Ace844

Hi All, To get us back on topic abit, I thought I'd post a copy of these recent studies.....Any comments...thoughts...??? http://journalsonline.tandf.co.uk/(amhyzzy...lesresults,6,6;COMPARISON OF PERCEIVED PAIN WITH DIFFERENT IMMOBILIZATION TECHNIQUES PREHOSPITAL PAIN MANAGEMENT A COMPARISON OF PROVIDERS' PERCEPTIONS AND PRACTICES Halim Hennes A1, Michael K. Kim A1, Ronald G. Pirrallo A2 A1 Department of Pediatrics, Pediatric, Emergency Medicine Section, Milwaukee, Wisconsin A2 Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin Abstract: Objective. To assess the knowledge of emergency medical technicians–paramedics (EMT-Ps) and compare their practice perceptions with actual pain management interventions in adults and pediatric patients (adolescents and children) with chest pain (CP), extremity injuries, or burns. Methods. This study included a cross-sectional survey of EMT-Ps and review of the emergency medical services (EMS) system patient care database. EMT-Ps were surveyed for: 1) knowledge of pain treatment protocol; 2) estimated number of CP, extremity injury, or burn encounters and the frequency of morphine administration; and 3) barriers to providing morphine. Data on patients transported with any above conditions and those who received morphine were abstracted from the EMS patient care database. Data were analyzed using descriptive statistics, and 95% confidence intervals (CIs) were calculated. Results. Of 202 EMT-Ps, 155 (77%) completed the survey. Eighty-two percent reported knowledge of pain treatment protocol for both adults and pediatric patients. For adults, EMT-Ps estimated they administered morphine to 37% with CP (95% CI 35, 40), 24% with extremity injuries (95% CI 17, 30), and 89% with burns (95% CI 52, 99). In children and adolescents, inability to assess pain (93%) was the most common reason for withholding morphine. According to the EMS database, 5% of adults with CP (95% CI 4, 5), 12% extremity injuries (95% CI 8, 15), and 14% burns (95% CI 8, 20) received morphine. In children and adolescents, 3% with extremity injuries (95% CI 1, 5) and 9% with burns (95% CI 0, 26) received morphine. Pain score was documented in 67.0% of adult patients, compared with only 4.0% in pediatric patients (? = 63.0%, 95% CI: 60, 65). Conclusions. Significant disparity exists between EMT-Ps' perceptions of acute pain assessment and the frequency of providing analgesia and their actual practice. Children and adolescents had less documentation of pain assessment and received less analgesic interventions compared with adults. Inability to assess pain may be an important barrier to the provision of analgesia. PREHOSPITAL PAIN MANAGEMENT IN CHILDREN SUFFERING TRAUMATIC INJURY Robert Swor A1, Christine M. McEachin A1, Debra Seguin A1, Kristi H. Grall A1 A1 Department of Emergency Medicine, William Beaumont Hospital, A Wayne State University Affiliated Program, Royal Oak, Michigan Abstract: Prehospital pain management has become an important emergency medical services (EMS) patient care issue. Objectives. To describe the frequency of EMS and emergency department (ED) analgesic administration to injured children; to describe factors associated with the administration of analgesia by EMS; and to assess whether children with lower-extremity fractures receive analgesia as frequently as do adults with similar injuries. Methods. This was a retrospective study of children (age < 21 years) who were transported by EMS between January 2000 and June 2002 and had a final hospital diagnosis of extremity fractures or burns. Secondarily, children with lower-extremity fractures were compared with a cohort of EMS-transported adults with similar injuries and transported during the same study period. Receipt of and time of parenteral analgesia were recorded. Results. Seventy-three children met the inclusion criteria. The mean (range) age of this sample was 12.4 (0.9–21) years, with only four patients aged < 5 years. A majority of the patients were male (49/73, 67.1%) and sustained femur (20/73, 27.4%) or tibia/fibula (26/73, 35.6%) fractures. Few pediatric patients received prehospital analgesia (16/73, 21.9%), while a majority received analgesia in the ED (58/73, 79.4%). Prehospital analgesia was associated with earlier patient treatment than that administered in the ED (22.3 ± 5.9 min vs. 88.3 ± 38.2 min). Comparing children (n = 33) with adults (n = 76) with similar lower-extremity fractures, a small insignificant difference was found in the rate of prehospital analgesia between children and adults (7/33, 21.2%, vs. 20/56, 26.3%). Conclusion. Few pediatric patients receive prehospital analgesia, although most ultimately received ED analgesia. Few factors were identified that could be associated with EMS oligoanalgesia. No difference was found between children and adults in the rates of EMS analgesia. THE FEASIBILITY OF PAIN ASSESSMENT IN THE PREHOSPITAL SETTING Samuel A. McLean A1, Robert M. Domeier A1, Heather K. DeVore A1, Elizabeth M. Hill A1, Maio DO, MS A1, Shirley M. Frederiksen A1 A1 Department of Emergency Medicine, University of Michigan Medical Center/St. Joseph Mercy Hospital (SAM, RMD, HKD, EMH, RFM, SMF), Ann Arbor, Michigan. Abstract: Objective. To determine the feasibility of prehospital pain measurement among patients 13 years of age or older using a verbal and numeric rating scale and to assess the severity of pain in a prehospital patient population. Methods. Retrospective cross-sectional study of emergency medical services (EMS) run sheets after the adoption of a universal prehospital pain assessment protocol. Data were abstracted from a sequential (1:4) sample of run sheets from the first three months after adoption of the protocol. Verbal rating scale (VRS) and numeric rating scale (NRS) pain assessment information was obtained, along with demographic, location, and call information. Run sheets without pain assessment underwent structured review and classification according to predefined protocol. Descriptive statistics and 95% confidence intervals were calculated. Results. A total of 1,227 run sheets were reviewed, 582 (47%) of patients were male, and 452 (36%) were 65 years of age or older. A total of 907 (75%) were nontrauma transports and 27 (2%) were unconscious. Among conscious patients, pain was assessed using the protocol in 1,002 of 1,200 (84% [range, 81%-86%]). Among patients reporting pain, 104 of 518 (20% [range, 17%-24%] completed a VRS but not an NRS. The greatest risk factor for no pain assessment was altered mental status (39% of patients not assessed). Forty-eight percent (23 of 48) of patients with altered mental status reporting pain completed a VRS only. Thirty-one percent (range, 28%-34%) of all patients in the sample reported moderate or severe pain. Conclusion. Prehospital pain assessment using a VRS and NRS was feasible in this patient population. Further studies are needed to confirm this finding in other settings. Moderate or severe pain was present in approximately 31% of patients. Hope this helps, Ace844

That's funny!!!

"Rid," ok, perhaps the number is greater than 2, and it may be larger like 3, but you have to admit the preponderence of the literature most noteably/recently these from CO and WA where they performed a multi-year/ center trial of pre-hospital nasotracheal entubations WITHOUT any intracrainal placements as well as a number of "in house" studyies essentially validating the same conclusions, or perhaps I'm missing some important pieces out there?!!? Also, the cases which are always quoted for this took place in the late 70's @early 80's, it seems that much like the entrenched DOGMA of ACLS we will be haunted by this for many years to come... There was even a Chorcrane review article about a year and a half ago on this very subject..Either way for the record, I don't usually make it a habit to confuse endotracheal tubes and NPA's, that gets embarrassing VERY QUICKLY! out here, Ace844

"PRPG", Duely noted, I agree and I missed the ' "could be considered to be" ' part of the post..I apologize, and agree with you in all of your above points.. As for your sidenote, I guess one can consider that in some ways where an airway is concerned you could use the philsophy that "bigger is better" within the realm that it will actually fit where it is "being placed".....Umm.... on second though perhaps that will take us to a place we don't need to go and be grossly misunderstood......!?!?!? Lastly, you wrote;

I got it as part of medic class and thought it was very enlightenting with soem things, and "old info" on others...a grand is a bit much for the class, but I did enjoy the baby pig portion of the lab!!! I like you enjoy as much education as I can get and recommend it for like minded peeps! out here, ace844

"PRPG," As you're an astute individual I am surprised that you are unaware of the literature concerning Naso-tracheal intubation in "head trauma" showing that it is beyon statistically unlikely that an naso-tracheal placed tube will infact be placed "in the cranial" cavity... The majority of that teaching is entrenched dogma that was seen in approx 2 isolated cases long ago. We had a discussion about this here some time ago and if anyone has a link handy feel free to post it.. So with the evidence and literature in mind if it is unlikely that a "rigid" endotracheal tube is unlikely to be placed in the "itra cranial cavity" I find it beyond ludricris to assume that a very "flexible" rubber/pvc hose will penetrate the anatomy on it's own... JMHLO!!! As far as #2,3, well I am sorry to say this, but the need for AIRWAY ADEQUACY, PATENCY, @ PROTECTION surpasses "bleeding" in every treatment algorhythmn, piece of literature and education I have ever attended. Think A as in airway and it being 1st!!!! thus the other's are "relative" contrindications, and considerations.... Hope this helps, Ace844

I agree with "Rid" and will add that along with everything he mentioned, i will add that it was enlightening and informative on how they tried to tech ER doc's in ancillary hospitals when it was a good idea to transfer "rapidly" as oppossed to "doing everything" then transfer....and its impact on patient M@M.. out here, Ace844

There is alot of dissention and ?'s regarding the accuracy of your #1, also with entubation. I am wuite sure that #2 and 3 are relative.... out here, Ace844

"Buddy," It's good to see a fellow EMS provider believe in something and to "get on board" to help improve pt care in the field!! I do have a few items to present for consideration as to your initial query on if this device may be "useful" in the field. DISCLAIMER:: These opinions are my own and based on my own prejudice, insight, and info provided, etc.. and subject to change. This is MHLO/.02 and YMMV. Also I a personally a big "proponent" of new and emerging technologies "coming" to the field to help improve pt. care. Having said that I have the following issues/opinions on this device and how it may or may not be useful "in the street". 1.) The vast majority of the studies posted did not use this device in the "initial assessment, test, decision making process" Thus the majority of Docs exposed to the products available info was only after the inital pt "workup" PE, and test results were back. Then the doc was provided with info from the device to see "if" this changed their decision making/Rx. Also, based on what i read there was no "chart/tree" to tell the physician or give them a measure of acute/chronic value for the indicies which the device measured and thus one can only assumed all info was against known physiologic norms. Because this device wasn't implemented "right away" in the acute patients care and assessment etc... One has to wonder the following things for the "in hospital" environment:" A.) Because there was no "baseline" measure of the patient's studied to "match against the Md had to assume "physiologic norms" which most of these patient's most probably weren't at while at baseline. B.) How long does it take to connect the device, how long was the pt monitored for before accurate values were obtained and how would this affect "acute/emergent" patient care C.) The samples from the studies listed were all very small and very different between them all and very loosely homogenous, as well as mostly being performed on "stable" patients. Thus small population in these studies and the "data" obtained is questionable as to how representative/accurate it would be against a larger population D.) How much did the corporation/funding have to do with the outcomes and how much input/influence did the company have on exclusion criteria, etc.... E.) There as I mentioned previously was no objective measure or method given to the clinicians to determine acute/chronic cardiac measures for the patient as well as acute/chronic measure states for the respiratory side. So as not to confuse I'll give a quick example. There alot of patients "nowa days" which are being D/c'd or being treated outpatient with the following PMHx's/comorbidities together: CHF, CAD/mi, Pulmonary edema (non-cardiac", Pulmonary Disease... So if one was to encounter a patient with a known ef of say....30% and chronic cardiac issues (MI, CHF) as well as emphysema and a clinician were to "use the device" then the numbers would be "mixed" and "abnormal" thus leaving the clinician with the same issue you were trying to reslove wiht info from the device.....Not all Pulmonary edema is cardiogenic, not all wheezing is COPD/chronic resp dx related, etc ..... F.) It was studied as much or more so in the "primary care" environment as it was acute care and the majority of times "seemed" to have been used on "stable" patient's as opposed to "Acute/emergent" ones. G.) I am leery of any device that has a relative sensitivity of a mere 63%, as a end all be all of a ceratin therepeutic measure Now lets cover "pre-hospital" arena and issues there: A.) Because I just mentioned it above see the issue from "E" B.) Device size and time to apply C.) How sensitive is the device and noting that you have approx 6 "electrodes" to obtain your "measures" how much artifact are you likely to experience D.) Cost and Size E.) Most prehospital providers haven't been educated to understand SVR, TFI, etc....so educational time and costs of the target population. as you I am sure noted by "browsing" the forums here education/trianing or lack there of is a big issue for "us" right now. F.) To go with the artifact issue how often does/would the device need to be calibrated, and how susceptible/sensitive is it to a harsh environment G.) In the street we don't have access to that all to valuable baseline info which will be critical to our decision making as far as patient treatment. This is one thing which the hospital has always had the benifit of which we don't have access to. In the ED or the hospital they can get old Mr's, and info as well as talk to the patient's PCP to get valuable info which will effect the ability of the clinician to be able to decide what is acute an what is not... this could also be a major factor in the effectiveness of this device "in the street" This is just a few of the things that I encountered while reading the literature and your posts which made me go HMMMMM..... Hope this helps, Ace844

Hi, Also, RI Hosp regularly runs this class as well as occassionally it is held at MHRI in Pawt. Send me a PM and I will give you a POC for those....Hope this helps, Ace844

"Richard," To keep it short. Diabetics are among the "highest at risk group" to suffer/experience "Silent or atypical presentation" MI's. It has to do with the neuropathy the suffer as a result of their disease, as well as the "vague" somatic dermatome/proprioception of the thoracic area... If there is alot of interest in "silent MI" here. I'll start another topic so as not to "hijack" this one.. Hope this helps, Ace844

"Buddy", Out of curiosity, do you work in the Field" at all? Do you work for this company? What level of funding/support did this corporation provide for these studies..? I have a few more ?'s, but I'll hold them until after you answer...Thanks in advance, Ace844

I had the same issue as "rid," even the copy paste thing didn't work.... out here, Ace844

I've seen both sides of this, unfortunately as has been posted in this thread ad nauseaum, one is more prevalent than the other....Like what you say here as a good example and alot like what I posted, I posted my statement the way I did due to the fact that I was both trying to make my point obvious, and trying to limit litigous/slanderous risk....This was more a case of a few bad apples in that particular system casting a cloud over the rest of the competent professional providers there. I'm quite sure that you experience the same thing in NYC... Also, I have heard that FDNY doesn't even caryy BGL machines, this is admittedly anecdotal and second hand though from a source I trust. As for me, I don't work in that particular system, and I don't compromise my morals, or patient care standards, for anyone period...Furthermore, if you were new here I wouldn't have said I was necessarily owed an apology, but you have been here long enough to have seen my posts and been able to better judge them, thus you should know I don't make a habit of I didn't "look up" or research your medic program and sounds quite similar to my own. I wasn't "thumbing my nose either", I suspected that since few programs have a cirricular similar to my own, that it was unlikely that you recieved as extensive a training regimen as I have. Yes that is abit self-serving and a general prejudiced statement, but unfortunately overall abit factual. I am essentially treated like a resident in my clinical rotations, so I know first hand what you speak of. My program also has a very good reputation and has put out a number of highly skilled professional medics as well. As for the "accrediation"part I posted that earlier. We started with 11 and will be "graduating" 4. But alas this isn't a discussion about P programs... out here, Ace844

No problem, you're welcome "Ruff," this wasn't a personal attack, more a fact of the teaching point that one shouldn't use them in isolated hip Fx...I make mistakes all the time and would rather they be "pointed out " constructively and objectively so I can learn rather than find out the "hard way"!! out here, Ace844

"flightmedic608," So you don't advocate the use of MAST in the situation you describe in this post...correct..?? out here, Ace844

"DustDevil @ flightmedic608," Sounds like we agree as well. If you notice the only part which seems to be different is the MAST/PASG part. Please read below. My contention for "Jim" when I say that MAST would be unlikely to be placed is not due to the fact that it isn't indicated or a good use in this case as I agree with you statement above.... However, it has been my experience that MAST application would be UNLIKELY in this case because of the following factors, and outside the setting of a rural or prolonged transport setting: A.) Most services don't use the MAST a great deal, and thus it will take precious additional time in applying them "with unpracticed lack of ease", and even more likely, reapplying/readjusting a few times B.) Most services because they are rarely used store them in the ambulance an inconveinently accessible place. C.) The crew most likely "going into the call" unless MAST was specifically requested by a FR or other crew, etc... Wouldn't likely take them with all of their other equipment when they go to eval this patient. So it is my contention that the combination of all of these factors can make for a significant and potentially lifethreatening M@M increase for this patient, allowing the benefit of it's application to be mitigated..... I mean really think about it. If you only have a 10-15 min tx time to a level 1 center, why would one potentially add 10-15 minutes additional on a scene to apply the MAST (It may take that long because as mentioned it's probably been awhile since you've used them...)?!?!?!!? Furthermore, wouldn't that 10-15 min be best spent getting this patient to an ER/OR and a place where more definitve/surgical care could be done, in some centers this patient may be brought to "the OR" quite rapidly. Lastly, I gave this advice because we all complain about how inaccurate these TV shows/Movies are when they portray us and our actions!! now here "jim's" giving us a legitimate chance to possibly change that at least once!!!!! Hope this helps, Ace844

You're Welcome, anytime...

"ER Doc," I don't believe there is a concreete "reliable" way like your thinking to tell the difference. I find for me H@P makes the biggest difference pre-hospital. In the setting of shock, gross hematuria, global pelvic crepitus, open book sx's you described, or rocking/pelvic loading creates gross crepital sounds/feelings I err on the side of Pelvic Fx. In isolated lower extremitiy trauma with shortening/rotation, etc...I tend to go with Hip Fx. and treat that. As you mentioned in your previous post, at this time there is no widespread EMS radiology services available to us. My big concern is that someone who is just starting will read "ruff's @ MedicRn's posts" and apply MAST on a Hip Fx patient improperly (READ-THIS SHOULD NOT BE HAPPENING AT ALL, AND CERTAINLY not to splinting pressure, and on a hip RATHER THAN PELVIS FX) and think its ok and run into problems....As this is not an indicated usage as I'm sure you'll agree and have above. If someone can produce evidenced based literature that shows MAST use in HIP FRACTURES works and is efficacious....I'm all ears....."RUFF@MedicRN, be careful if you are doing this in your practice as you can see even our resident "ER Doc" agrees and states this; "There's no purpose to use them in HIP fxs," food for thought. out here, Ace844

"ER Doc," With all respect, I said that an indicated use was for a pelvic FX as I stated when I said this; I was against it's use in an isolated hip Fx as posted by "medic RN", and "Ruffems", as further evidenced by "Ruffs" statement of and "Medic Rn's" statement of As far as your starement of My statement of "contraindication" applied to an (open Hip-read-upper femur/femoral head FX) as evidenced by my statement of To repeat I think MAST is a great tool for the use of stabilizing the pelvis, and bilat/severe lower ext trauma....I guess I am abit confused with your contention with my post "ER DOC" as we agree..... out here, Ace844

"Jim,: I see your in LA, you could always try to get ahold of some of the county/city paramedics there, especially the south central kind, as I am sure they are quite fimiliar and have lots of practical experience dealing with the injuries your looking for info on as well as knowing the local prcatice parameters/protocols. There are even 1 or 2 here, but they don't seem to post that much... Hope this helps, Ace844

I understand both the phys, and what you meant, you obviously misunderstood the context....They provide no benefit to the patient, and have a larger amount of risk, also few instituions/providers are comfortable and or familiar enough to feel comfortable using them. If one were to take your advise in todays current practice environment...Well I say to you...GOOD LUCK B/C YOUR GONNA NEED IT... Please reread my previous post and or the literature, any ?'s feel free to ask. I'm always willing to help...Conversely feel fre to post any literature and evidence that i am wrong with my information and I will gladly stand corrected. We all learn everyday in this business and when we think we don't it's time to stop, IMHLO, just my .001. Out here, Ace844

"Medic RN," I've been doing this for awhile myself...I'm not new either....I was taught all about MAST in both my basic and medic programs. I have applied them myself in pre-hospital practice, so i hardly think that you're assertion that I am clueless because Well guess what, you're not the only one with experience who posts here.... Usually MAST is most often used "at splinting pressures" for A) an unstable pelvis B.) severe Bilat lower extermity trauma C.) any combination of A and B D.)Traumatic arrest . I Find it hard to justify under the circustances of a hip Fx (UNLESS IT WERE SO BAD AS TO BECOME OPEN, which would contrindicate their use anyway...) the use of MAST/PASG, and frankly I think if you ask the docs that are your Medical contol they'll agree with me. Most Hip Fx's aren't severe and or with enough hemodynamic compromise to require their use. Even at your asserted "splinting pressures"..As a nurse you have to see hip Fx's ALOT in the ER, so you of all people should know better. Furthermore I think that there would be an evengreater possibility that the ER you would be transporting to would both ? your decision to use MAST in this case, and probably try to pursue soem kind of corrective training/reprimand. Also, if you truely doubt me, go ahead and ask an Orthopeadic surgeon, if he thinks MAST is a good idea. I'm sure they will look at you "Funny", make an offhanded albeit polite remark and walkaway to later tell the story about that "medicRN" who wants to use MAST on hip Fx's because he's "old school" and "Protocol" says....... In short MAST/PASG outside of a narrow range of therepeutic/treatment uses are THE WORK OF THE DEVIL, They cause harm, and even in some cases in crease injury related morbidity. this stuff is Right up there with that telephone hot line, ASK A NURSE!!!! :) ahhahaaha, LOL!!! out here, Ace844

"jim", A patient suffering an injury like the one you describe is unlikely to be placed in MAST pant's for treatment. But, I do agree with the advice of speaking with someone in your area about local protocols as they vary across the nation. Also, I think it'd be unlikely that some one would use hemostats to "clamp" an artery in the leg (outside of the hospital, and get away with it, as they'd most likely have to "go fishing in the wound" to do so). I think more than likely you'll find someone watched "Black Hawk Down" a few to many time and is trying to be a "cowboy" in their pre-hospital practice. More than likely if this person did this they would no longer be practicing for very long afterwards...hopefully !!! The treatment is expose, look for the exit wound, dress and bandage, use direct pressure, and elevate to the extent possible, estyavlish 2 large bore IV's and fluid resus. as needed, monitor, O2, and depending on the path of the missile spinal immobilization, followed by rapid transport to an ER and shortly there after an OR. Hope this helps, Ace844