing doctors to interpret research. If they cannot even interpret the research correctly, what is the research they design going to look like? We need to start doing a much better job of educating people about research and the scientific method.


You also claimed that there is no research showing worse than a 75% prehospital intubation success rate.


Again, results can be biased.



Yes.

The difference between good research and bad research is that the good research goes to extremes to exclude the influence of bias. Bad research may not recognize bias, or may come up with pathetic excuses for using the biased methodology. Not that there aren't other ways of creating bad research.

Some of the reasons I started this blog are:

To educate people about research.

To get people to discuss research.

To get people to look critically at research, rather than just say, That is too complicated for me.

To get people to seek out research to persuade doctors of better ways to provide patient care.


For your last regarding how medics should be trained and certified I agree, but is it possible and should MD's/Residents be held to the same standards.



I think that doctors should be held to higher standards than medics. This is one of the reasons for having EMS as a separate medical specialty. Sort of a way of saying, If you want to make contributions to EMS, this is the background you need to have. If you do not meet the criteria for board certification as an EMS physician, then go away. We still have too many non-emergency medicine physicians in the EDs, but this would be a start.

We are facing a lot of misunderstanding/obstacles from doctors, who think they understand EMS, even though they do not. That is one thing holding EMS back. Our patients deserve better.


Should we add a new cert level?

EMT-Pi



Forget about EMS 2.0, we're going straight to EMS 3.14159 . . . . Well Vince may enjoy the math humor, even if not many others do. :-)

I think that we need to be continually assessing the appropriateness of the different levels. Just because this is the way things have been done, does not mean that it is the way things should be done. There will be a lot of change in EMS. We should be doing things to try to make the changes good for the patients. Maybe a different certification. Maybe just more widespread use/recognition of the EMP-CC (critical care) level. Maybe much fewer medics and a lot more medical directors growing a set (metaphorically only, since some are women). We need to have an organization with the authority and the understanding to keep us moving in the right direction. I do not see the DOT (Department of Transportation) as that organization. Anything that combines EMS with firefighting, police, homeland security, or any other Wouldn't it be cool if we could be used as an excuse for them to syphon off money for their pet projects? agency.


Love your posts, I've read them all. You too AD.



Thank you. As you have noticed, I enjoy a good debate. I think that we will not change things until we have identified all of the problems. I certainly do not have all of the answers. I don't even have all of the questions. You contribute a lot to the discussion.


I'm on your side I promise. You really could take my blade away, I really do only tube as a last resort and I like Mystery Medic's idea. Glidescopes are nice.



You point out one of the problems. The ones in need of having intubation taken away are the ones who will fight to the death (the patient's) to keep intubation, but will resist any refresher/retraining/minimum requirements. They do not get that this is about the patients, not about making medics feel good, briefly, before going back to the routine calls that we do not feel challenged by.

I have not used the Glidescope. I have read good things about it. I think that it has the same potential for leading to bad outcomes as anything else - too much focus on the airway, as if the airway is not connected to a patient. A patient, who might not even have primarilly an airway problem. How many patients suffer anoxic brain damage because of intubation attempts? This is something that we should be able to avoid with excellent oversight, but we do need that oversight.


What do you feel about walking a pt to the bathroom around a corner in the house after getting diltiazem for rapid Afib that reduces and refuses to go with you to the hospital unless she can pee, assuming she is is on O2 and the monitor. Had a partner almost have her own stroke on my decision.



I have probably induced a few TIAs in partners, nurses, doctors, et cetera. If the patient has the capacity to make informed decisions about her own care, she may do pretty much anything that we think is unwise/dangerous.

We can pretend that we know that allowing a patient to do something, that we think is a bad idea, will kill them or make them much worse, but we do not know that. We can present them with all of the information about why we think it is a bad idea, but unless we are abducting the patient, or been given power of attorney, or have involuntarily committed them, . . . we do not have the authority to force the patient not to do what we think is unwise, nor do we have the authority to force patients to do something that we think is essential.

I will write more about this, because it is important and we seem to be very poorly prepared to deal with patients who do not agree with us. I just graduated EMT/medic/nurse/doctor school and I know everything. Usually the person making such an assertion is demonstrating that they actually are the most ignorant person in the room, but they often get their way, because they are the most insistent/intimidating/arrogant person in the room. Except when I am there. ;-)


Then the follow up to Ambulance Driver's comment.


Yeah I gotta fess up. I worked very hard on that first post to A) piss you off a little because I enjoy your follow up to BS and trolls and B) because I think if shows what many medics still really think.



Nothing to apologize for. We need to have good debates about what is best for patients. We currently have to rely mostly on expert opinion, because the research is too often inadequate to answer the question of what is best for the patient or what are the right requirements for intubation.


I still believe current research is biased and I would love to see a wide scale study in direct favor of the patient with all aspects of the pros/cons of intubation.



Research will always have problems, but it is still the best method we have of answering the questions of what is best for the patient. I would like to see that research, too.


I see turmoil in our future. We as medics are expected to learn more every year and that makes it harder to be proficient in the skills we already perform. We do this all without getting a pay raise, my cost of living increase alone was frozen for another year.



That is a problem. We do need to have medics dedicated to EMS. Not cross-trained as anything else. There is too much that we need to do to maintain proficiency to have paramedic be something done in addition to another job that people think is interchangeable, or related, or a way of saving money. These are generally not people you would want providing care for any real patient, yet they make decisions about how that care is delivered. Politicians are the enemies of EMS.

Tom Peters writes about this problem, but not as an EMS topic. He asks the question, Do you suffer from too much talent?

In EMS, we seem to act as if we have such talented medics, that cross-training in another field is not going to interfere with their ability to provide excellent care.

Maybe we just don't care about excellent care - until we are the patients (or our families). Isn't a 52% intubation success rate, even if partially inaccurate (12% esophageal intubations is also ridiculous) worse than bad patient care?

Do we suffer from too much talent?


Hope no hard feelings, RM, great follow-up :)



I do not take criticism personally, so there would be no reason for hard feelings. I like it when you make me think.

Thank you.


Other blog posts commenting on this, by others and by me, in order of posting, have been -

The Airway Continuum at EMS1.com by Kelly Grayson, AKA Ambulance Driver. 11/06/07

Teaching Airway: EMS Educast Episode 33 at EMS EduCast. 10/02/09

Teaching Airway - Part I at Rogue Medic. 10/10/09

Teaching Airway - Part I at Paramedicine 101. 10/10/09

Teaching Airway - Part I - comment from Anonymous at Rogue Medic. 10/11/09

Teaching Airway - Part I - comment from Anonymous at Paramedicine 101. 10/11/09

Rogue Medic's Comment Section… at A Day In The Life Of An Ambulance Driver. 10/11/09

Paramedics and intubation at 9-Echo-1. 10/12/09

Attention all Companies at The Happy Medic. 10/12/09

Snapshot from the Paramedic Battlefield at Firegeezer. 10/12/09

Have You Seen This? at The Fire Critic. 10/12/09

Comment On A Comment at Too Old To Work, Too Young To Retire. 10/13/09

Airways and ET tubes... at 9-Echo-1. 10/14/09

EMS as a Profession? at The Fire Critic. 10/20/09

Airway comments by Rachel at Rogue Medic. 10/21/09

Airway comments by Rachel at Paramedicine 101. 10/21/09




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