ClinCon 2009

Adam Thompson, EMT-P | 6:35 PM | | 1 comments

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.


For more information on ClinCon click here.

Thanks for stopping by,

Adam Thompson, EMT-P

Chemistry for prehospital providers

Tom B | 1:09 PM | | 1 comments

I love these guys! :)

Hydrogen



Oxygen



Potassium



Iron



Magnesium



Carbon



Sodium



Nitrogen



Sulfur



Plenty of others to choose from: CLICK HERE.

Strip Tease 12

Adam Thompson, EMT-P | 8:57 PM | | 17 comments



20 y/o post-ictus from seizure.


**Update**

The second 12-lead

Why Can't Medics Intubate?

Rogue Medic | 11:12 PM | , , , , | 9 comments





A study of prehospital intubation[1] 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.

and

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.

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.



Footnotes:


^ 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.

.

Exposing Patients: Balancing Necessity and Dignity

Star of Life Law | 5:45 PM | , | 9 comments

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.

Prehospital Spinal Clearance Part III

Adam Thompson, EMT-P | 1:00 AM | , | 2 comments


The evidence is here...

You have heard me mention the NEXUS study a few times, and in this post I am going to finally explain exactly what it is and ask if its the solution.

NEXUS stands for National Emergency X-Radiography Utilization Study. This study has been used in a few different aspects of emergency medicine, but has definitely shown its worth in the prehospital environment. [1]
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.
The following image is of a flowchart that utilizes the NEXUS guidelines to determine whether or not to implicate spinal immobilization. It is almost identical to the one found in my Prehospital Trauma Life Support (PHTLS) book.


I know its hard to read, you can use the instructions on the right side of this page for larger viewing.

This criteria has come from the results of the study and has shown to be successfully implemented in the protocols of a few EMS agencies nationwide. The criterion is very similar to the NEXUS criteria for x-ray in the emergency department. Even though the criteria was initially intended to rule out the need for an x-ray for spinal clearance, it is being used to rule out the need for spinal immobilization. The following is the intended use of the NEXUS criteria.
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
and
2. No evidence of intoxication
and
3. Normal level of alertness
and
4. No focal neurological deficit
and
5. No painful distracting injuries

Explanations:
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.

  1. 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.
  2. 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.
  3. 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.
  4. Any focal neurologic complaint (by history) or finding (on motor or sensory
    examination).
  5. 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.
See how this can easily be converted in to a prehospital guideline? Of coarse you can, I already showed it to you.

It only makes sense that the same criteria that physicians use in their assessment to clear a cervical spine be used by EMTs/paramedics. If it can be taught to a doctor, why not us? We have all seen physicians take the cervical collars, that we have applied, off the patients that we bring in. This criteria has been questioned and compared to other studies such as the Canadian method, and I will go over a retrospective comparison of these two methods in my next post on this topic.

Click here for the Michigan protocol that I mentioned in my last post on this topic. Even though they implement some of the same assessments as NEXUS, they do not cite them as a reference. Their protocol includes a rule in method. If any of the specified findings are present, they are to immobilize.

Click here for the 2002 version of Maine's spinal clearance protocol. They appear to have included all of the NEXUS criteria and then some. They claim to have an increased sensitivity of spinal assessment:

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.
Finally, we have found research that was done on a large enough scale to be considered conclusive evidence to support a prehospital cervical spine clearance protocol. In fact, it is currently being used by many prehospital clinicians already. So why isn't it universally accepted?

As I stated, in the next post on this topic I will go over the comparison between NEXUS and the Canadian method. Maybe we haven't reached the final answer.


[1]Hoffman JR, Wolfson AB, Todd K, Mower WR: Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Annals of Emergency Medicine 2001.

Strip Tease 11

Adam Thompson, EMT-P | 11:12 AM | | 2 comments

An old 12-lead I have saved. v4, v5, & v6 are cut short. Please provide your impressions.



Prehospital Spinal Clearance Part II

Adam Thompson, EMT-P | 9:00 PM | , | 3 comments

A closer look at the research...

With the start of this topic, I thought I would get by with some easy research and criticisms. As I dove into this subject I soon realized it wasn't going to be that easy. In part one, I explained what struck the question and I began to look further into statements made by Trauma.org. The replies to my first post have given me new ideas and directions. The research is all there for me, and there isn't a need to reinvent the wheel here. There is a need however to ask some good questions and get the unbiased answers. In my next couple of posts on this subject I will try to take a look at the timeline of research and with skepticism I will provide you with the evidence I find. With the evidence out there, I don't see a reason we don't have a universally accepted guideline for clinically clearing the cervical spine in the prehospital environment. Liability is unfortunately the most-likely answer to a question like this one--not science.

The 1999 study mentioned in part one listed Michigan and Maine as cohorts that implemented the criteria they studied for the use of spinal immobilization depending on mechanism of injury. After a couple go-arounds with Google, I found the 2005 edition of the Spinal Injury Assessment and Immobilization guideline of the Southeast Michigan Regional Protocol. I was able to find Maine's 2002 protocol, post NEXUS, and found it very interesting. I am going to get into those in a further post to stay chronological.

I want to take a look at some literature I found from the AANS & CNS that was done just after the turn of the new century. This was done prior to the NEXUS study (I will get into this study later) so NEXUS didn't make the 101 reference list. That's right, there is really 101 references, consisting of research from 1966 to 2001.

Right from the get-go[1]:
Standards: There is insufficient evidence to support treatment standards.
Guidelines: There is insufficient evidence to support treatment guidelines.
In the 101 references they listed, they couldn't find enough evidence to support treatment standards or guidelines. Almost 40 years of research, no sufficient evidence--amazing! Give me time and I will go through their references, but for now lets take a further look at what this paper has to say.
Options:
  • 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.
They have insufficient evidence to support treatment or guidelines, but they promote a treatment that they have guide-lined. I am being critical of the literature so far, but this next statement gives me good reason:
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.
Okay, I agree that we should be concerned with causing further harm or injury to our patients. Where do they get their estimate from regarding post-incident spinal cord injuries? They list 6 of there citations after that statement. 3% to 25% is a big margin, and to think that a quarter of all spinal cord injuries could be caused by first responders is scary. It may not be impossible, but I feel this is very unlikely. They then state that multiple cases have been reported where mishandling of the cervical spine lead to injury; they list 4 of there references after that one.

In the same paragraph the paper attributes neurological improvement of the spinal cord injured patients over the last 30 years to EMS. This conclusion was made after they state that in the 1970's, 55% of spinal cord injuries presented with complete lesions and in the 1980's, 61% had incomplete lesions. This is pretty interesting as well, and might lead to one of the answers to a seemingly easy question.
Where is the proof that spinal immobilization even works?
-Rogue Medic
It would be extremely difficult to show that without the implementation of full spinal immobilization a patient would suffer further injury. It is enlightening to read that there has been noticeable improvement since the implementation of prehospital spinal precautions. In further parts of this discussion I will revisit this question because it is a good one and deserves more than a one paragraph answer.

Back to the study in question:
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.
They follow this up footnoting four of their citations and a statement regarding a triage-based criteria to determine appropriateness of immobilization. This is exactly what we are looking for. I wish they would have elaborated more in this paper though. Here is an abstract from one of the listed references[2]:
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.
I'm not going to lie, the first thing I always read in these abstracts is the conclusion. Read the conclusion to this one. Doesn't that statement contradict a couple points we just mentioned. How this same paper attributes neurological improvement to EMS, and how immobilization is a vital part of the treatment rendered by EMS. Looks like we revisited Rogue Medic's question earlier than expected. Before we do, I want to look at a few more of this paper's references to see what we can find[3].
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.
Interestingly enough, this study contradicts statements made in a study in my first post on this subject. The research in the other study concluded that emergency physicians and EMTs disagreed on the matter of cervical spine immobilization. This is a moot point by now because it doesn't prove or disprove anything. Whether EMTs and physicians agree or not does not reflect the efficacy of a prehospital spinal clearance protocol. This next abstract is promising[4]:
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.
I'm sorry if this is turning into a post full of abstracts but this one in-particular is the first one I have read that was conducted before the year 2000 and shows positive results using a prehospital spinal clearance algorithm. This evidence was available prior to the statements made in that Trauma.org article, and could have been cited. I am going to stop criticizing Trauma.org for the rest of this discussion because I think I have proved my point. However, we have gone beyond that and into a greater discussion.

So far, what I have...

Prior to 2002 there has been much scrutiny in regards to the prehospital clearance of the cervical spine. There has been bold statements made by prestigious organizations to emphasize this point. There has been plenty of research on the topic, and as always, it is very contradictory. The question on why to immobilize patients in the first place has been touched on, but we haven't completely answered it yet. We also have some evidence that EMTs are capable of agreeing with emergency physicians on this subject--go figure. I have about 200 more references to sift through, and hopefully I can create a pretty elaborate timeline to show you where we have been and where we are. I have yet to share the conclusive evidence on this matter, but it is coming! Hopefully this will be developed into a universally accepted guideline, since it is somewhat accepted already by many prehospital agencies. I am also going to share some of the protocols from these agencies and hopefully some post-implemented research.

I'm going to take a pause with this literature for now and I will be revisiting it in the near future because some of the other subtopics in this discussion are brought up in this paper. In the next part I am going to take a look at the infamous NEXUS study and PHTLS recommendations. To take part in a current discussion on this post please visit EMTcity.com. I list that forum a lot just because it is the one I actually enjoy posting on. Also, please provide your commentary right here if you have any. I use your comments when authoring these posts.


Works cited

[1]American Association of Neurological Surgeons and the Congress of Neurological Surgeons. "Pre-hospital cervical spinal immobilization following trauma. Sept 2001 The PDF

[2]Hauswald M, Ong G, et al: Out-of-hospital spinal immobilization: Its effect on neurologic injury (comments). Academic Emerg Med 5:214-219,1998.

[3]Brown LH, Gough JE, et al: Can EMS providers adequately assess trauma patients for
cervical spinal injury? Pre-Hospital Emergency Care 2:33-36,1989. Pubmed abstract

[4]Muhr MD, Seabrook DL, et al: Paramedic use of a spinal injury clearance algorithm
reduces spinal immobilization in the out-of-hospital setting. Pre-Hospital Emergency Care
3:1-6,1999.

Strip Tease 11: Answer

Adam Thompson, EMT-P | 6:36 PM | | 0 comments

By definition this is a Wide Complex Tachycardia (WCT)

  • Its wide > 120ms
  • Its fast 150bpm
-A right bundle branch block(RBBB) is apparent in v1
-Pathological left axis deviation suggests left anterior fascicular block (LAFB)
-This would be considered a bifascicular block (RBBB & LAFB)

If you take a look at lead II & v2, the flutter waves have been marked with arrows.

ANSWER: This is a 2:1 atrial flutter with bifascicular block

Pearl: The rate around 150 is highly suggestive of 2:1 atrial flutter

Prehospital Spinal Clearance Part I

Adam Thompson, EMT-P | 5:00 PM | , | 16 comments

An evidence-based approach...



It's no secret that I am a diehard advocate of progressive prehospital medicine. I am also a proponent of evidence-based medicine. Sometimes these two views can be conflicting because of the lack of evidence to back new medicine. I have often changed my views on certain treatments in light of new research. The outstanding presence of bias and valid arguments associated with medicine drives me to keep reading on, even after discovering what may seem like a correct answer. Looking in one place will never be an adequate solution to a complicated topic, at least this is true when it comes to medicine.

Here in my EMS system we practice evidence-based medicine. We also like to consider ourselves a pretty progressive organization. Our medical director gives us a lot of leeway, and holds us to a pretty high standard. You could see five different medics treat the same patient five different ways here in our system, and they will all have valid arguments for each treatment.

When it comes to a traumatic injury, backboards and neck collars are used at the discretion of the lead paramedic. I have seen paramedics that immobilize every patient they encounter that was involved in a car accident or any other blunt force traumatic event. I think this might be what we call CYA (cover your ass) procedures. These medics might have seen a missed spinal injury be improperly treated in their career, and an unfortunate victim of that care acquire a lifelong need for a wheelchair.

I have developed my own systematic approach to these trauma patients. Of coarse manual cervical spine immobilization is applied upon initial contact. If the patient is under the influence of alcohol, he/she gets the full package, board and collar. I have just had too many drunks that haven't felt a stab wound or broken arm, let-alone a possible spine injury. This is also a strong consideration with anyone who has recently taken analgesics or elicit drugs. If they aren't under the influence of drugs or alcohol I give an appropriate physical exam. I consider the mechanism of injury and touch the patient to assess for tenderness. If the patient is pain free, able to move all extremities, and rotate their head without pain or involuntary movement, they get to stay off the board. This isn't evidence-based and I have begun to question my own rational.

Luckily, I haven't had this go wrong. I pride myself in my assessment skills and appreciate the patient's comfort level. A backboard is a very uncomfortable bed cushion for someone who doesn't need it. Quite often, if they didn't have pain to begin with, they will after being on a backboard for only a few minutes. Of coarse, muscle pains from being on a hard board is nothing in comparison to chronic paralysis from being mishandled; I can also appreciate this fact.

Recently I read a statement on Trauma.org that has sparked yet another need for further information gathering[1]:
There is no conclusive evidence in the literature that supports clinical clearance of the spine in the prehospital environment. There is enough variation between prehospital and in-hospital assessments to recommend that prehospital removal of spinal immobilisation be avoided.
This is a pretty blunt statement; no conclusive evidence, not any? What is Trauma.org's definition of conclusive, I wonder. I know there must be something out there that supports the paramedic's ability to adequately assess their patient and make a decision like this. I also wonder if the statement is made only in regards to removal of previously applied spinal immobilization. What kind then, manual immobilization or the whole package? Or is this statement in regards to all blunt trauma patients; should we immobilize them all? Maybe they are referring to only neck and/or back pain patients. The list of questions has quickly become a long one, luckily the authors listed their sources.

The first source listed is from a journal that I personally subscribe to, Prehospital Emergency Care. Unfortunately, this is from 1999 and I don't have the issue. I used Medline to find the article but was only able to come up with the abstract. Here is the abstract from the cited study[2]:
INTRODUCTION: Traditional EMS teaching identifies mechanism of injury as an important predictor of spinal injury. Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine. Maine requires automatic immobilization of patients with "a positive mechanism" clearly capable of producing spinal injury. OBJECTIVE: To determine whether mechanism of injury affects the ability of clinical criteria to identify patients with spinal injury. METHODS: In this multicenter prospective cohort study, EMS personnel completed a check-off data sheet for prehospital spine-immobilized patients. Data included mechanism of injury and yes/no determinations of the clinical criteria: altered mental status, neurologic deficit, evidence of intoxication, spinal pain or tenderness, and suspected extremity fracture. Hospital outcome data included confirmation of spinal injury and treatment required. Mechanisms of injury were tabulated and rates of spinal injury for each mechanism were calculated. The patients were divided into three different high-risk and low-risk groups. RESULTS: Data were collected for 6,500 patients. There were 209 (3.2%) patients with spinal injuries identified. There were 1,058 patients with 100 (9.4%) injuries in the first high-risk mechanism group, and 5,423 patients with 109 (2%) injuries in the first low-risk group. Criteria identified 97 of 100 (97%) injuries in the high-risk group and 102 of 109 (94%) in the low-risk group. Two additional data divisions yielded identical results. CONCLUSION: Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury in this population.
So the first thing that stands out to me is the year the study was done. 1999 was 10 years ago. Sure, it isn't that long ago, but think of how much things change in the medical field in a matter of a few years. That doesn't mean that the data isn't valid though. The next thing that stands out is the study itself. It is questioning the relevance of mechanism of injury(MOI)in determining a cervical spine injury, not the ability of a paramedic to adequately clear a cervical spine.

This study gave the paramedics a set list of criteria, it didn't expand off of the paramedic's assessment skill. The study used paramedics in their research, but they were not testing the medics, just the method. So if the criteria were invalid, how does this reflect on the assessment skill of a paramedic?

Unfortunately this abstract leads a lot to the imagination. I'm not sure if the low risk group was intended to be injury free and ended up with 94% of them having injuries (highly unlikely). It seems to me like their low risk criteria appropriately identified 94% of the injuries and the high risk criteria caught 97% of the injuries. That seems to have pretty good specificity to me. I am still looking for the full text for this study (hint hint Rogue Medic).

The conclusion pretty much states that MOI does not effect clinical criteria when predicting spinal cord injury. Does this mean that a possible spinal cord injury is not at all predictable by the MOI. I didn't find conclusive evidence (be it just an abstract) that states paramedics should not be clinically clearing the cervical spine in the field.

That isn't exactly what I am looking for though. Without evidence of benifit, we wouldn't be practicing evidence-based medicine. The next refference that Trauma.org cited was a study from The Journal of Trauma. Once again, all I could find (even in my college's extensive database) was the abstract[3]:
OBJECTIVE: Determine the level of agreement between emergency medical technicians (EMTs) and emergency physicians (EPs) when applying an existing emergency medical services/fire department protocol for out-of-hospital clinical cervical spine injury (CSI) clearance in blunt trauma patients. METHODS: Prospective observational study of consecutive blunt trauma patients transported by emergency medical services/fire department during a 3-month study period. The setting was an urban Level I trauma center. Measurement of interrater agreement (kappa) was determined. RESULTS: Mean age of the 190 patients was 34+/-19 years (range, 6 -98 years). Fifty-nine percent of the patients were male. One hundred forty-six patients (77%) were immobilized by EMTs; 17 of these patients were clinically cleared by EPs. Forty-four patients (23%) were clinically cleared by EMTs and presented without CSI precautions; of these, 61% (27 of 44) were immobilized by EPs and 57% (25 of 44) had cervical spine radiographs obtained. Overall, 141 patients (74%) required radiographic clearance. CSI were detected in five patients (2.6%); all five were immobilized in the out-of-hospital setting. Overall disagreement between EMTs and EPs regarding out-of-hospital CSI clearance occurred in 44 patients (23%) (kappa=0.29; 95% confidence interval, 0.15-0.43; p less than 0.01). CONCLUSION: Significant disagreement in clinical CSI clearance exists between EMTs and EPs. Further research and education is recommended before widespread implementation of this practice.

An even older study, done in 1998, but the data is still relevant (also, keep in mind, the Trauma.org article is from 2002). This study doesn't disprove the ability of paramedics, or EMTs for that matter, to clincally clear a cervical spine. This abstract questions whether EMTs and emergency physicians agree. I hate to point this out, but according to the abstract, the EMTs properly immobilized every patient that came back with a positive cervical spine injury. This doesn't disprove the purpose of the study however. What I get out of this is the need for the emergency physicians to be on board with a prehospital spinal clearanace protocol.

These were the only two references cited by Trauma.org. Neither reference seems to disprove the ability of an EMT to clinically clear the cervical spine. What was the original statement in question though?

There is no conclusive evidence in the literature that supports clinical clearance of the spine in the prehospital environment. There is enough variation between prehospital and in-hospital assessments to recommend that prehospital removal of spinal immobilisation be avoided.

We still don't have the conclusive evidence to support cervical spine clearance. One abstract questioned the relationship between MOI and cervical spine injuries. The other study states that physicians and EMTs disagree, but that isn't necessarily a definitive reason to avoid prehospital clearance of the cervical spine. Just because the studies were both conducted in the prehospital environment doesn't mean that they tested the ability of the prehospital personnel.

Part II will include my own research on this topic.


Works Cited

[1]Brohi K. 2002. "Clinical Clearance of Cervical Spine Injury" Trauma.org, Link to article

[2]Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J, Frederiksen SM, and Shork MA. 1999. "The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury." Prehospital Emergency Care: Official Journal Of The National Association Of EMS Physicians And The National Association Of State EMS Directors 3, no. 4: 332-337. MEDLINE with Full Text, EBSCOhost (accessed May 30, 2009).

[3]Meldon SW, Brant TA, Cydulka RK, Collins TE, and Shade BR. 1998. "Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians." The Journal Of Trauma 45, no. 6: 1058-1061. MEDLINE with Full Text, EBSCOhost (accessed May 30, 2009).

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