Making Sense of Shock
This month, a clinical review article by Adam Fox, DPM, DO, on hemorrhagic shock (“Shock Sense: Detecting & correcting hemorrhagic shock in trauma,” April JEMS) brought up some differing opinions among readers regarding shock management, definitions, assessments and treatment.
Good intentions notwithstanding, the article’s scenario and sequence of management therein is mistaken and even dangerous both for the rationale and the order of treatment. Somehow, although the bulk of the article is given to discussing the latest theories of hemorrhagic shock management, the scenario’s actual order of treatment directly contradicts the article’s learning objectives.
The article, by being featured in JEMS, a premier source of information for many EMS professionals, is bolstered in its apparent validity. And for those readers who rely on the typically academic, but potentially misleading measure of validity, (i.e., the number of references cited), let’s just say that many of them are listed without contributing useful information.
The treatments the article appears to endorse, summarized below, follow a sequence I can only describe as backward: perform rapid sequence intubation (RSI), and intubate the patient; establish two large-bore IVs; apply compression dressing; administer fluids and tourniquet (partial).
The underlying problem stems from the resolute adherence to an “ABC,” which seems to advocate the action sequence of providers who follow alphabetical order better than thinking, and who, as a result, may do more harm than good because the cause and effect of the patient’s condition isn’t understood.
Although the article describes a hypothetical scenario, I’ve witnessed the results of work performed by efficient sounding and mnemonic-heavy paramedics who are otherwise uncomprehending. Acronyms and mnemonics are useful in helping one to recall critical steps while under stress, but the benefits are also limited and
I originally brought this article to Tony’s attention specifically because the scenario was so atrocious … I also sent it to my students at the same time with the same purpose, i.e. “don’t do this” in mind. It brings to mind the completely useless scenarios I’ve read in paramedic textbooks and sets a horrible example for EMTs, paramedic students and paramedics. Although we all acknowledge that JEMS is not a peer-reviewed research journal, it does, as possibly the most widely read resource for EMS, have a responsibility to its readers to present responsible and accurate information that is as up-to-date as possible. It this case, it seems to have fallen short of that mark in all the ways Tony pointed out.
Author Adam Fox, DPM, DO, responds: I want to respond to comments about my article. Some confusion seems to exist about the nature of my article on hemorrhagic shock. The majority of comments are focused on the case scenario used to introduce the article. Although this may not have been clear, the scenario wasn’t fictitious, but an actual case seen in our trauma bay. It was meant to be a jumping off point for the article. The objectives of the article were actually met. However, the following may be helpful in addressing the concerns raised by a few.
The scenario was kept vague for the very reason that this wasn’t meant to be the focus of the article. For instance, it was intentionally not mentioned how many providers were on scene/transporting the patient, how the patient was intubated, how long the transport time was. Making presumptions about the case that was presented, based on personal bias, is problematic and dilutes the core teaching points that the article makes.
When arriving on the scene of a polytrauma patient who is unresponsive, it’s not appropriate to get sucked into the obvious trauma. Many injuries look worse than they are. There are often many more problems under the surface that can be unrecognized when focusing on the external injury. The reason simple approaches, such as the ABCs, have been advocated is precisely for this reason.
Understanding physiology is important and may drive alterations in the sequence of care, but the majority of times, the provider will be well served by following PHTLS and ATLS guidelines.
There was no specific order (like a cookbook) that was advocated in the case scenario. Everyone recognizes that multiple interventions are frequently needed and sometimes have to be triaged for importance. This scenario wasn’t trying to do that. Additionally, the vagueness of the scenario didn’t tell you that there were multiple providers performing these interventions simultaneously. The article actually goes on to say one should “immediately initiate hemorrhage control.”
Nowhere does it say that the patient had a rapid sequence intubation. Assuming so is fairly bold and isn’t used in all situations. The patient was noted to be obtunded but breathing. Contrary to suggestions elsewhere, intubating this patient will not take away a neuro exam. An obtunded patient is just that, obtunded.
Not all EMS agencies are using tourniquets. As mentioned in the body of the article, it has only recently come back into vogue. It requires training and thought to apply it early in a scenario, but just because it wasn’t placed early on doesn’t mean it can’t be applied later.
Recommendations still exist to infuse crystalloid fluid in the shock patient. As the article describes, there’s a trend toward hypotensive resuscitation. But referenced in the article is that this has essentially only been studied in penetrating trauma patients. Wholesale application of this concept, although logical, hasn’t been studied.
Finally, a word about references. They’re necessary to provide access to sources provided in any piece of literature. Counting the number of references is beside the point, and the real measure should be the type of article cited and the impact factor of the journal it was taken from. Those who may not frequently review literature may be surprised to learn that scholarly articles aren’t published every month on every topic. In fact, there may very well be a paucity of literature on topics that would normally be thought of as common.
Every article referenced in the shock piece was meant to reinforce a point being made in the article, and they were used to provide a broad perspective for those who will actually look up the articles and not just count them.
Adam Fox, DO, DPM, is an assistant professor of surgery and the associate director of trauma at Penn State Milton S. Hershey Medical Center. He serves on the JEMS Editorial Board and spent 10 years as a New York State AEMT-CC.
Our service installed the accelerometer cameras and adopted a policy that if you are seen even looking at your cell phone while behind the wheel of a moving or en route vehicle, it’s immediate termination, no questions asked. Sounds a bit extreme, but I feel safer in my rig because of it. Also, our maintenance guys tell me that since the installation of those cameras, we get two to three times the mileage out of our brakes!
I failed the lap test while still in park (reaching for a mic that fell)! That was a cold, wet lap winters’ day. I also think putting someone on the cot, hot beverage in hand and driving them around is a great teaching tool. They will know how a patient feels with bad driving.
In “A Whirlwind Response” in the May 2011 issue, we incorrectly stated the year as 2001. It should be 2011. We apologize for the error. JEMS
This article originally appeared in June 2011 JEMS as “Letters.”