It’s no secret that EMS providers have to be up on the latest medical technologies and conditions. This can be challenging given how quickly things change, and it sometimes might seem better to just ignore it all. However, T. Ryan Mayfield, EMS educator and quality assurance/quality improvement (QA/QI) research specialist for Porter, Littleton, Parker EMS in South Denver Metro, noticed an educational gap in paramedic training that he simply couldn’t ignore.
“There is such a huge gap in effectively identifying patients in septic shock,” he says. “I honestly didn’t know that septic shock was a problem, and there is so little education done on sepsis for EMS. a current paramedic textbook has less than two pages out of 2,000 spent on this topic.”
With the support of his medical director, Mayfield started educating himself and soon realized the enormity of the problem. The mortality rate from septic shock is 50 percent. “So that means that every other patient you see in septic shock is going to die, if they follow the laws of statistics,” Mayfield emphasizes.
“It was unbelievable to me that it was something I didn’t know about,” he says. “I consider myself a pretty good paramedic, and I had no idea.”
Mayfield decided it was time to do something about the lack of EMS education around septic shock.
“I had patients who I thought in the back of my mind were probably septic, but I didn’t have a good understanding of what that actually meant, what that meant to their mortality rate, and what could be done,” he says. “And that’s where this started.”
Looking for Clues
To better understand the seriousness and underlying implications of septic shock, Mayfield began comparing patients with sepsis to those with chest pain to identify commonalities. “I started comparing all the chest pain patients and septic shock patients that came into the hospital, and the numbers were hugely different,” he says. “Most of the chest pain patients would walk out of the emergency department.” But that wasn’t so with the sepsis patients.
Part of the problem with early detection of sepsis, Mayfield discovered, is the lack of a definitive test. When checking for glucose, a properly administered test can definitely point to low blood sugar. But detecting sepsis can take a little more effort.
“It’s a conglomerate of signs, symptoms and vital-sign changes,” Mayfield says. “It can be a little bit sneaky. Patients can be in septic shock and not showing any outward signs of hypoperfusion, so their blood pressure is still fine, but internally they are going into shock.”
He adds that EMS isn’t alone in struggling to identify and treat sepsis. “Every emergency [physician] has those cases where the patient looks fine, and 20 minutes later they are circling the drain,” he says.
Research further indicates elevated lactate levels are an indicator of shock even before vital sign changes are seen and can suggest cryptic sepsis. “They are going into shock, but their vital signs aren’t showing it yet,” he says.
Some in-depth research unearthed an effective and inexpensive lactate meter, which is available in the U.S. and as easy to use as a glucometer. “It was developed for endurance athletes for training,” Mayfield says. “We purchased them through a generous contribution by three of the foundations we work with. We were able to outfit 50 ambulances in the area.”
The meters are easy to use and easy to read. “We take a little blood sample and are able to take a lactate reading to determine if the patient has cryptic sepsis,” Mayfield says.
He also created training materials that paramedics could use out in the field, including a Sepsis Alert Criteria card that outlines the criteria for septic shock.
For instance, the patient must have at least two of the Systemic Inflammatory Response Syndrome (SIRS) criteria, such as a temperature greater than 100.4 degrees Fahrenheit, a pulse greater than 90 and respiratory rate greater than 20. Patients must also have a suspected or documented infection and hypoperfusion. Mayfield also created a simple card that calculates mean arterial pressure.
“We reintroduce the concept of mean arterial pressure because that is something that’s a pretty good application in EMS work,” he says. “Unfortunately, when it’s taught in paramedic school, it’s taught with a formula attached to it that is not easy to do in your head. So I developed a quick reference card to calculate the mean arterial pressure based on the systolic and diastolic [pressure].
We train paramedics on why that is important and then give them this tool to use. It negates the need to do long division in your head at three o’clock in the morning.”
Mayfield’s training had also taught him enough to know that the key to surviving septic shock is early recognition and treatment, and the first treatment modality is fluid.
“Paramedics can be a little afraid to give, say an elderly patient, lots of fluid because they are afraid of sending them into congestive heart failure,” Mayfield says. “So they’ll give them maybe 200 to 500 ccs of fluid, worried that they’re going to overload them. But some of the septic shock patients that we’ve had coming through have received 30 liters of fluid in the first few days.”
Armed with this information, Mayfield developed a two-hour continuing education class on septic shock, and the EMS team he works with taught 900 paramedics and EMTs in 30 days. “This was a group effort to get the education out there,” he says.
The Goal of a Sepsis Alert
If a paramedic in the field suspects a patient of being in septic shock prior to hospital arrival, EMS personnel are taught to start the initial steps of Early Goal-Directed Therapy. This also allows EMS personnel to call a “Sepsis Alert.”
Although many hospitals in the country have in-house sepsis alerts, Mayfield thinks this may be first in the country that allows EMS personnel in the field to call the alert.
“In Early Goal-Directed Therapy, ED staff have things they have to do within a certain window of time, like antibiotics within the first hour of recognition,” says Mayfield. “EMS can start this Early Goal-Directed Therapy to treat septic shock, prior to getting to the emergency department, and the emergency department can carry it on from there.”
The alert is modeled after the successful stroke, trauma and cardiac alert programs. This warning gives emergency departments (EDs) the time to assemble the multidisciplinary staff required to aggressively treat a sepsis patient, improving the odds of providing necessary treatment within the recommended six-hour window.
Mayfield says the three hospitals his department works with share an emergency physician group, which unifies the treatment. The physicians in the program are an experienced and tight-knit doctor group. By the time the patient arrives, the ED is ready for them. “The doctor—and at least one nurse—is there,” says Mayfield. “They have a central line kit and an ultrasound already in the room.”
He adds that they also have a radiology and respiratory therapy response. “By the time the patient arrives, everybody who needs to be there is there,” he says.
Treatment usually begins with lots of fluids. “We also teach paramedics protective ventilation strategies to do less damage to the lungs, if necessary,” he says.
Most published literature supports the belief that the earlier you start treatment on a sepsis patient, the better the outcome, and Mayfield’s program is definitely having an impact. “I think that’s what we’re showing here,” he says. “We are starting before patients even hit the emergency department, and our outcomes are doing very well right now.”
Final numbers are still being collected, but preliminary data shows patients in septic shock with a Sepsis Alert called prior to the arrival at the emergency department have a significantly decreased mortality rate. Additionally, EMS patients with a Sepsis Alert called have shown a decreased length of hospital stay and a decrease in total health-care costs.
Even patients who were not called, but were later discovered in the ED to have sepsis, had a lower mortality because of the education now surrounding septic shock.
“Part of that is heightened awareness because we have been talking about it so much,” Mayfield says. “We’re looking at those patients that were called for septic shock, but also those that EMS should have called, and didn’t, to determine if those who had training didn’t recognize it.”
Although final numbers for the program aren’t expected for a few months, Mayfield and the EMS providers and ED doctors involved in the program already know they have a winner.