L.A.T.E.R

Dr Crippen posts about the Princess Diana documentary and draws attention to the ideas of 'Stay and Play' or 'Scoop and run' in the ambulance service.

There is a discussion that has been going on for some time in medical research circles about the training of paramedics (and I would suppose also us lowly EMTs) and what we should be doing on the scene of an accident.

Let us imagine a young man with a stab wound to the chest – a nice 'trauma' job. Should the ambulance crew remain on scene for a long time, getting venous access (so that fluid can be given to prop up the patient's blood pressure), examining the wound to see where we think it goes (to determine the severity of the injury) and conducting a full physical examination by cutting off all their clothes (to make sure that there aren't injuries that have been missed). In America the crew would probably also immobilise the neck because the patient had fallen over*

Or.

Would it be better to load them into the back of the ambulance, do up the straps and rush them into hospital where there are doctors and surgeons and operating theatres?

It is complicated somewhat by the policies of the ambulance service. Unless there is a really good reason we have to record a full set of vital signs for every patient we pick up, that's blood pressure, pulse, oxygen level, rate at which they are breathing and blood sugar. We can also be expected to do 12-lead ECGs and measure the amount of carbon dioxide someone is breathing out.

So the option to just 'run' is fully out of the question – if the patient dies we would be up in front of the coroner and they would be asking awkward questions about our lack of vital signs.

So we have to stay on scene to check those signs. What else do we need to do?

Some stabbings are 'nothing' jobs, a little slice, or even a minor skin scrap have been reported to us as stabbings, if we were to 'blue light' these calls in we would be rightly laughed out of the hospital. So we need to do some form of assessment to determine the severity of the injury. To properly do this we would need to cut off the patient's clothing.

Gaining venous access would depend on the patient's vital signs and how close they are to the hospital – I am personally a big fan of 'scoop and run'. The place for a sick person isn't in the back of an ambulance.

But.

Here is where I consider myself lucky. I work in London, I'm never more than ten minutes away from hospital; if the patient is in the back of the ambulance then I can get them there really rather quickly (sometimes the trick is getting the patient into the ambulance, but that is a discussion for another time). I have that luxury of being a very short distance from a fully equipped hospital. If I were to work in the depths of Essex then I could be an hour away from hospital, then there is more of an need to stabilise the patient before transport (or doing such work while on the move).

Someone once mentioned LATER – Load And Treat En Route. Something that I've done myself with 'naughty' jobs – for instance heart attacks; if the ECG shows a heart attack then I'll get going and do the rest of my treatment on the way.

I don't know where Dr. Crippen works, but I would guess that if paramedics want to stay and play it'd be because he's a long way from a hospital. I may of course be wrong, I would guess that there are those ambulance types who see themselves as 'masters of trauma' and will fart around if it gives them something interesting to do – I don't know any myself.

Strangely enough, and tying it back into the death of Diana, we find ourselves 'staying and playing' when there is a doctor on scene (most often from HEMS). We all have stories of HEMS** turning up when really what we would like to do is 'scoop and run' with the patient. Of course they do come in handy when we have that delay getting the patient into the ambulance for example when they are entrapped in a car crash.

So while I don't think that Dr. Crippen is wrong in the treatment of trauma patients, I do think that he doesn't understand the mindset of your average ambulance staff. This may be a wild generalisation but we know we aren't doctors (even though the government is making us cover for doctors). We know where the limits of our education are, you won't see us trying to do things that we haven't been trained to do, and I'll tell you why – it's because we are scared of being sued. We like a nice easy job, pick someone up, drop them off at hospital, everyone is happy. We don't wear our pants on the outside, because we sure as hell aren't Superman.

I agree that the study and cover of 'traumatology' in this country is awful and I don't think that it will ever get any better.

Finally the good Dr. mentions his bad experience with paramedics – I've got to say that the last few disecting AAA patient's I've seen, all the ambulance crew present recognised it for what it was and blued the patient into hospital, doing the BP and such-like on the way. But if I may be cheeky I'll counter his bad paramedic experience with my own story of the A&E SHO who was convinced that the patient was having an asthma attack when every nurse in the department (me included) was shouting at him that the patient was having a disecting AAA.

(Apologies for a hastily scrawled blogpost, but I'm extremely busy today)

*I may be wrong, this is just the impression that I get.

**Talk of the devil the noisy sods are circling my house at the moment.

14 thoughts on “L.A.T.E.R”

  1. I understand the problems with this issue but must say that I don't know any Paramedics/Technicians that don't act in the best interest of the patient.If there is a 40 minute delay on scene it will generally be because this is the shortest time it took to assess and move the patient. Doctors don't realise that even someone who is “off their legs” may take 30 mins to load up and get down 5 flights of stairs.We do do a lot for the patient, but only if we think it's necessary. I don't stay and play unless it's absolutely necessary. Like most I'm pretty adept at canulating in the back of a moving bus.We all know that definitive care starts at the hospital. Thats it. We bring people to hospital so they van be cured/saved. Anything we do prior to that will be done because it is deemed necessary at the time.

  2. Apparently you all don't have the problems US medics have with misplaced ET tubes. We have capnography available for other purposes, but Pennsylvania recently stated that all advanced life support ambulances must carry capnography for the express purpose of never, ever having a misplaced ETT again.Although clinical skills are important, I do really enjoy getting a good capnography before-and-after on an asthma patient, watching the waveforms change from shark-fin to normal.

  3. Tom – have you seen any of the stuff on reperfusion injury ?After an arrest cells do not die from ischaemia [at least not for some time] but are killed by aggressive oxygenation during the resuscitation effort – delivered of course by paramedics, HEMS, hospital staff, etc.

    This has led some authorties to advocate the use of cardio-respiratory bi-pass or hypothermia so that resuscitation is managed over a much longer time scale – apparently with very promising results when compared to traditional Resus Council methods.

    It certainly makes you think ?

  4. This seems to be one of those things, which, as you say, is very much circumstantial. there will inevitably be those who say to 'always' stay and play, but you wouldnt, as you say, do this for a ECG-implied heart condition. I think the only way this can be solved is to use the breadth of your experience (as always).

  5. Stay & play is all well and good if your patient is stable and you have the luxury of a Doctor and/or Paramedics. I work as a double EMT crew and on those naughty jobs you don't want to hang around on scene for too long, 9 times out of 10 you can spot the naughty ones as soon as you walk into the room, so while your crew mate is getting the gear to load and go you can get those first set of obs and then put the lead boot on and get them into hospital.Unlike Tom, we don't always have the luxury of an A&E department close by, and I have had more than one very long drive to the hospital with a poorly patient in the back, sometimes we have a para available to back us up, but sometimes its not feasible, for instance it might take us just the same amount of time to get them to A&E than for the para to attend. I think you just have to take it as it comes, a cop out really, but what else can you do?

  6. Spinal immobilisation protocols vary by state, region and even medical control hospital here, but in general we are supposed to immobilise stab wounds to the trunk. The theory being not so much because they may have fallen, but that the knife itself may have done damage to the spinal cord. I only have experience in the southwest region of Connecticut, but we (as EMT-Bs) are allowed to rule out spinal injury on conscious patients by a quick assessment. I know this is not true for all regions/states.

  7. Many prehospital docs are now going with the idea of permissive hypotension in trauma- i.e don't aim for a normal BP, aim for a blood pressure adequate to perfuse brain/kidneys/myocardium- in your example of a young trauma victim (e.g 19 year old male, fit and well), this may be very low e.g 60mmHg systolic. This comes from the idea that a normal BP may actually increase bleeding, and the bleeding may be from somewhere you can't stop without a surgeon. Given this, why do you want to hang around getting IV access when you can have a go on route? I can understand not wanting to transport a patient long distances without adequate access, but logically; if you're that rural, you probably took a long time to get there, so if they're really very sick, they self-triage and die. In the urban environments familiar to many ambulance crews, surrounded by excellent hospital facilities, I can see practically no justification for faffing on scene with seriously ill patients (except if e.g trapped). Even in STEMIs- why thrombolyse pre-hospital when you're 20 mins from primary angioplasty? I am quite certain I know which one I'd like if that was my myocardium.And, for my interest, do you really have to measure CO2 as part of your obs? How are you doing this? Is this in the JRCALC guidelines?

  8. Good comment – I have been known to mutter about 'blowing off clots' by throwing in loads of fluid myself.We don't thrombolyse in London for exactly the reason that you mention.

    CO2 monitoring should be done with 'proper' difficulty in breathing, but not many people do. It is after all a good way to tell your panic attack from your pulmonary embolism. We have lifepack-12s in all of our ambulances and they accept CO2 monitoring lines.

    I'm completely with you of LATER. Maybe if we came across a fitter who is known to have serial seizures it might be an idea to stick a line in when they are 'quiet' rather than wait for them to start fitting again.

    If I recall correctly didn't the idea of permissive hypotension come from research on injuries from the Falklands war?

  9. I may sound stupid in asking, (my moto is if you don't know, ask….) but what is a “disecting AAA”? I have googled it but it has brought me back to this page….Many Thanks Bex

  10. AAA is an Abdominal Aortic Aneyrusm – this is a weakness in the biggest artery in the body. 'Disecting' is a fancy way of saying it's got a big hole in in. So blood doesn't go to where it should go, instead it goes into the spaces around the organs rather than to the organs themselves.Untreated a disection like this will kill you. In surgery I *believe* the survival rate is around 10% (But I may be out of date on that)

  11. And to all the medics in the audience I know that the definition of disection may include chronic damage into the tunica media, but I'm trying to keep it simple and go to bed…

  12. I started to reply to this,then decide to blog about it , in a roundabout way.Sorry for self advertising!

  13. Hi Tom,Re. CO2 monitoring

    Panic attacks and PE will both, usually, have LOW CO2 levels. The patient will be breathing fast in both situations and thus will blow off all of their CO2. The CO2 will not rise in PE unless it is a massive PE: but then, they will be minutes from death and looking very unlike the panic attack patient. Measuring expired CO2 is also very inaccurate unless you use an entirely closed mask e.g as found on BVM, and even then, you have to have a perfect seal on the patient's face.

    With regards to the fitting patient, as you've mentioned, I'm sure it would be a very sensible idea to get access while they're not fitting, have tried and failed myself in thrashy fitters, it's not very easy đŸ™‚

  14. We have capnography, so we can check out the different waveforms, which is handy for things like asthma.Because, we could never do that before with our clinical skills…

    (And may be why I rarely feel the need to use it)

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