Should we teach / use the Shock Index?

[chbare]

I am not quite following you Dwayne? I have never said the SI is useless, only asked if people have looked at the literature. It looks as though you have done some searching; however, I do not find the conclusion particularly compelling. It may allow us to raise suspicion but it is highly insensitive and if it is normal, you still cannot rule out or lower your suspicion of major injury. In other words, it may indicate a problem but does not rule out a problem and problems can exist even if it's normal. I am not sure that is what I would call high yield information for an entry level provider.

However, any single number assessed in a vacuum is not going to give you a particularly broad and well focused picture that can be used to make clinical decisions. My problem with focusing on single numbers in a vacuum, especially when it comes to providers with limited educational background, is my fear that they may fall into the trap of making decisions based solely on an isolated value.

[DwayneEMTP]

I am not quite following you Dwayne? I have never said the SI is useless, only asked if people have looked at the literature. It looks as though you have done some searching; however, I do not find the conclusion particularly compelling. It may allow us to raise suspicion but it is highly insensitive and if it is normal, you still cannot rule out or lower your suspicion of major injury. In other words, it may indicate a problem but does not rule out a problem and problems can exist even if it's normal. I am not sure that is what I would call high yield information for an entry level provider.

However, any single number assessed in a vacuum is not going to give you a particularly broad and well focused picture that can be used to make clinical decisions. My problem with focusing on single numbers in a vacuum, especially when it comes to providers with limited educational background, is my fear that they may fall into the trap of making decisions based solely on an isolated value.

Yeah, didn't mean you Chris, as I saw that you'd only asked for evidence of it's validity as a physiological marker. I have no problems with that. Your posts are always worthwhile.

I don't find the above compelling either, but it appears that I'm the only one that searched at all. But despite not finding it, so far, to be a valuable diagnostic device for me, I did find the concept interesting, and the search turned up a lot of things that I hadn't known before. I would have enjoyed the discussion.

More I was addressing the attitude that I perceived in the thread, that I found, and find confusing. What I believe(d) to be the willingness to discount the idea presented without even understanding it, giving it a value of X, and then state than another thing has more value. My Idea is greater than X, though X was never defined. See what I mean?

I don't know man..I'm getting older, and maybe crankier, certainly dumber, but it seems, and perhaps this is just my rose colored glasses coming into play, that we used to give a persons' thread some respect and attempt to explore the idea that they found interesting, or choose not to participate. Now it seems that a blase' "Whatever..this is what I've heard" is more the norm. Where did the hunger to explore, to debate, the need to jump on board with a contrary opinion simply to see where thinking differently might take you, go?

It seems that only the average Joe is really welcome here lately. If you're new there are to many that can't wait to say, "Ha! You're an idiot!" and they're gone. If they're posts are above average, as I believe this posters often to be, there seems to be an attitude of, "Don't bring your uppity shit here. We're really not impressed." and they're gone.

Or maybe it was always this way and I'm just remembering it wrong.

Anyway, speaking of disrespect for someone's thread...my apologies for derailing this one. I'll continue this in another thread...

Dwayne

[Bieber]

Dwayne, you caught me. I admit I didn't do any in depth research on the subject. I recall SI briefly from having read about it before, but it's been a while and I should have done a little bit more research before coming to any solid conclusions. I'll do some more reading on it tonight. My bad for dropping the ball on it.

Here's some links I quickly found regarding SI:

http://www.ahcmedia.com/emreports/pearls/pearls27.htm

http://www.ferne.org/Lectures/2008_research_lecture/pubpdf/DCLHb_saem01_shock_index_newformat.pdf

http://journals.lww.com/euro-emergencymed/Abstract/2011/04000/The_utility_of_shock_index_in_differentiating.8.aspx

http://www.ncbi.nlm.nih.gov/pubmed/8922013

http://www.annemergmed.com/article/S0196-0644(94)70279-9/abstract

It looks like, from what I'm reading, that while a low SI is too insensitive to rule out anything, an elevated SI can be associated with serious illness.

[DwayneEMTP]

No worries Beibs...I just really want to figure out why it's happening.

I think part of it is that you, Matty, Josh and a bunch of other really strong posters stopped posting. Not sure, but you all were certainly good, positive catalysts for the threads...

We'll work on it. Every time I come up with one of these beefs I end up finding out that I was often the worst offender...

[Steve Whitehead]

Thanks for all the input everyone. There are a bunch of really good observations here. I'm surprised to see that the shock index appears to be relatively unknown to this group. I'd never heard of it before I encountered it recently. I'm still on the fence about using it as a teaching tool. I think most fo the folks who are advising not to teach it seem to infer that I'd teach it as an actual assessment tool to be calculated and used in the clinical setting. That's not my intention. Actually, that's the one big minus I referenced in the original post. I don't want EMT's thinking they should calculate this on the fly. I'm still wondering if the concept has merit to try to illustrate that vital signs don't live in a compartment. They are associated with each other and the rest of the assessment.

And every patient assessment needs to be considered in the context of that patient and the rest of the exam. This is a really difficult concept to teach new EMTs.

Once upon a time I thought the Glasgow was crap. Unitll I started teaching it. I teach it regularly. For new EMT students it is a great was to explain the different elements that need to be considered when assessing the patients responsiveness and how significant they should consider different levels of responsiveness. It also has fairly good predictive value for multi-system trauma mortality as well as the need for advanced airway intervention. Having said that, I never calculate it in the middle of patient care. I assess and I act. I don't teach my students to calculate it in the midst of patient assessment. It's just not appropriate. But to a new EMT learning how to figure out what it means when the patient doesn't respond normally, it has tremendous value.

Someone said it was crap because they had never heard of it. There are plenty of valuable assessment tools that I've not yet heard of. I haven't reached a point in my career where I consider my absence of awareness of a technique or concept as evidence of its uselessness. That's why when I heard about this I decided to explore it instead of reject it. I've learned a lot of great stuff over the years by being honest about my own knowledge shortcomings.

I agree that a single vital sign like blood pressure cannot be used as a definitive sign of shock (or any other abnormality). That's the exact reason I kinda like this concept. It's simple, but it shows the association between to major vital signs. I also think it would have greater predictive value for shock states that are blunted by pharmacology. For our beta blocker patients I suspect that the shock index would rise as they entered decompensated shock even in the presence of a normal heart rate. For our patients on multiple anti-hypertensives like ACE Inhibitors, I think this dynamic might still play out.

I'm wondering if we should teach the shock index as a concept for the very reasons your saying it's worthless. I agree that tracking any single vital sign is worthless. That's the exact reason I like this concept.

[Bieber]

Thanks for sharing this with us, Steve, and thanks again to Dwayne for kicking some sense into me. Does anyone know how much (if at all) the shock index is used in their local ER's and hospitals? I'll try to remember to ask about it when I go back to work after my vacation, next time we're up at the hospitals.

Ultimately, like you said, Steve, there's no single diagnostic test or assessment that can give us the full picture when it comes to assessing our patients. Utilizing as many tools as we have available to us to try and paint a picture of what's going on is only going to benefit us, so long as the science is strong.

[mobey]

"Conclusion: The SI can be a valuable tool, raising suspicion when it is abnormal even when other parameters are not, but is far too insensitive for use as a screening device to rule out disease. A normal SI should not lower the suspicion of major injury." (Journal of European Emergency Medicine, 2011)

http://journals.lww....ntiating.8.aspx

A Google search seemed to show that though no one here finds any value in it that physician level medicine seemed to take it at least halfway seriously for more than a little while.

I'm surprised, particularly in this group, that so many were willing to say "I don't really get it, but I'm willing to say that it's no good, particularly when compared to X." "I don't really know how Amiodarone works, but Lido is sure as hell a better option, I'll tell you that."

If you don't understand an idea, one that I've found listed on many physician level sites and in many scientific journals, how then do you decide it's relative prehospital value and then even compare it to something else?

I long for the days at the City where this idea would have had the entire thread trying to figure out why it might work, and/or intelligently proving and explaining exactly why it might not work instead of saying, "Meh...It's probably nothing..." Or at least understanding it enough to be able to intelligently compare it to something else. My guess would be that in most cases of 'the unknown v. the familiar' that familiar is a hands down winner.

I'm curious, to those that claimed that MAP is a more valuable tool, without Googling, can you explain the value that some have attributed to SI, and in what areas they have found it? What are the relative strengths and weaknesses that were discovered in those areas? And if you can't do so, how can you make an intelligent comparison to MAP, or anything else for that matter?

I do believe the message of my post may have got lost in the breif delivery.

I was responding to the question "Should we teach SI to EMT-Bs?"

I am not saying MAP is better as a general rule, I don't know that because I have not reviewed the literature comparatively. However, for the EMT-B curriculum my opinion remains the same, I believe MAP is better for a basic to use as a diagnostic tool. Not only is it readily available when using a LP 12-15, but it is "universal" language. Just look at how many here have never heard of SI, vs MAP. Perhaps SI will be the new upcoming measurement to replace MAP in trauma patients, but should that start with EMT-B's in the USA? Prolly not.

More I was addressing the attitude that I perceived in the thread, that I found, and find confusing. What I believe(d) to be the willingness to discount the idea presented without even understanding it, giving it a value of X, and then state than another thing has more value. My Idea is greater than X, though X was never defined. See what I mean?

It seems that only the average Joe is really welcome here lately. If you're new there are to many that can't wait to say, "Ha! You're an idiot!" and they're gone. If they're posts are above average, as I believe this posters often to be, there seems to be an attitude of, "Don't bring your uppity shit here. We're really not impressed." and they're gone.

I dunno..... I have not intentionally opressed anyone here since crotchitymedic (see the thin line there?)

Anyway, if Steve feels stepped on, I am sure he would stand up for himself and tell us to shut the F up, in an eloquent professional manner.

I suspect you may be having a bad hairday?

[Steve Whitehead]

I agree that MAP has great assessment value. I've shied away from teaching it at the EMT level because of the complexity of the calculation itself. But (if I could get over that hurdle without eating up too much class time) it may be a better concept.

Regarding perfusion being a simple concept, many of the concepts that we teach at the EMT level are simple, yet we still need to teach them, just like someone needed to teach it to you. I think it's valid to consider how best to teach these concepts, regardless of how "simple" they may be now.

Regarding getting stepped on...hummm. I think there are some folks on the city who are prepared to give good, cogent feedback that is useful and helpful. And there are some folks who are...less prepared to do so. I feel like I can pick the good stuff out. You do have to come to a forum with thick skin for sure. My time is limited and I'd prefer to not invest too much time in the folks who aren't here for the community.

[Asysin2leads]

I really think the best approach in EMT class is to teach the early, warning signs of shock, the later signs, and what the appropriate course of action is. EMTs should be like scouts, IMHO. They should be the first line who gets there, and make a general assessment, and then either call in or cancel more intensive resources. I think the best approach is clear, simple concepts, that can be remembered by the newest of EMTs, in the dark, in the rain, etc. I think the best skill an EMT can have is when to call for the calvary and when not to.

[croaker260]

But Kiwi, the question wasn't only whether or not it should be taught as a diagnostic aid, but if it should be taught as an adjunct teaching aid to help clarify other more complex issues of perfusion at the EMT level.

Why are you guys so quick to say that this is shit? It's an intelligent question presented in a respectful intelligent manner...Perhaps in your infinite wisdom maybe you can explain from a physiologic perfusion point of view why it makes no sense?

Maybe I'm just getting City burnout, but these kinds of posts are really starting to piss me off...

But I guess if it's not going to change treatment, then it can't possibly have any value...or have you maybe spent a shitload of time battling that ridiculous statement in the past?

Amen !

Dwayne had another good point, what is the research behind it, and how does it correspond to predict mortality/morbidity, or with other interventions. If it has a verified validity (such as MOI did before cars got on the "safety bandwagon"...damn engineers ) then I think it may indeed be useful in triage. Especially with the growing concern behind prehospital recognition of septic shock and triage of same patients to specialty center.....

It also may be a good approach/concept to incorporate into at least the new AEMT , the old EMT-I. Perhaps even tot he EMT level depending on hours.

SO, not "shit" at all. Just curious on the research.