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

Marty Munro marty_munro at yahoo.ca
Sat Apr 7 00:51:32 BST 2012


Mr. Richey,
 
Here in Canada, or at least Ontario, we have two EMS providers. We will get firefighters on scene, and they will come with us in the back if we ask them to. However, they are trained to the first responder level, and most do not wish to have anything to do with an ambulance. As a result, having a firefighter do airway management is not the greatest idea in most cases. Assuming the intubation is done en route, then yes, it is easier to ventilate. Also, all I have is midazolam to assist with an intubation, which of course, is not ideal with a head trauma patient and the increase in ICP associated with intubation. It is also against the policy of most service providers to allow firefighters to drive the ambulance. Police may under our Highway Traffic Act, however, often they are not used to driving an ambulance, and tend to just want to move fast, not realizing they have unbelted individuals in the back attempting to provide treatment. 
 
There is more to the story lawsuit that I mentioned. First off, I just read the article again, and the scene time was 12 minutes, not 7, so my apologies. Twelve minutes is still pretty good, considering it takes 1-2 minutes to make patient contact, a few minutes to assess, provide any treatment, get the stair chair, carry the patient out, secure the patient to the stretcher, put the stair chair away and grab their equipment and load the patient. The patient was the wife of a firefighter whom is now retired. Originally, there was an investigation launched due to the complaint and the ruling was that there was no wrong doing. It was ruled that the small delay (which really isn't a delay) did not cause the patient's death. However, this firefighter managed to get some documentation from a cardiologist with a cited study that states that third degree blocks are very treatable if given the proper care. In this case, it would have been in the hospital. So,
 the Court of Appeal has re-opened the case based on the fact that third degree heart blocks are treatable, which is not new information at all, but it is new for this case.  In all likelihood, the case will be thrown out, but these medics are still required to sit through this 16 years later. On a side note, many firefighters here, especially old school ones, don't understand that paramedics have more training and skills than they do. They believe that our training is like their first responder training (which is about one week long) except medics are shown how to give some drugs. As a result, they can't understand why we don't just scoop people up and drive fast to the hospital. This old school firefighter most likely has that mentality. 
 
It just makes me think about a quote from one of the medical directors in Ontario from back about 10 years ago. When discussing the medical care that paramedics provide, he stated openly at a paramedic conference "just take them to the hospital where the real health care professionals can treat them".  As a paramedic, I should feel somewhat insulted by this, but the longer I am in this job, the more I feel that if all of us just became "ambulance drivers" again, it would make our jobs a lot more simple, and take away the risk for law suits. I used to want extra skills, but I would be perfectly happy if they took away all of my skills, and just told me to give oxygen and drive.  It's not like I would lose any respect from the general public, because the general public does not have any respect for paramedics to begin with. Well, I'd be happy with it as long as my pay rate remained the same. 
 
I apologize for the rest of this group for getting away from the initial topic. 
 
Marty

--- 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, 6:18 PM


Here's the way it works in the US at least.  We always have at least two
people on board an ambulance (one place I worked at for a couple of years
staffed three on all ALS ambulances).  Usually we have firefighters
standing around so we grab one, he drives while my partner and myself work
on the patient.  If things are a really big cluster **** I'll grab a second
firefighter to assist in the back (most of them are at least EMTs).  It's
an unusual occurrence for us to have a critical patient and only one
provider in the back even if it means grabbing a police officer or
firefighter as that extra set of hands since anyone with half a brain can
ventilate (once the patient is intubated or has an LMA or Combitube in
place) or do compressions.

Most malpractice lawsuits are against the targets that are going to have
the greatest ability to pay out (such as the service or the medical
director) unless the provider actually did something (or didn't do
something) that directly harmed the patient.  Proving that in court is a
lot more difficult than people think and there is probably more to that
case than you're aware of (there is in most cases especially one that is
dragged out for 16 years like you are talking about....never heard of one
going on that long even with a high value defendant).  Crap like that is
why one should always carry malpractice insurance on himself independent of
anything the employer provides.

On Fri, Apr 6, 2012 at 6:06 PM, Marty Munro <marty_munro at yahoo.ca> wrote:

> Mr. Richey, while I believe you make some sound points, I am curious as to
> how you ventilate, suction and initiate an I.V. or I.O. all by yourself en
> route to the hospital? While preparing your I.V. equipment you are still
> able to ventilate and suction? That's pretty impressive.
>
> Yes, one could argue that by not having the transfusin in the field, the
> patient didn't get the best possible care. However, that lawsuit would be
> on the service provider, and not the individual medics since if the
> procedure didn't exist, they can't be expected to perform it. Personally, I
> couldn't care less if my employer gets sued as long as there is no possible
> way for me to be sued or lose my job. And if the fault is on the employer
> for not providing a procedure, then one cannot fault the medics. You say
> that I am being paranoid, however, I can tell you that there is a case here
> in Ontario currently where two paramedics are being sued from an incident
> that happened in 1996. It was not a trauma, it was a medical that involved
> a third degree heart block. At that time, advanced life support units were
> very scarce in Ontario and therefore, pacing and pharmacolical intervention
> was not available at this time. The medics had an on-scene time of 7
> minutes,
>  and the time from their arrival at the residence to the time they arrived
> to the hospital was a total of 17 minutes. Yet, the court has stated that
> these medics took too long on scene, which caused the patient's death, and
> that the lawsuit should procede. Seven minutes from the time of arrival on
> scene, getting themselves and equipment inside, assessment, stair chair and
> then departure was seven minutes. I think that's pretty damn good. Yet, the
> courts say it is not. The more procedures we do as medics, the more risk
> there is for lawsuits. And I am not a physician, I cannot bill for each
> procedure. Do the wages go up for paramedics as more skills are given? No,
> of course not.
>
> I realize that this post was meant to argue the medical side of providing
> blood, however, as a paramedic, I do not think that it is a good idea
> practically.
>
> Marty
>
>
> --- 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, 5:11 PM
>
>
> 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
> > > --
> > > 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
> > --
> > 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
> --
> 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
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/


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