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Giving packed red blood cells in the prehospital phase of care... a good idea?

Stephen Richey stephen.richey at gmail.com
Fri Apr 6 22:11:08 BST 2012


Marty, honestly if the patient is sick enough to require a transfusion and
they don't have fairly obvious veins, they are getting an IO.  I'm not
screwing around with trying to find a vein in someone who is a tough stick.

How does starting the transfusion *en route* waste time?

I think you're being a touch paranoid with this concern about the chances
of a lawsuit.   Using the same line of reasoning you're using, one could
conceivably argue that by NOT having the transfusion in the field, you
deprived the patient of the highest standard of medical care possible.

Also, I've worked in a lot of ambulances (both ground and air over the past
15 or so years) and the only ones I've seen that resemble a dimly lit
utility closet are the helicopters.  With just you, the patient and your
partner, you should honestly have plenty of room.  I don't believe that
transfusions have a broad utility in the field, but at the same time let's
base the argument for or against it on more practical issues than fear and
supposition.

On Fri, Apr 6, 2012 at 4:45 PM, Marty Munro <marty_munro at yahoo.ca> wrote:

> Speaking as a paramedic, I would not want this responsibility. It's just
> one more thing to go wrong in an often unstable environment, and one more
> reason for me to lose my certification, job, or be sued. We are always
> taught to limit our scene times in traumas and provide required care en
> route, for obvious reasons. This means that often, we are unable to
> establish an I.V. due extreme movement of the vehicle, accessibility of
> available veins and the requirement to maintain a patent airway as a
> priority. Therefore, arriving at the emergency department/trauma room in a
> timely manner is a medic's priority. There is conflicting evidence as to
> whether or not a fluid bolus is even beneficial, and evidence that suggests
> it is harmful to the trauma patient. So now, if medics start carrying
> blood, will they be expected to always have blood running en route to the
> hospital? And when they are unable to, suddenly the topic becomes "the
> patient could have survived
>  had the paramedics started an I.V. and given blood en route".  The law
> suit begins, the medics lose their certifications and become the subject of
> an investigation and inquest.  And if they do start an I.V. and give blood
> and the patient dies, the topic becomes "paramedics wasted time by starting
> blood en route to the hospital". I am all for progressive medicine in the
> pre-hospital care, but I think that those who choose to implement certain
> things should try this first. Next time a trauma comes in to the hospital,
> instead of going to the nice bright trauam room, the patient should be
> taken into a utility closet, with only one physician and one extra person
> and all the care should be provided in a cramped closet by the single
> person while the extra person continuously shakes the mattress of the bed.
> Then think about how realistic/beneficial adding in extra skills/procedures
> is to pre-hospital staff. That's just my opinion.
>
> Marty Munro
> Advanced Care Paramedic
> Ontario, Canada
>
>
>
> --- On Fri, 4/6/12, Stephen Richey <stephen.richey at gmail.com> wrote:
>
>
> From: Stephen Richey <stephen.richey at gmail.com>
> Subject: Re: Giving packed red blood cells in the prehospital phase of
> care... a good idea?
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Received: Friday, April 6, 2012, 3:25 PM
>
>
> For the most part, I would say no at least here in the US since the average
> level of education for a paramedic leaves much to be desired (speaking as a
> former EMS educator myself).  The issues with quality control, supply
> maintenance, the need to determine clinical need (EMS providers tend to
> massive over-estimate the severity of patients' conditions because most of
> them are taught "cookbook" defensive medicine) and cost.  I am not sure how
> the blood banking situation is in other countries but here there are often
> region-wide shortages of blood products so the sequestration of a
> significant amount in the hands of EMS providers would probably only
> exacerbate the situation.
>
> Also, the problem is worsened by the fact that the patients who would
> probably benefit most from field transfusions are the ones in the areas
> least suited to its use because of administration, training and supply
> issues.  Rural EMS tends to be almost all volunteer and many of these folks
> never even meet their medical director let along receive any meaningful
> QA/QI feedback.  The idea of giving the blood to the local HEMS operators
> and using them to deliver a higher level of care isn't going to work
> because you're going to delay the arrival of the patient in the OR in all
> but the most remote of areas.
>
> In urban settings, you're not going to have that much need for transfusion
> because of the proximity to trauma centers.  Here for example, it's
> abnormal for EMS providers (such as my fiancee) to take longer than 20
> minutes from call to arrival at the hospital.
>
> On Fri, Apr 6, 2012 at 3:12 PM, Karim Brohi <karim at trauma.org> wrote:
>
> > So our trauma helicopter emergency medical service recently started
> > carrying packed cells:
> > http://www.bbc.co.uk/news/health-17232529
> >
> > We'll obviously be auditing its use closely, but I'm interested in
> > garnering the lists opinions on this:
> > Who should get PRBCs?
> > Should anyone get PRBCs?
> > Why aren't we carrying plasma as well?
> >
> > There are a couple of prehospital services in the US carrying blood
> > and plasma to my knowledge, and it is used by MERT teams in combat
> > zones.
> >
> > So??
> >
> > Karim
> > --
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> >
>
>
>
> --
> Stephen Richey
> Founder and Chief Researcher/Designer
> Kolibri Aviation Safety Research
> 5174-B Winterberry Circle
> Indianapolis, IN 46254
> 317-985-4740
>
> "I think the best thing, and the only thing in our infinite inadequacy in
> making up for the loss of life, is to say something we have been able to
> say in a lot of other accidents to grieving families.  That is 'Those
> deaths will not be in vain. We will not let them be in vain. Every one of
> those lives will be made to count in terms of making sure that three, four,
> five or ten other people do not die."- John J. Nance
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>



-- 
Stephen Richey
Founder and Chief Researcher/Designer
Kolibri Aviation Safety Research
5174-B Winterberry Circle
Indianapolis, IN 46254
317-985-4740

 "I think the best thing, and the only thing in our infinite inadequacy in
making up for the loss of life, is to say something we have been able to
say in a lot of other accidents to grieving families.  That is 'Those
deaths will not be in vain. We will not let them be in vain. Every one of
those lives will be made to count in terms of making sure that three, four,
five or ten other people do not die."- John J. Nance


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