IC established! We'll have several different sections reporting in - recent research, local topics, or highlighting areas of the Sponsor Hospital Council of Greater Bridgeport protocols.
*** Keep in mind - this website does not replace your protocols, and these posts do not reflect SHCGB or Bridgeport Hospital policies. This is a place to discuss research, controversies, or discuss possible future protocols. When in doubt, check your current protocols through the official source.
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.
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.
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!
