Have you hit someone in the chest today?

Have you hit someone in the chest today?

They started whacking people in Australia.  This is what they found:

Unsurprisingly, defibrillation was substantially more effective. Combining the data from both rhythms, precordial thump resulted in ROSC in 5/103 patients (estimated NNT of 26.2) while defibrillation led to ROSC in 188/325 (estimated NNT 1.7). More concerning, 10/103 (estimated NNH of 10.3) thumped patients shifted into rhythms with poorer prognosis (8 VT -> VF; 1 VF -> PEA; 1 VF -> Asystole).

That’s from BoringEM–all the links to the studies are on his site.  Food for thought and kind of fun, if nothing else.

Pulmonary Embolism. Do we care?

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First of all, free up two hours of your time and listen to this: Smart EM Undoes PE.  Now head over to EM Lyceum to read their evidence-based blog post about diagnosing and treating PE in the ED setting.

(Ok, I don’t really expect everyone to be able to do that, but they’re great sites and will help in understanding pulmonary embolism much better.  Even if you don’t check those out, keep following along and check out how the mortality associated with PE may be greatly overstated and know that there is only one not-very-good study to support anticoagulants for treating PE).

Now that you’re extremely well informed on the problems associated with PE diagnosis and treatment, we can have a conversation about what that means for the prehospital provider.  In their podcast, Dr. Newman and Dr. Shreves discuss how they as physicians can have very little wiggle-room to change their practice in the emergency department (due to our medical-legal culture).  So what can we do?

Interestingly, it seems as though we can only improve our practice when faced with PE.  If you consider that the role of EMS in many instances of acute injury and illness is recognition and activation of the system needed for definitive treatment (I’m thinking code stroke, code STEMI protocols), perhaps prehospital providers can play a similar role in identifying PEs.

For example, look at the Wells’ Criteria, one of the go-to diagnostic tools used to identify PE in the emergency department.  EMS providers are certainly knowledgeable and skillful enough to go through each of those scoring criteria, even if we don’t have the ability to do d-dimer testing in the field (a blood test that, when combined with a rule out criteria like the Wells’ Score, eliminates the need for further testing).

Or maybe that isn’t so crazy.  There’s an interesting study that was done in Slovenia where researchers used the Wells’ Criteria, End-Tidal CO2, and a field D-Dimer to diagnose (or at least effectively rule-out) PE prehospitally.  Basically, if a patient has a low clinical probability of having a PE (low Wells’ score) and has a PetCO2 > 28mmHg, they can be safely ruled out of having a PE even if their D-Dimer was positive.  And if they were clinically suspected to have PE and had a PetCO2 < 28mmHg, those patients were pretty likely to have a PE (93% specific for positive PE).

The question is, at the end of the day, what does it matter?  If Smart EM came to the conclusion that they, as physicians, have little ability to change their practice, AND, if they did, they would be doing even less testing/treating for PE than they do now, why should a paramedic carry around a card with the Wells’ Criteria on it?

It might not change our treatment today or tomorrow, but having a better understanding of this disease process may just help better diagnose patients before they get to the ER.  Or it might help to move the train of thought from PE to some other respiratory disease that we can treat.

I think this is certainly a point for conversation, and I’d love to know what you think.  Especially considering the limited resources available for training prehospital providers AND operating under the presumption that paramedics would like to move into a more professional realm, what is our responsibility for recognizing/interacting with diseases such as pulmonary embolism that are beyond our treatment capacity?

PE Reference Bits

A Brief Note on FOAMed

This blog is called Prehospital FOAM, which sounds like something in which one would bathe.  It’s not.  FOAM(ed) is a new and wonderful movement that is taking the medical community by storm.  Basically, a couple years ago, several ER docs were having a drink after a conference and decided that there was no reason that the internet and social media couldn’t be better utilized to share educational resources and experiences that have been heretofore inaccessible to a large portion of the medical community.  And if our shared endeavor is better care of our patients, hiding away useful knowledge and information seems…stupid.

So now we have FOAMed–a medical “education” (let’s be careful about that, though) for “anyone, anywhere, anytime.”  LifeintheFastLane.com, the real hub and home of FOAMed, defines FOAM as such:

FOAM is the movement that has spontaneously emerged from the exploding collection of constantly evolving, collaborative and interactive open access medical education resources being distributed on the web with one objective — to make the world a better place. FOAM is independent of platform or media — it includes blogs, podcasts, tweets, Google hangouts, online videos, text documents, photographs, facebook groups, and a whole lot more.

This sounds great, and it is, but what we still need to be reasonable here.  This morning, for example, I listened to a podcast from PHARM (see FOAM Sites in the menu) about prehospital intubation in the presence of TBI.  A lot of evidence says that it’s not such a great idea.  But listening to one podcast–even if it is very well done and comprehensive–does not make me an expert, nor does it give me the skills and knowledge base to change my practice.  Not yet.  I still need to read the research for myself, read the textbooks, know the physiology, and THEN (and only then) can I reassess my practice under my protocols.  As Dr. Weingart has said talking about FOAMed, it is not gospel.  It is not knowledge, but tacit experience.  What we need to do is read the literature for ourselves and come to our own informed decisions.  Basically, FOAMed can jump start you in a direction toward better understanding, but it is close to meaningless without the legwork to create a foundation for yourself.

With that said, I hope this site can do a couple of things for prehospital providers: first, I hope to show you some of resources that are readily available and of high-quality to supplement your current education.  Secondly, and perhaps more importantly, I hope to make some of the literature–evidence based medicine that is necessary for real comprehension and knowledge–more accessible for EMS providers who may have never seen a randomized controlled trial before.  Because that is the kind of base knowledge we need for EMS to be respected as a profession.

Please stay tuned and check out some of the sites that are linked already on the page.  The larger community of EMS professionals (I’ll use that word) have every right to be involved in the FOAMed conversation, and I think it’s about time we started weighing in.

**UPDATE–found this video on DEMTed.com, which summarizes some nice points about FOAM**

Sign-Offs Done Right

At my full-time service, signing-off patients is a responsibility reserved for the paramedic, and there’s a reason for that.

While the importance of a well-conducted sign-off is primarily medical-legal in nature, at the heart of the risk is a concern for the well-being of the patient.  There doesn’t appear to be a huge amount of literature on EMS sign-offs, but what there is suggests that we should aggressively encourage patients to be transported and that, although the risk of patient admission/death may be minimal, sick people still sign-off.

Regardless, every sign-off needs to be both performed well and documented well.  This post, from ALiEM, discusses how doctors sign patients out AMA, but I think we can use the same approach in the pre-hospital world.

ALiEM: The Proper Way to Go AMA

**Update**

After writing this post, I created a “macro” of sorts that incorporates elements of this article as well as specific language from my service’s sign-off that I put in my narrative. I would encourage you to create your own, but if you would like an example, my documentation can be found here.

This is your office.

Office

This is your office.  You work here for long periods of time and under the most uncertain of conditions.  Like most people, you do your best to be proficient.  To treat your patients to the best of your ability.  Now you have a new tool.

This site is geared for the pre-hospital providers that want to be the best at what they do.  Free Open Access Meducation is, like it implies, free and readily available for anyone and everyone, and my hope with this site is to filter down some of the most pertinent resources for those who take their work on the road.

Please contact me with questions, concerns, or leads on new material.  I do not claim to be an expert or resource myself; my hope is to serve as a “gateway drug” to the greater FOAM community and all of its resources.

Enjoy, and be safe out there.