Investigated Because They Did Not Start The I.V. Enroute To Hospital

[BushyFromOz]

i love the fact then when we start bitching about "delaying transport" to a trauma centre that there is only ever an inference on the IV. For example, you have never seen anyone say "You delayed transport of major trauma patient to put a c-collar on?!!" or a pelvic splint or provide pain relief for their extruciating injuries.

Where is the attention to wholistic patient management?? Where is the attention to time management of the whole case from start to finish?

Why do we instatly go "you fucked up" instead of "Good work guys, that was a tough job", and the criticism is only ever based a what amounts to a few seconds in time over the sometimes hours of a single case.

BEorP, i think your being a bit black v white here man.

[systemet]

It does not specifically say what the charges are here- negligence, malpractice, etc.

I think it's a fatalities inquiry. So it's not a criminal proceeding, but the judge has the power to make findings and recommendations for changes that might be useful in preventing a similar case in the future. As I understand it, the information given at the inquiry can be used in criminal or civil proceedings at a later date, and pretty much any member of the public can come and ask questions to anyone called to give evidence. But some of these rules may vary by province. I'm not very familiar with this, so someone else might have better information.

Prehospital IVs in trauma patients don't save lives. This type of patient is why the OPALS study showed that severe trauma patients treated by ACPs (likely getting IVs) had worse outcomes than patients treated by providers not certified in IV therapy.

I agree with the spirit of this. I just wanted to point out that the OPALS Major Trauma Study only showed a difference in a high risk subgroup of patients with GCS < 9 (60.1% v. 51.2%; p = 0.03), and the issue identified was intubation (adjusted OR 2.8, 95% CI 1.6–5.0 -- i.e. patients were 2.8x more likely to die if intubation was attempted), whereas IV therapy had no measurable effect (adjusted OR 0.8, 95% CI 0.4–1.4)

Much of this study suffers from similar problems to the San Diego RSI trial, with historical controls, etc. But what's interesting here is this group was reporting a fairly respectable 94% intubation success rate in cardiac arrest, but in this study with trauma patients, only intubated 71.8%. This might speak to lack of an RSI protocol in this region.

We need to put the 'never start an IV before rolling' with the Golden Hour and the Platinum 10 as absolutes that have no real place in intelligent patient care. In my opinion of course.

I also agree with this. Most blunt trauma patients are non-surgical, or at least, aren't going to necessarily benefit from rapid OR intervention. The rapid transport concept makes more more sense when you have someone with penetrating trauma to the torso who needs immediate damage control surgery.

I'm not saying these guys necessarily did the right thing. I think it would be optimal to start the IV en route, but maybe as Dwayne, and other pointed out, it wasn't possible given the situation.

Ultimately, the doc quoted here is going on the record to say that he is backing the medics in question. If there were a question or concern on behalf of this doc the tone of this article would be very different.

I think it's great that he took that stance. There's no doubt that ER physicians are experts when it comes to emergency medicine, but I've seen too many situations where they've questioned or criticised decisions made by field providers in environments they have no or little experience with, e.g. MCI triage.

[BEorP]

Agreed about delaying transport for an IV being flat out wrong- unless there were extenuating circumstances as I mentioned above, but I find it impossible to believe that this in any way contributed to the death of this patient. The docs even agreed this patient's outcome was not affected by their actions.

I agree as well that this patient's outcome wasn't likely affected (going to have to trust the docs on that...), but if you had a large number of similar patients and delayed transport to start an IV, less of them would survive. So I would say that it wouldn't have saved this girl to get to the hospital three minutes earlier, but it would have saved some.

Agreed about delaying transport for an IV being flat out wrong- unless there were extenuating circumstances as I mentioned above, but I find it impossible to believe that this in any way contributed to the death of this patient. The docs even agreed this patient's outcome was not affected by their actions.

I agree as well that this patient's outcome wasn't likely affected (going to have to trust the docs on that...), but if you had a large number of similar patients and delayed transport to start an IV, less of them would survive. So I would say that it wouldn't have saved this girl to get to the hospital three minutes earlier, but it would have saved some.

So are you suggesting then that fighting with and sitting on this combative patient until the ambulance was rolling, instead of sedating, (Theoretical case of course, and assuming worst case, no IN drugs.) is a more realistic approach? As she soon died from her injuries I have a hard time believing that this could be considered 'doing no harm', right?

Actually I think we need to define 'delaying transport' as I don't believe that transport would be delayed if it was not realistic to actually get the patient into the ambulance. An extremely combative trauma patient is not so different from one that's entrapped as I doubt that you will do much less damage by continuing fight with them then you would by simply ripping many traumas out of their entrapments.

It's not your general argument that I have an issue with but the absolute statement. I've heard of that study, but haven't read it on my own, which I would need to do as most every study of it's type that I have ever been exposed to has been heavily flawed.

But even so I'm willing to bet, and you can help me out as it seems that you have read it, that their conclusion wasn't 'There is never a need to begin an IV prior to transport as no trauma patient has ever been helped via that intervention."

We need to put the 'never start an IV before rolling' with the Golden Hour and the Platinum 10 as absolutes that have no real place in intelligent patient care. In my opinion of course.

Dwayne

Thanks for bringing up the important point of defining, "delaying transport." To me, this means that you're ready to go, but you sit on scene to start the line (likely with the patient already loaded in the truck). If the patient is trapped and you start a line, then transport was not delayed. If the patient was so combative you could not transport them without sedation, then you did not delay transport either.

Certainly there may be a subset of trauma patients who could benefit from an IV even if it delays transport, while the majority would not. It would be silly to think that we're able to pick out the ones who can benefit though. It surely can't be as easy as picking out the hypotensive ones. (Unless you are so confident in your skills that you know someones BP, SpO2, and ICP just by looking at them... see other thread.)

So without knowing who might benefit if there is this small subset of patients, I wouldn't delay on scene for an IV in a serious trauma patient.

Edited December 20, 2011 by BEorP

[romneyfor2012]

In one accounting, I read that she was not trapped, but it took them several minutes to get across the icey road and into the truck. It also claimed that the patient became combative at some point.

[Just Plain Ruff]

We are missing the biggest point here. The doctor said this.

If those factors hadn't come in to play, Dreyer said, the ambulance may have arrived at Welland three to five minutes earlier.

3-5 minutes earlier. My reading of this is that they only delayed transport for a minimal time to start the IV.

3-5 minutes in my opinion will not make the difference in survivability.

Plus the findings of the doctors was that the patient suffered catastrophic injuries and would not have survived even if she was taken to one of the trauma centers listed in the article.

So the question is, did the delay cause patient harm?

I find according to the article that it most likely did not.

I also think that in order to restrain her or do what they needed to sedate her that I would have probably stayed on scene for a few minutes to do it right rather than down a icy road where everyone on this site knows that icy roads DO NOT make good rides.

[DwayneEMTP]

I agree that in this patient that it almost certainly did no harm...

But If I was BEorP what I would be reading here is, "It's close enough to zero difference, and this situation almost never happens, so what difference does it make?" As I know you all, I know that that isn't what you're saying, but that's how it could be read I think.

While the point I get from him is, "Leave for the hospital if you can, as the 3-5 minutes 'might' make a difference, and sometimes catching all of the 'mights' can add up to a significant difference." And man, I get this completely.

I once stayed on scene with a medical patient trying to get his sats up above 50%, convinced that if I could just get some friggin' air into him I could make him stronger before moving him...I won't go into detail but I had terrible compliance to bagging so made multiple nasal intubation attempts, chest decompression, etc, on scene. He went into cardiac arrest enroute.

The problem arose when I looked at my timeline while at the hospital. When I considered my scene time it turned out that he would have been at the hospital, though not really much of a hospital, 5-10 minutes before he arrested had I just bagged, scooped and ran.

I told the doc, "You know what doc, I totally fucked this one up. I would have been here 10 mins ago if I'd just scooped and run. I don't know what that means for him, or for me, but I'm not going to cry over whatever beating that I've got coming."

He said, "It meant nothing to him, but yeah, you fucked this one up. Next time make better decisions." I said, "What would the better decision have been here?" He said, "Obviously to bag and run, right? Look at your timeline. But I probably would have decompressed and tried to intubate before leaving." and then walked away. I remember standing there thinking, "So what does that mean!! What should I do next time??"

With my timeline as a guide I wish I would have just run to the hospital. Without hindsight I know I would have always hated the fact that I transported him for 15-20 minutes with his sats in the 50's. I was confident that if I didn't get some O's into him before moving that I would be running an arrest in the back on my own, so didn't think of doing these things on the way. I think the doc was telling me, "Sometimes medicine sucks. Get used to it yet still make better decisions on very call." Which I try and do, with varying success.

Turned out that he had a big spontaneous pneumo, so the decompression was appropriate, a significant P/E, was end stage lung cancer...etc, etc...

If I could have gotten him ventilating/oxygenating again I believed he would have been hugely improved before we moved him. Unfortunately even if all of my brilliant interventions would have been successful the P/E means that I still wouldn't have achieved my goal. Goddamnit!

I guess my point is that there is always a balance between making our patients strong enough to be moved, and to travel if we can without denying them access to the really smart people as soon as possible. I really, really wish I had a machine for that decision.

It's a balance that I'm not anywhere near 99% on, even with all of our fancy gadgets....

Dwayne

[HERBIE1]

I agree that in this patient that it almost certainly did no harm...

But If I was BEorP what I would be reading here is, "It's close enough to zero difference, and this situation almost never happens, so what difference does it make?" As I know you all, I know that that isn't what you're saying, but that's how it could be read I think.

While the point I get from him is, "Leave for the hospital if you can, as the 3-5 minutes 'might' make a difference, and sometimes catching all of the 'mights' can add up to a significant difference." And man, I get this completely.

I once stayed on scene with a medical patient trying to get his sats up above 50%, convinced that if I could just get some friggin' air into him I could make him stronger before moving him...I won't go into detail but I had terrible compliance to bagging so made multiple nasal intubation attempts, chest decompression, etc, on scene. He went into cardiac arrest enroute.

The problem arose when I looked at my timeline while at the hospital. When I considered my scene time it turned out that he would have been at the hospital, though not really much of a hospital, 5-10 minutes before he arrested had I just bagged, scooped and ran.

I told the doc, "You know what doc, I totally fucked this one up. I would have been here 10 mins ago if I'd just scooped and run. I don't know what that means for him, or for me, but I'm not going to cry over whatever beating that I've got coming."

He said, "It meant nothing to him, but yeah, you fucked this one up. Next time make better decisions." I said, "What would the better decision have been here?" He said, "Obviously to bag and run, right? Look at your timeline. But I probably would have decompressed and tried to intubate before leaving." and then walked away. I remember standing there thinking, "So what does that mean!! What should I do next time??"

With my timeline as a guide I wish I would have just run to the hospital. Without hindsight I know I would have always hated the fact that I transported him for 15-20 minutes with his sats in the 50's. I was confident that if I didn't get some O's into him before moving that I would be running an arrest in the back on my own, so didn't think of doing these things on the way. I think the doc was telling me, "Sometimes medicine sucks. Get used to it yet still make better decisions on very call." Which I try and do, with varying success.

Turned out that he had a big spontaneous pneumo, so the decompression was appropriate, a significant P/E, was end stage lung cancer...etc, etc...

If I could have gotten him ventilating/oxygenating again I believed he would have been hugely improved before we moved him. Unfortunately even if all of my brilliant interventions would have been successful the P/E means that I still wouldn't have achieved my goal. Goddamnit!

I guess my point is that there is always a balance between making our patients strong enough to be moved, and to travel if we can without denying them access to the really smart people as soon as possible. I really, really wish I had a machine for that decision.

It's a balance that I'm not anywhere near 99% on, even with all of our fancy gadgets....

Dwayne

That's why they call it "practicing" medicine, Dwayne- even though we aren't officially practicing on our own. We make decisions out there, based on our patient, our capabilities, transport time, available resources- and yes, sometimes those decisions don't always work out. It sucks when things go south- sometimes it works out, sometimes not. We do the best we can, and speaking for myself, I learn VOLUMES when things go bad. I think- damn- I will NEVER do that again, or geez- next time I will try this. The problem is, no 2 patients or scenarios are exactly the same, so it's rare we get a true "second chance" with the same parameters.

It's easy to play Monday morning QB, but we simply do the best we can for the patient, and hope for the best.

[DFIB]

My question is this; If the IV was medically nessesary for this patient, is it fair or correct to say that transport was delayed? Or would it be more correct to say that transport was rendered when the nessesary medical procedures were completed in accordance to the evaluation and treatment plan set forth by the medics on the scene.

[CPhT]

My question is this; If the IV was medically nessesary for this patient, is it fair or correct to say that transport was delayed? Or would it be more correct to say that transport was rendered when the nessesary medical procedures were completed in accordance to the evaluation and treatment plan set forth by the medics on the scene.

I think the thing that might come back to haunt them (or it very well may NOT come up, because of the "damned if you do, damned if you don't" response of the ER docs) is your question, or rather an answer to it. It's all about how any other medic would have handled that case. Given the circumstances, if 9 out of 10 medics would have done the IV on scene, there was no deviation from standard of care. Heck, make it 5 out of 10. However, if competent professionals can attest that they would have given the IV en route to the hospital, and that extra 3-4 minutes (am I being too generous with that estimate?) could have saved her life, then that could be deemed as negligence.

Now again, this is Canada, where the legal system makes slightly more sense than here state-side (except for the funny wigs... why Canada? Why the wigs?). In Canada, I would like to think that they would look at the whole picture and say "regardless of when the placed the IV, regardless of standards of care, this patient would have died".

[paramedicmike]

Just because 9/10 medics do something one way doesn't mean that it's the standard of care. It could very easily mean that only 1/10 medics was doing it the right way.