dr-exmedic.com

EMSI is the corporation contracted by the state EMS folks to oversee EMS in my neck of the woods. Some time ago, they used money that’s “donated” by people who get traffic tickets to spread around a bunch of portable CO detectors, which is something that I was certain I’d thought up (but, of course, I was far too late).

For this, I thank them, for saving my wife’s life–or at least sparing her the agony of a crippling headache and a couple of hours in my ED.

A couple of days ago (though I only heard the story today–thank you, work schedule!) my wife was dispatched to an unresponsive person. A portable monitor went off the moment she entered the house, and as a result (after someone spent 30 seconds figuring out whether it was a false alarm or not) she was able to minimize her time in the house, thereby sparing her anything worse than a mild headache–when the fire department showed up, the levels were actually above the operating range of their meter (1600 ppm).

So thanks again, EMSI, for your visible commitment to provider safety.

Studies have tried very hard to find a correlation between prehospital intubation and mortality rates, and few have found anything remotely positive to say about prehospital ETI–though there are plenty of studies suggesting no difference, and plenty suggesting harm. It’s hard to say that those suggesting harm are 100% accurate, though, since many have used hospital data to identify research subjects rather than the EMS tripsheets.

That’s why a more recent study is so interesting: the ROC Group studied a group of patients based solely on medic-documented GCS of 8 or less in the field. Interestingly, the intubation attempt rate was pretty close to 50% (758 patients had an attempt and 797 didn’t). Patients with an intubation attempt did worse, with a mortality rate of 57.3%, compared to the 33.6% of those with no attempt. However, those with an intubation attempt were almost twice as likely to have had hypotension, were more likely to have penetrating trauma, and had an average GCS 1 point lower, so it’s not surprising that they died at a higher rate. Less surprisingly, those intubated patients who died had worse BP and GCS numbers than the intubated patients who didn’t die.

That’s not a surprising or even unusual finding. What’s next is.

The group also found that the sites in the ROC consortium with the highest intubation rates had a trend towards having the lowest mortality, both total and among those with an intubation attempt. Let me steal the raw table (with a bit of cropping and cutting out boring columns, click to enlarge):

Doesn’t look like much, does it? Let’s show it another way:

It suddenly jumps out a bit more, doesn’t it? Granted, the actual study used statistics to determine that there was indeed a significant trend, but this is a bit easier to see. It’s also a tremendously interesting finding, and is similar to what I’ve felt about prehospital ETI for the last couple of years: it’s not that prehospital ETI is dangerous for patients, it’s that prehospital ETI as it is currently practiced in many places is dangerous for patients.

We’ve seen a proliferation of first-aid programs for smart phones, including ones that will teach you CPR on demand (in both iPhone and Android flavors). These are great, but to save lives, they require several conditions:

1. for starters, you need a smart phone in the hands of someone who’s come across a cardiac arrest
2. the person has to have been proactive enough to download the app
3. the person has to remember that they have said program
4. the person has to figure out where said program is in a short enough amount of time to make a difference.

So one company has skipped all of these conditions and done something brilliant: put a video screen and CPR instructions right on the AED itself. Check out an interactive demo here.

I thought that one of the advantages of using computers, instead of a real live human being, was that they didn’t need to take breaks, but apparently things are different when trying to file local taxes:

The best time to internet file your no tax due 2010 PGH-40 return is during normal business hours between 8:00 am to 4:00 pm, Monday through Friday. If you attempt to file at any other time and the system does not allow you to file, please try again or file during normal business hours.

And lo and behold, at 1PM on a Saturday well in advance of the filing deadline, I can’t connect to the server. Secondary thought: can I only file a no-tax-due return? This is seriously getting out of hand….

I think I’ve mentioned before that I’m reviewing a “Medical Director’s Handbook” that will be published by the federal government. The latest draft is in its comment period, and I’ve put up a copy here.

The current version is, on my first (non-detailed) reading, a bit better than the last one. It’s been tightened up a bit, which was one of my biggest complaints–there was precious little in the first draft on certain important subjects (such as protocol writing for medical directors not covered by state protocols) while there were tedious pages describing which NFPA and OSHA standards governed mass casualty response.

An interesting little article recently made me think about one area where EMS education really shines: direct observation of students.  The article opens with a quote from physician George Engel:

If musicians learned to play their instruments as physicians learn to interview patients, the procedure would consist of presenting in lectures or maybe in a demonstration or two the theory and mechanisms of the music-producing ability of the instrument and telling him to produce a melody. The instructor of course, would not be present to observe or listen to the student’s efforts, but would be satisfied with the student’s subsequent verbal report of what came out of the instrument.

Clearly, this is one area where EMS field preceptorship succeeds, and EM residency fails:  a search for articles about direct observation of ED residents returned just 7 relevant studies. Meanwhile (at least to my knowledge), not a single paramedic or EMT student is sent on an ambulance to manage a patient alone–a preceptor sees the student’s exam, and is immediately present to provide advice or feedback.

This is not to say that all doctors are horrible. (In fact, it’s quite a testament to medical schools’ selection of students that anyone is out there not performing weak exams on patients.) However, the limited research out there shows that people with performance problems improve more rapidly after some direct observation–which means that, given the limited amount of time in an EMT or paramedic program, it’s not only good but crucial that supervision is so close. Now, if only direct observation were more common among residency programs….

Imagine this scenario:  you’re dispatched to a 66-year-old male with a report of “defibrillator fired.”  On arrival, you find a 66-year-old male without other complaints stating his ICD fired 3 times over the last few minutes.  The patient admits to a history of CHF, with ICD and LVAD.  You feel for a pulse and can’t get one.  You throw him on the monitor and find VF.

If you’re like me, you were told at some point in your schooling that if someone’s talking to you with VF, either A) wait 15 seconds for that to change, or B) something’s wrong with your monitor.  But no–this gentleman not only actually was in VF, he stayed in VF for the next 3.5 hours, until (after electrolyte replenishment and some amiodarone) he was successfully defibrillated.

So the takeaway point?  First, any sentence in medicine with the words “always” or “never” is most likely wrong.  Second, this was just a pretty cool case to talk about.

This billboard was visible from Pittsburgh’s Liberty Bridge last baseball season, though I’m just now getting around to posting it:

So what is it that Budweiser does with this ad?  Are they trying to link their beer to the first North American professional sports franchise to have 18 consecutive losing seasons, or to the yellow P?  I figure it’s a loss either way.

Several months ago, the National Institute of Standards and Technology (NIST) announced that in a study they’d performed, certain ALS tasks were performed faster with more ALS providers on scene.  I greeted this announcement with a resounding “Who cares?”  The full study was finally released early this month, and I’ve finally gotten around to looking at its 70 pages.   (There’s so much there to talk about that I’m going to have to break this into several posts.)

One sentence description:  a study based on scenarios that are so standardized that I don’t think you can generalize from the results, and which measures few things actually known to improve patient outcomes.

Part 6:  summary (more…)

Several months ago, the National Institute of Standards and Technology (NIST) announced that in a study they’d performed, certain ALS tasks were performed faster with more ALS providers on scene.  I greeted this announcement with a resounding “Who cares?”  The full study was finally released early this month, and I’ve finally gotten around to looking at its 70 pages.   (There’s so much there to talk about that I’m going to have to break this into several posts.)

One sentence description:  a study based on scenarios that are so standardized that I don’t think you can generalize from the results, and which measures few things actually known to improve patient outcomes.

Part 5:  trauma  results (more…)