We’ve seen some remarkable changes in the way EMS is provided around the country since its inception more than 50 years ago. We’ve gone from rudimentary first aid skills and rushing every patient to the hospital, to an expanded scope of practice that includes numerous treatment modalities and drugs, coupled with triaged response and selective, cautious transport.
But we haven’t always relied on science and evidence to make our decisions about new devices or protocols. Until recently, we’ve demonstrated a propensity to grab on to the latest gizmo or newest treatment fad based solely on assumptions. That’s changing.
Medical research now tells us that few 9–1–1 calls require a rapid response with emergency lights and siren, and even fewer need quick transport to a hospital. For cases that do, time is as critical a factor to the patient’s outcome as receiving the correct treatment and definitive care at the appropriate hospital. ST-elevation myocardial infarction (STEMI), stroke and severe trauma patients do far better with proper treatment in the field and rapid transport to a hospital that’s prepared to care for them.
In many cases time isn’t the issue, at least as it relates to the patient and the resolution of their medical problem. We can take our time to care for the patient, assess them, treat them and determine their best option for disposition.
Having advanced technology that improves our assessment and our treatment would seem helpful. Ultrasound devices, mobile blood chemistry units and access to patients’ medical records through health information exchanges (HIE), all seem to be beneficial adjuncts to our current armamentarium. Or are they?
Let’s take the ultrasound device. It promises to enhance a paramedic’s ability to identify internal bleeding, fractures, pneumothoracies, even hard-to-find veins for IV access. Is it worth the extra time needed for practitioner training and maintenance as well as the cost to purchase, update and replace? Is it worth the extra time on scene to use on patients we suspect are suffering from serious anomalies?
If we suspect a patient has a pneumothorax, does it improve the majority of patients’ outcomes to withhold thoracentesis while we use the ultrasound to confirm our suspicion? We’d only alter our treatment if we conclusively determine that there’s no pneumothorax. How likely is that, and is it worth the delay to others?
If we encounter an injured patient who otherwise meets the protocol for transport to a trauma center, would we ever actually decide not to transport based on a negative ultrasound scan? The time it would take to do a body scan and the lingering possibility that we missed something lethal would make it prudent to still move the patient with all deliberate speed to a trauma center. All we would’ve done is delay transport.
The only times I can think of when an ultrasound would benefit our practice would be on noncritical patients with vague symptoms or questionable diagnoses. For example, patients who present with minor injuries, who, once we scan, show an internal bleed not yet severe enough to evoke symptomatology indicative of transport to a trauma center. Or, the patient with questionable, nondescript chest pain who’s actually suffering from a pericardial effusion.
I could see ultrasound used as an additional verification tool in specific, less routine cases, such as proper endotracheal tube placement and pronouncement of death. However, for both of these, we have other, less expensive and more definitive mechanisms of determination.
Health Information Exchanges
What about the emerging technology of quickly gaining access to a patient’s medical records on scene? Surely this capability would dramatically aid our ability to treat patients and substantially improve their outcomes. It seems intuitive.
Let’s explore our time-sensitive patients again, this time with connection to HIE systems. How would HIE change how we treat a STEMI, stroke or trauma patient? I don’t think they would alter our care or reduce our need to move quickly.
If we encounter a patient experiencing chest pain and our ECG shows a STEMI, would it matter what their previous medical records said? We’d still treat them according to our system’s STEMI protocol and move them quickly to a catheterization lab.
What about a patient showing symptoms of a stroke? Would anything in their medical records dissuade us from following protocol and transporting them quickly? I don’t think so.
Even in noncritical patients, what’s the practical value of real-time, on-scene access to a patient’s medical records? Consider an unconscious but stable patient. Regardless of their past medical records, we don’t know what caused their current situation. We’d follow our system’s protocols.
Whether their records showed they were or weren’t diabetic, wouldn’t we still perform a blood glucose level (BGL) and administer glucose according to protocols?
I don’t see the value of some of the new technologies being marketed to our industry, to our patients and their outcomes. Let me know what you think in the comments. Tell me when HIE, ultrasound devices, or even blood chemistry units would make a significant difference in how we treat patients and improve their outcomes.