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Friday, January 6, 2012

The IV placed by EMS: Too much, yet not enough.

If I see one more blog post about whether or not paramedics should be intubating...

Ok, that's not fair. RogueMedic, in particular, makes strong arguments about the role of ETT placement, and JEMS has a great website as a resource for discussing airway skills and research.
And airway cartoons!

But how often do we intubate? Unless your day job is as a CRNA, not often. Given all the ink and electrons that have been spilled writing about whether or not the ET tube "defines" ALS practice, it isn't a daily activity.

On a day-to-day level, however, placing an IV defines ALS care. Note that I did not say that it should be the defining act, just that from the perspective of your BLS partner, as well as the billing department, that is the point at which ALS care starts. It doesn't have to have fluids running, or even an immediate need for a medication push. But woe to those who bring in a stable chest pain or dyspnea without popping in a 20g!
Take your work seriously. Very, very, seriously.
A couple of recent papers discuss IV placement by EMS, and the results probably won't provoke the sort of teeth-gnashing discussion that EMS intubation research generates, but it is both far more relevant to your daily work, as well as pretty interesting.

The author of the first paper, Dr Seymour, is not an EMS doctor, or even in emergency medicine. He's a critical-care physician, but has been studying how EMS can improve care of sepsis in the field.

The paper, Intravenous Access During Out-of-Hospital Emergency Care of Noninjured Patients: A Population-Based Outcome Study, was conducted in Washington state. The researchers had an interesting idea - they wanted to see if there was a relationship between EMS placing an IV, and the patients' in-hospital mortality. They did this all retrospectively, looking over run reports and hospital records.

They looked at over 56,000 patients who were transported by King County EMS by ALS to the hospital. About half of the patients got an IV. The researchers then found two results:

  • Patients who got an IV were more likely to die in the hospital.
  • Patients who got an IV were less likely to die in the hospital, if you accounted for a bunch of other stuff.

The "bunch of other stuff" included the patient's "age, sex, out-of-hospital location, initial out-of-hospital vital signs, receiving hospital, year in cohort, mode of transport, and EMS interventions, diagnosis, and severity code."


Soooo, that's it. You can't really pull too much more out of this study. It has the advantage of having a huge number of subjects in the study, but being retrospective and superficial, you can't figure out why the simple act of placing an IV saves lives. EM Literature of Note concluded about this study that it "could end up telling us something, or nothing."

Now, while it can't really answer the question of why shoving a small piece of plastic under the skin (and occasionally into the vein) saves lives, it serves as a useful response to critics who would prefer that EMS place fewer lines.

A former partner, placing an IV like a boss!

For example, the authors of Unnecessary intravenous access in the emergency setting conclude that a "significant percentage of IVs initiated in the emergency setting are used inappropriately." One of their results that they base their conclusion on was that "only" 38% of EMS-placed IVs were used in the ED, while 46% of ED-placed IVs were used.

In another study (Out-of-hospital intravenous access: unnecessary procedures and excessive cost.), researchers determined that 56% of the IVs placed during their study were "over-treatment" per their criteria.

On the other hand, the new study helps bolster the argument that, sometimes, EMS needs to be more aggressive in establishing IV access, particularly in children. In the last study mentioned, while they found that adults were often "over-treated," kids were far more often to be "under-treated" than the adults - 33% vs 3% rates of under-treatment.

Likewise, the authors of Prehospital intravenous access in children found that while medics were pretty good at getting IVs in kids, they held off on doing so; in children < 6 years of age who the ED thought needed an IV, only half the medics had done so; this was true even if the child was in cardiac arrest or a trauma patient.

 So, sometimes an IV is too much, and sometimes it is just right.
And, speaking of too much...

How about when it's not enough?

A recent study compared the IO against the IV during EMS resuscitative efforts in cardiac arrest patients. I'm not going to belabor the obvious - placing an IO in the tibia is both easier

and faster

than getting an IV, no question. Science just proved it!
"Well, we have something that's faster and easier, sir."
Rogue Medic already discussed this in some depth, and I would not necessarily disagree with his analysis. Trenchant and witty! Nonetheless, establishing vascular access is the current practice in cardiac arrest, and using the IO likely accomplishes all the desired elements. I don't like that the equipment costs more - it costs too much to die already - but the simplicity and speed are appealing.

The Bottom Line

Placing an IV may save lives, but we don't know how. Sometimes unneeded IVs are placed, and sometimes medics don't put in a line when they ought to. And sometimes you should place something that's faster and easier.

You guessed it - more study is needed!

3 comments:

  1. The larger issue, at least I think the larger issue, is all ALS systems versus tiered systems. In a system where at least one person is a paramedic is likely to have an expectation that every patient is an ALS patient. In fact, some systems pretty much require at least one ALS procedure on every patient. An IV is seen by some as a benign procedure because "The patient is going to get an IV in the hospital anyway."

    Hand laceration? IV. Ankle injury? IV. MVA with neck pain? IV. You see where this is heading. It's a variation on the old adage "When the only tool you have is a hammer, everything starts to look like a nail."

    Which is a pretty poor way to practice EMS if you ask me.

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  2. Great post, and welcome to the blogsphere! :-)

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  3. "One of their results that they base their conclusion on was that only 38% of EMS-placed IVs were used in the ED, while 46% of ED-placed IVs were used"

    This is ridiculous. Why are 54% of hospital initiated IVs unused? Are they actually starting IVs in the ER without having any reason for them? Ugh...where I live the rate of usage of ER initiated IVs is probably around 95%, any lower is embarrassing.

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