Who can see the future

[Just Plain Ruff]

Yes I do Doc,

Here is the Istat website with a comprehensive list of their tests.

http://www.abbottpointofcare.com/Patient-Care-Settings/Hospital/Emergency-Department.aspx

I would think that an ammonia level test would be beneficial, as well as Troponin,

Others in this link would strictly be used in the ED setting and not valid for EMS work.

One other would be a valid Alcohol level as well as a drugs of abuse test.

I think if I had my choice I would rank them in importance

1. Trop I

2. HGB/HCT

3. Drugs of Abuse

4. Alcohol

5. Ammonia (strictly a routing tool to the appropriate facility - super high ammonia gets a non general hospital but gets a specialty hospital)

6. CMP/BMP

7. Glucose(we already have the machines to do this)

[WolfmanHarris]

What about serum lactate and CBC for sepsis screening and early intervention? I don't know a lot about lab results but that's the first that comes to mind. Could be especially useful in an environment that begins to move away from transporting everyone.

[Just Plain Ruff]

none of the test listed in the link have a CBC as a result so you might not get your wish Wolfman.

But it might be found from a different company, just not Abbott.

Edited December 11, 2012 by Captain ToHellWithItAll

[chbare]

I think the ability to run gasses on intubated patients would be helpful in addition to having the ability to run BMP's to appreciate potentially lethal electrolyte imbalances. I'm not sure I see much use for anything else on a "standard" EMS platform. Even lactate monitoring is not high on the list as many things cause an elevated lactate and many issues such as suspected sepsis complications are going to be managed and identified clinically and I'd still look at fluids and so on regardless of a point of care lactate value.

[ERDoc]

I fully agree with the troponin level. It would definitely have an affect on destination. I would have to disagree with the ammonia level. I don't think it would add much in the prehospital setting. If you have someone with liver disease and they present with encephalopathy you pretty much have the diagnosis nailed. I think a BMP would be great. You could know if you are dealing with a potassium level pretty quick. It is something that can be rapidly fatal and is easily fixed. One issue I can see is overly zealous providers who over use the test. Think of the number of dialysis pts that EMS transports and now throw in a buff with a toy and see how many people who have a normally elevated potassium on a daily basis end up in the ER.

Some of the istats can run a cbc, or at least a hemoglobin and hematocrit. I don't think WBC or lactate will have much use in the field. If you have someone where you are concerned about their WBC and lactate level, you shouldn't be considering not transporting them. I like the alcohol level, drug screens are more interesting than they are useful. I think PT/INR would be good. If you have a pt where you are worried about an intracranial or GI bleed, you could see if they are supratherapeutic and give some Vitamin K (of course you would need to carry the vitamin k).

[jkc]

I'm with wolfman: I think lactate and WBC could be very useful. Not for transport decisions, but there's a lot of literature supporting early sepsis treatment with antibiotics and aggressive fluid replacement. And this is ideally before the patient is hypotensive, so field lactate would be a great indicator along with the rest of the clinical picture before you have significant vital sign changes.

[Just Plain Ruff]

I only threw in the ammonia level due to my friends ammonia level was so high a couple of times and his was missed (nearly fatally twice at a local small town hospital) and having that ammonia level could have directed his transport to a higher level of care than little doc in the box than the level 1 facility that he should have been at to begin with. And of the Istat's none have ammonia so it's a wish list not a requirement.

The drug test one is a good one but you don't have to have it in the field but we in our ER had them at our disposal but they were based on urine not blood so the patient had to either give you a sample or you had to catheterize them (we could do catheters in the field as well).

But I still stand by my list other than the ammonia.

[ERDoc]

I'm going to go off topic here, but in a way it does have to deal with the future and EMS. In regards to the WBC/lactate levels, jkc brings up giving antibiotics in the field. Here in the US, the Center for Medicare/Medicaid Services (CMS) and JCAHO set our core measures. One of the is that we must give antibiotics to pts who are being admitted for pneumonia within 6 hours of hitting the door AND we must have 2 sets of blood cultures from 2 separate sites before the antibiotic are given. Meeting these core measures will determine our payments. How will prehospital antibiotics affect this? I realize there is no correct answer right now, but it's a fun mental masturbation exercise.

EDIT: drug screens are overused. They don't really provide much information that is useful. About the only reason I order them anymore is because the inpatient service or psych facility makes me do it before they will accept a pt. Sometimes it is fun to see what people are on, despite their insistence that they don't know how everything got in their urine.

Edited December 11, 2012 by ERDoc

[WolfmanHarris]

Some of the istats can run a cbc, or at least a hemoglobin and hematocrit. I don't think WBC or lactate will have much use in the field. If you have someone where you are concerned about their WBC and lactate level, you shouldn't be considering not transporting them.

By way of context I was considering a particular patient type when envisioning istat for sepsis coupled with a new program in development where I am. I was thinking of an elderly nursing home patient with advanced directives and patient's stated wishes that they did not wish transport to hospital unless absolutely necessary. They are generally in frail condition and the call if for "generally unwell - failure to thrive. "

The new Community Paramedicine pilot envisions a partnership with the NP service that is currently available during business hours for Nursing Home patients. The goal of this partnership will be to identify 911 patients that can be better treated in their nursing home and can safely wait until the NP visits to continue care. We still know very little about how this will work yet but patients I've considered being ideal for this include skin tears, generally unwell.

My thinking for the lactate and WBC was as part of a thorough sepsis screening to ensure that these patients are identified early. In this context is this a more reasonable test or am I reaching?

[island emt]

We had a big push for us to purchase Lactate monitors last year from the state EMS office. A lot of services did bite the bullet and spent serious money for them.

Well guess what?

The company that sold the monitors is no longer producing them for sale and will only have strips available for a couple of years.

I didn't buy one for our ambulance , as I couldn't see where it was going to affect our treatment or transport decisions based on a given reading.

glad I didn't waste that money!

Now giving us the ability to get a tropinin level in the field would make a difference on decision making of where to transport when used with other data from the 12 lead and history taking.