Prehospital sepsis - new research

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Sometimes, it can be pretty discouraging to keep up on the EMS literature. Seems like everytime you hear of a new study, it’s showing that something that EMS does is either harmful, or just doesn’t matter. 

MAST, pediatric intubation, ACLS drugs, IV fluids for penetrating trauma – it’s enough to make a proud medic hang up her laryngoscope. 

This is no longer the standard of care?!

In a nice change of pace, a couple recent studies point out the value of EMS in treating sepsis, an area that hasn’t had much emphasis in EMS education and protocols in the past. Even better – the results show that EMS is probably making a difference, even without trying!

These recent publications tie in with a patient that AMR brought us in Bridgeport recently. The paramedic called med control, looking for some advice. He was bringing in an older gentleman from an ECF, and he was reasoning out some antiarrhythmic therapy. We talked on the radio some about the rhythm, but the most important thing he got across to me was that this guy was sick looking. That’s enough for me, and I met them at the door and we got things rolling. Fever, hypoxia, altered mental status, nonsustained VT – yep, he was sick! Three liters of NS and 3 antibiotics later, the ICU team was wondering what all the fuss was about.

Of course, if EMS hadn’t identified this guy, he might have slipped through triage, as his vital signs looked OK at the moment he came through there. We would have noticed when his pressure or sat dropped, but we would have been behind at that point, delaying his antibiotics and fluids for some time. 

One recent paper, hot off the presses, may illustrate the benefit of EMS in cases like this. 

The folks at U Penn wanted to see how EMS was affecting the care of these kinds of patients. They already had a bunch of data on the severe septic patients they were treating in their ED, and so they examined the records to see which of them were brought in by EMS.

What they found was that EMS only brought in 41% of the bad sepsis players. Of course, they were sicker than the 59% that came in by other means. The EMS patients were older, had higher initial lactate levels, and higher APACHE II score (rating system for critical illness). The EMS patients were also far more likely to be African-American, which usually predicts worse outcomes, no matter what ailment you’re talking about.

The two critical interventions in the treatment of sepsis are IV fluids and antibiotics, and the EMS patients got these in the ED about 40 minutes sooner than the “walk-ins.” That’s pretty big, considering that, in the ED, we're scrambling to get the antibiotics in within the first hour! 

No, they couldn’t show that EMS was saving any lives, but this study wasn’t designed to show that. But that really isn't the point either. Nowhere in the paper do they describe any specific education that EMS had, any QI process, or any change in protocols. EMS was just doin' what they was doin'.

Well, okay, maybe this isn't a big deal. We all know that using EMS is a great way to skip the line at triage if the long wait at the ED bothers you. Heck, maybe toe pain gets seen faster if it comes in by EMS. Is there any evidence that having a conscious EMT in the back of the rig changes anything?

In 2010 year there was another paper that showed similar findings, and added some others. 

The first author is hiding his paramedic roots.

The ED at Carolinas Medical Center looked at a similar group of ED patients, bad sepsis, and wanted to see if the people who came in by EMS got fluids and bug juice sooner than non-EMS arrivals. 

Just like the first paper, the EMS patients were a sicker bunch, but they got treated sooner. Interestingly, they had the same approximate differences in time to treatment – 40 minutes – that the U Penn group found.

The really neat thing about Studnek's paper was that the researchers also checked to see what the prehospital providers had written on their run-sheets. If the medics wrote the word “sepsis” somewhere in their impression, it turns out that the times in the ED for those patients were even better. Those EMS-identified patients got their antibiotics about 50 minutes earlier, and had resuscitation started an hour earlier! Again, just as in the preceding study, the researchers made no mention of any specific EMS sepsis protocol or pre-arrival alerts.

I'm fascinated by the results of these investigations.

For example, why would a medic record an impression for “sepsis” if there weren’t a corresponding protocol or pre-arrival alert? I'm imagining an analogous study: picture a system where the EMTs received basically no education on heart problems, angina, MIs - nothing.

As in, pre-Johnny and Roy

What if we then looked at the patients who had STEMIs, and then went to check if arriving by ambulance affected the door-to-ballon times? Furthermore, what if the patients who had a prehospital diagnosis of "heart trouble" got the cath lab even faster? That's kind of what is going on in these studies.

This is the benefit, I believe, of having educated and aggresive prehospital providers. The results above don't seem to reflect any new QI project or protocols. However, I think that Basics and medics are often at their best when they are “off protocol.” The medic who brought in my septic patient was calling med control to discuss treatment for salvos and runs of VT, but he was really calling in to tell me he had a “sick-as-something” patient.

Of course, we don’t have a “SAS alert,” but he was doing what he could with the system we’ve set up. When I was a resident up in New Haven, I had a medic call in a STEMI alert. When we looked at the ECG, however, it certainly did not meet any of the standard criteria for an activation. Looking at the patient, however, he certainly met classic SAS definitions – sweating, pale, cold, screaming in pain. A closer look at the ECG showed a classic left-main occlusion pattern. The medic had never heard of this rare pattern, but he knew that the ECG had some ugly things on it, and that the guy was circling the drain.

Bridgeport, I'm calling in with a CTD alert.

The potential for EMS to be involved in the care of sepsis is huge. Jeez, look at how much effort we’ve put into cardiac arrest, and for what? We might be just as well off with taxis and AEDs! (Insert a winking emoticon here…) 

Sepsis is a whole new area for EMS to show its worth, to make a difference. There is going to be more research on this; findings ways to identify septic patients in the field, start interventions, calling alerts.

One request in the meantime, though: Just don’t call in any SAS alerts for now!

***Late breaking*** 
Dug up this study, buried deep in the JEMS website:

 Decreasing Blood Lactate Levels in EMS Patients
By T. Ryan Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P

Introduction: Research has shown that clearance of blood lactate is associated with better outcomes in patients with severe sepsis and septic shock. One of the primary treatments of these patients is administration of IV fluids. This study looked at blood lactate levels before and after EMS treatment to determine if there was a significant change.
Hypothesis: There will be a change in blood lactate levels between EMS and hospital lactate levels.
Methods: Paramedics were provided with and given training on the Lactate Pro blood lactate meter by Arkray Inc. This meter is FDA-approved and CLIA waived, and has shown a good correlation to hospital lactate tests. Between May 1, 2009, and Sept. 15, 2010, 134 patients with suspected severe sepsis or septic shock underwent blood lactate readings by EMS. Patients with a lactate reading of ≥ 4.0 mg/dL were considered to be in shock regardless of their corresponding blood pressure. Treatment was not dictated by this study and was administered according to EMS protocols.
Results : Of the 134 patients, 120 had hospital lactate levels available for comparison. Overall, hospital lactate levels were lower after EMS treatment. EMS patients were divided into groups that received greater than 1000 mL of fluid between readings (Group A), and patients who received between 250 mL and 1000 mL (Group B). Group A had a median decrease of 2.25 mg/dL (p = 0.0003) while Group B had a decrease of 1.1 mg/dL (p < 0.0001). Analysis used the Wilcoxon-Rank Sum Test.
Conclusions: There was a significant decrease in lactate levels associated with EMS treatment. Further, the group that received greater amounts of IV fluids had an even larger drop in lactate levels. These results illustrate the importance of EMS treatment and how it might impact patient outcomes. Further research and training needs to be done to expand the role of lactate in EMS, as well as reinforcing the importance of fluid administration to these patients.

Use of the Straight ("Miller") blade

A lot of people are talking about the future of endotracheal intubation for EMS, about when it should be done, allowed, or even if it should be taught. This is NOT one of those discussions.

Also not a discussion of the utter nonsense shown in this picture.

If you are going to intubate, however, you should know how to do it. And it shouldn't be just one way to do it, but more like 2 or 3. 

On the other hand, I started with the Mac #3 as a new medic, but quickly became a "The-#4-Mac-has-never-let-me-down" kinda guy. Still am, even as an ER doc.

Candid confession - I have no talent for the Miller
I'll be honest though. One of the chief reasons I'm a "#4 Mac guy" is that I never learned to use the Miller effectively. 

Sure, people say that "It's better for peds," or "It's better for trauma intubations." But I've had trouble sweeping the tongue with the tiny flange when I used it like a Mac, placing it on the right side, and trying to move the tongue to the left. 

Placing it in the midline was even worse; I had no control of the oropharynx, and the tongue would just flop around. And it didn't even make sense to me - if moving the tongue with a curved blade didn't give me the view I needed, why would smooshing the tongue help?

A completely mythical view of the cords.

Turns out that my instincts were not far off the mark! A number of anesthesiologists have come up with a better techniques for use of the straight blade for difficult intubations, avoiding any tongue-control issues, as well as providing clearer views of the cords.

Paraglossal approach with the Miller
There are some variations, but they all start with proper positioning of the head and neck, either in "sniffing position," as with your medical patients, or in neutral, in-line stabilization for your trauma patients. 

Much like a Mac, you place the blade into the corner of the mouth, and advance it along the groove between the tongue and the tonsil ("paraglossal"). Then, however, things go a little differently.

Levitan, on his excellent AirwayCam website, describes the paraglossal approach:

"Proper position is achieved with straight blades by deliberately directing the blade to the right paraglossal space. No tongue should be present to the right of the blade.  Full insertion of the blade should occur through the right lateral mouth, over the molar dentition, and while the distal blade may then be directed medially, the proximal blade should never be brought back towards the midline, otherwise it will hit the central incisors.

After the epiglottis edge is identified, the handle must be tilted forward (e.g., the tip moves backward, toward the posterior hypopharynx). The blade is then inserted slightly farther (~1-2 cm), and the tip passed under the epiglottis.  Once the epiglottis is “trapped” under the blade tip, the blade is rocked slightly backward (handle brought slightly more upright) and then the lifting force increased."

Note that the blade is to the right of the nose, and that the ET tube runs under (not through) the blade lumen.

"Tube delivery should be done using the extreme right corner of the mouth, and come up from below the line of site.  An adult tube will not fit through the lumen of a Miller blade (and should not be attempted)."

Here's a drawing of the technique, from a key article by Henderson:

Blade stays on the right side of the nose.

Look at that finger hooked into the corner of the mouth - that's a real helpful technique in normal intubations, and it's key here. You are not moving the blade to the left, so you need some help on the right to insert and manipulate the ET tube. (Great article - contact me by Twitter or the Facebook page if you want a copy.)

Does it work?
A study from 2010 in China confirmed the benefits of this technique. The title says it all: Prevention of dental damage and improvement of difficult intubation using a paraglossal technique with a straight Miller blade. Of course, we don't care that much about teeth when TSHTF, but it's a nice touch.


Another study (download here), done in 2008 in Canada, also showed that you could get a better view with this technique than with  the standard curved-blade approach. There is also a great discussion about the history of laryngoscopes, and how we ended up with the current designs.


Better view - but more difficult to place the tube? 
One trade-off of this better view may be that it is harder to actually place the tube. 

In the 2003 paper "Straight blades improve visualization of the larynx while curved blades increase ease of intubation," Spanish anesthesiologists noted that use of a Macintosh blade, while providing an inferior view of glottis, nonetheless made it easier to place the tube. (Download) 

Of course, if you don't have gottic view in the first place, it's going to be hard to place the tune


The Bottom Line

So, while the future of EMS ET intubation is a matter of much discussion, the need to be proficient in various techniques is not. Anybody who checks a set of blades at the start of a shift should know a number of techniques for using them. Hope this helps!

2013 update
 

Pain control - Recent controversies and research

Second post, and I wanted to go over recent issues in one of my favorite topics, prehospital analgesia. I found a couple discussions in EMS forums that piqued my interest. If you don't want to stick around for the conclusion, I'll give it to you here now; you can feel safe in using the SHCGB protocols to treat pain, and using them aggressively.

You can give morphine to patients with abdominal pain, you can give it to pregnant patients - no worries. 

You can also feel extremely comfortable with the protocol dosing. Giving 2-5mg IV of morphine, to a total of 0.1 mg/kg, is a very conservative dosing strategy.

Opiods in pregnancy
One discussion I found over at JEMS Connect involved pain management for a pregnant female who had sustained an isolated femur fracture in an MVC. A number of folks, as well as the OP, expressed some concern about the effect of opiods on the fetus, and felt accordingly hesitant about giving morphine or other meds in that situation. One of the quotations stood out to me - "I am normally a huge advocate of pain management in EMS but the risks (harming the fetus) don't seem to outweigh the benefits (not being in pain) when all things are considered."

I'm sympathetic - after all, primum non nocere! You would think that there would be more written on the topic, but Rosen's, the 18 pound bible of EM, says only that "The short-term use of opiates appears to be safe in pregnancy," but doesn't give us any evidence to support that.

Opiods in abdominal pain
Another forum posting, this time over at CTFIRE-EMS, was a discussion trying to elicit people's feelings about giving analgesia as a medic in general. One of the more interesting points was about giving analgesia to a patient with abdominal pain, with one poster believing that "most if not all surgeons would prefer to examine the abdomen before pain meds are given." Other posters weighed in with different opinions (Clashing opinions in a paramedic forum? Unheard of!),  and the observation that protocols in CT are evolving.

Our protocols
And what do the SHCGB protocols recommend? The language is clear:

"Patients in severe pain (7-10/10), in whom a narcotic analgesic will have a beneficial effect on outcome should be considered as candidates for pain management."

No exceptions for abdominal pain, pregnancy, young or old age - go for it!

In the second part (coming up!) I'll go over some recent research about prehospital narcotics, and I'll review some of the other protocols out there. I think it'll really drive home why you can feel safe using our protocol aggressively.

Prehospital Administration of Tenecteplase for ST-segment Elevation Myocardial Infarction in a Rural EMS System.

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Get a reprint here.

For the inaugural posting for Mill Hill Ave Command, I selected a recent publication that suggests the potential of what EMS can be. It isn't great science, maybe it didn’t save any lives, and as for cost-effectiveness - I have no idea. But this sort of project that Crowder et al. describe here is nonetheless exciting, and is the sort of thing that excites all of us, whether we’re the ones giving the patch, or the one who is taking it.

The author, a paramedic, describes the 9-year experience that his EMS agency and their local hospital have had with giving TNK in the rig for STEMI. Evidently Wilkes EMS is located in a fairly rural part of North Carolina, and it takes about an hour to transport to the nearest PCI-capable hospital. Business-as-usual used to involve transporting the (EMS identified) STEMI patients to the local hospital, where they would administer lytics in the ED. This would typically be followed by transfer to the regional PCI center afterwards. This seemed like a waste of both petrol and myocardium to all involved, and so they started a program that permitted direct transport to the PCI-facility, as well as the administration of fibrinolytics by paramedics, often in the patient’s home.

“The plural of anecdote” is a retrospective case series, which is how they describe this paper. Essentially, they just want to talk about their project, and that’s fine. Heck, they earned some bragging rights with this. And besides, not every cardiology study needs 10,000 Italians.

They describe the results they had with “consecutive patients presenting with an onset of chest pain that met criteria for prehospital thrombolytics and received tenecteplase between January 1, 2001, and April 1, 2010...” This is a fairly select group, as the numbers will bear out in the results. I’ll just point a few items that will limit (probably appropriately) the percentage of STEMI patients that could have been enrolled.

First off, not all STEMI patients have chest pain, as we all know. Before everyone yells out “Women present atypically!” let me just say that I will tackle that chestnut in a later posting. Diabetics and the elderly, however, are well known to present with “tombstones” in the anterior leads, and “just some indigestion.”

I actually don’t believe that the chest pain requirement was followed strictly. I know too many good medics who will slap on the 12 leads, following their clinical gut, and I’m sure that’s how they roll in NC as well – I expect a good number of the “chest pain” patients were actually calls for SOB or nausea that the medics picked up.

As for exclusion criteria, I wonder how many potential field lysis patients were disqualified based on an initial high BP that subsequently came down, or because of unequal blood pressures in their arms. Fun fact: About 20% of people have at least a 20 point difference in their upper arm blood pressures.

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After 9 years they had treated 75 patients through this process. Unfortunately, the prehospital ECG was only available for 66 of them. Now, there is no real valid way to pull any good outcomes data out of this study – the plural of anecdote, and all that. But the authors are able to legitimately discuss how appropriate it was for each of the patients to have been treated by this process.

A nice point of the paper is that they use both an EP and a cardiologist to review the initial ECG and history, and, not surprisingly, they disagree in some measure. The EP thought that 89% of the patients were, in retrospective, accurately diagnosed with a STEMI, while the cardiologist found that only 82% were. Statistically, that's fair. Eventually, they all came to a “consensus” that the lytics were correctly given 86% of the time. Eleven percent, though, were found to have been lysed inappropriately.   

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There is also a lot of discussion in the paper about how this process probably saves a lot of time, and how this likely helps the patient, and that’s all well and good. Maybe it does, maybe it doesn’t. You could even argue, perhaps, that the cost and increased oversight needed to treat this relatively small number of patients (about 3 every 2 months) can’t be justified in a cost-benefit analysis. Going further, you have to wonder about the STEMIs they didn’t enroll or catch, the patients who had lytics inappropriately withheld. They don’t have that data to share with us, and you can be tempted to start pointing out flaws and omissions that weaken the paper.

That’s all sort of missing the point, though. I actually don’t care that much if this program can be justified based on the number of muscle cells saved, or proper allocation of resources, or dollars spent. Doesn’t matter. Even if it turns out to be a small boondoggle (and there is no way it can be worse than helicopter EMS), it is emblematic of a system that relies on the intelligence and the initiative of both paramedics and physicians. It only works for 9 years if both parties have learned to expect a high degree of professionalism from each other, and are working to maintain the processes. These kinds of behavior and attitude don’t just manifest on the STEMI calls, or even just the cardiac calls. One would hope that even the lowly altered LOC from the nursing home is being assessed with a bit more care, that the EPs are relying more heavily on information from the field. Stuff to aspire to!