Does anyone else see problems with this seemingly poorly vetted April 2011 JEMS article titled Shock Sense: Detecting & correcting hemorrhagic shock in trauma...?

 

Article Scenario (critical treatment steps indicated in order by bracketed numerals and article excerpts are in bold italics):

A prolonged extrication yields a young, female patient, who’s removed by the rescue team on a backboard with a C-collar. Your initial and rapid exam reveals an obtunded but breathing patient with active bleeding from a traumatic amputation of her left lower extremity at the knee level. Her heart rate is in the 140s, with a blood pressure of 110/90 mmHg. [1] You orotracheally intubate her for airway protection due to a diminished level of consciousness and transport her without delay to a trauma center. [2] Two large-bore IV lines are initiated, and a [3] compression dressing is placed over her bleeding stump. After updating the trauma center, you notice the patient’s blood pressure has dropped to 100/90, and your compression dressing has become saturated with blood.  [4] You infuse 1 L of normal saline and apply a new pressure dressing, but it’s becoming clear that this standard approach isn’t going to be effective. [5] You apply a tourniquet at the thigh just a few minutes before arriving at the hospital, significantly reducing the bleeding. On arrival, the patient has a heart rate of 136 and systolic blood pressure (SBP) of 98 mmHg, with a moderately saturated dressing.

 

The rest of the article devolves into a general discussion of shock beginning with Samuel Gross’ 1872 definition of the syndrome.

 

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, though the bulk of the article is given to discussing the latest [usually rediscovered] theories of hemorrhagic shock management, the scenario’s actual order of treatment manages to directly contradict 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 heavily on the typically academic, but potentially misleading measure of validity, i.e. the number of references cited, well let's just say that many references are listed without ever appearing to really contribute useful information to the treatment example posed by the article.

 

The first oversight is with the article's initial and apparently undecided definition of hypovolemic shock:

Key Terms
Hypovolemic shock: A state of physical collapse and prostration caused by massive blood loss, about one-fifth or more of total blood volume.

Types of Shock
Hypovolemic
>> Hemorrhagic
>> Non-hemorrhagic

 

To start off, if no more than to establish consistent and accurate terminology, the term "hypovolemic" refers to a relative low volume, typically of fluid.  This meaning is immediately evident by noting the word’s prefix/root combination.  In the "terms" section of the article, hypovolemic shock is incorrectly defined so as to make it synonymous with hemorrhagic shock.  Later, under “types of shock” hypovolemic shock is now correctly described as the umbrella term for non-specific volume depletion shock and, under it, the shock subcategories are then identified as hemorrhagic or non-hemorrhagic.

 

The treatments the article appears to endorse, summarized below, follow a sequence I can only describe as backward: 

 

1. RSI & intubate the patient

2. Establish two (2) large bore IVs

3. Compression dressing

4. Fluids

5. Tourniquet (partial) 

 

Why is this sequence wrong? 

 

STEP ONE was RSIing a spontaneously breathing, hemorrhaging patient to "secure" the airway before doing anything else. Why?  The patient’s problem isn’t respiratory in nature and the airway is scarcely germane to the immediate crisis.  The patient isn’t described as having ineffective breathing, agonal breathing, gurgling, or otherwise having a valid airway problem.  With RSI, the patient's system was now additionally stressed with body-wide fasciculations from the initial dose of succinylcholine.  After being RSI'd, the paramedics' finest meter of end organ perfusion....mentation...is now taken away.  Intubated, the patient must tolerate positive pressure ventilation (PPV) which, for hypovolemic shock and the accompanying diminished right sided preload, is dangerous.  PPV is well known to reduce preload via its unnatural (we normally breathe using Negative Pressure Ventilation, or NPV) respiratory mechanics. "Securing" the airway has, over the years, come to have a mantra-like meaning of importance but still, it should probably never be the first line of treatment for a patient with life-threatening hemorrhage.  A relevant, inexplicably missing component of this scenario, especially in a publication like JEMS, is mention of capnography.  This is a critical oversight for anyone who performs advanced airway management, let alone RSIs.  If the RSI was performed on a patient in shock, the PETCO2 values could be used by the savvy medic or physician as a meter of the patient's ongoing cardiac output and perfusion status, and perhaps even to help guide resuscitation measures.

 

STEP TWO was to establish venous access using two (2) large bore IVs.  I’m guessing at least one had to be established for the RSI procedure unless the Versed / Ativan / succinylcholine were given IM instead?  While it is difficult to imagine the two large bore IVs would be started without fluids being given immediately thereafter, the scenario defers on this point and goes on to….. 

 

STEP THREE when a compression dressing is [finally?] applied. 

 

STEP FOUR: Belatedly it is realized the compression dressing isn’t working, and blood is still being lost.  In contravention of the very references the article cites, isotonic crystalloids are given in a large bolus despite not having control of the bleeding.  Predictably, the patient worsens and finally in desperation…

 

STEP FIVE a tourniquet is applied.  The bleeding is reduced, though not stopped, so it can be assumed the tourniquet was not arterial.  Fair enough.  Unless one has commercially available tourniquets such as those the military uses, placing a tourniquet correctly is a skill that is taught both rarely and inadequately. In this regard the military has it right: tourniquet application is a timed skill because time is everything when it comes to life-threatening hemorrhage.  While a person can be apneic for minutes and be easily resuscitated by replacing O2 and getting rid of retained CO2, blood cannot be replaced in the field.

 

What would be the correct way to manage this patient? Well the scenario is artificial and built to illustrate a point, but since it’s all we have and the cause of the patient’s condition is well identified, the answer is simple:

 

FIRST: Stop the bleeding via compression or tourniquet—whatever it takes. Why? Hemorrhage is the source of the problem and it’s easiest to stop if you know how.

 

TWO: Supplemental O2 by mask unless the patient is unable to breathe effectively.  Why?   The additional O2 will complete the saturation of any lonely hemoglobin molecules and boost the plasma-level O2 (PaO2) pressure.

 

THREE: Warm, but don't overheat, the patient.  Shock and even slight hypothermia are a bad combination for numerous reasons, both at the scene and at the hospital. Recent war experience has proven this—again.

 

FOUR: IV access enroute.  Why? The emergency department may need to administer blood or blood products.  Then, the patient WILL be going to surgery and therefore need RSI, analgesics, anesthetics and antibiotics: none of this will come from the prehospital side.  Other fluids should be minimal and given only once bleeding is controlled, a concept known and written about since at least World War I (1914-1918).

 

FIVE: ALS airway management….as needed, if respirations are failing or cease.

 

The underlying problem behind the treatment sequence described in in this article is highlighted by its resolute adherence to an “ABC” approach in spite of, and in the face of the article’s own overwhelming evidence that a different approach is necessary. The simplistic approach described and endorsed by the article (one at least tacitly endorsed by JEMS since they published it) seems to advocate the action sequence of medics who follow alphabetical order better than thinking and who, as a result, may do more harm than good because the cause & effect of the patient’s condition is not understood.   Though the article I have commented on describes a hypothetical scenario, I have personally witnessed the results of work performed by efficient sounding and mnemonic-heavy, but otherwise uncomprehending paramedics. A real-life with real-death example involved an otherwise bright medic who, when questioned about her ABC ordered treatment priorities on a patient with an obvious tension pneumothorax, wagged her finger in my face while patiently explaining with a school teacher’s voice, "Airway before Breathing!"  She intubated the patient after a few minutes of PPV, and the patient, obliging the laws of obstructive shock, sank into a PEA-arrest thereby accommodating the paramedic’s ingrained obsession with kindergarten grammar.

 

Much medical training [note I leave out the word education] and the resulting treatment paradigms, especially of allied health types, has been reduced to memorizing one algorithm or mnemonic after another.  Go to most any paramedic or EMT program and watch the testing process: students are struggling to memorize steps for one condition or procedure after another, their struggle often coming at the expense of understanding the whys.  At the same time, with all the public focus on higher education, the same robotic paramedic programs tout their increasingly higher levels of quality learning and education while instead the opposite is happening. There is no doubt about the benefit of acronyms and mnemonics in the right situation.  They certain help one to recall critical steps while under stress….whether at the scene of a critical patient or, coincidentally while in front of a testing proctor, but the benefits are limited and even limiting. 

 

Why the either-or approach?  The answer may be simply that students can only do so much in the time they’re given and, if learning by mnemonic and memorizing multiple-choice answers is the way to pass an exam, they will do so.  Otherwise, the mental and emotional resources rarely allow them to do both.  For putative teachers, the reasons to use these simplistic methods are equally compelling.  It is much easier to grade a scantron or skills checklist than it is to read and grade essays. Fewer students complain of discrimination with the standardized tests and less time is required. The victims of our streamlined system of training, left lying on the sacrificial altar of expediency, is true understanding and its partner, the ability to intelligently assess, decide and treat based on valid cause-and-effect.

 

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If you join NAEMSP as a professional member, you get access to PEC.  You can subscribe, print or on-line, to both, or either.  If you're serious about the science of EMS, you should read both, regularly.
Maybe it was the Google search I did, but I never found the website for Prehospital Emergency Care...had I found it, I would have noted cost to subscribe, not difficulty to access. If you wouldn't mind posting a link for me and one else following this discussion, it would be appreciated. Thanks.



dr-exmedic said:

Let's call a spade a spade here, Prehospital Emergency Care isn't difficult to access, it just isn't free.  It is also intellectually challenging (written above 6th grade level), and doesn't have glossy pretty pictures. (I realize that most of the population of this board, at least, doesn't have problems with those latter 2.)



dr-exmedic said:

Let's call a spade a spade here, Prehospital Emergency Care isn't difficult to access, it just isn't free.  It is also intellectually challenging (written above 6th grade level), and doesn't have glossy pretty pictures. (I realize that most of the population of this board, at least, doesn't have problems with those latter 2.)


Another thing is that academic journals leave implementation up to the individual. Someone implementing what's published in an academic journal needs to evaluate the conclusion in terms of both an independent analysis of the published data ("Do I buy the author's conclusion based on the data provided? What are the limitations? Does the information apply to either my patient population and/or this specific patient?") and evaluate the information against their own scientific foundational education ("Does this mesh with what I know? How much evidence do I need to change my practice?). Ignoring outside education, EMTs definitely do not have the background needed to do this and too many paramedics (how many paramedic programs don't require college level anatomy and physiology? How many paramedic programs cover statistics and/or epidemiology?) don't require this either.

If you need someone to draw conclusions for you, industry magazines like JEMS works. If you're looking to draw your own conclusions, then academic journals (Journal of Emergency Medicine, Prehospital Emergency Care, etc) works infinitely better.
Oops...anyone else...

Adrienne Linn said:
Maybe it was the Google search I did, but I never found the website for Prehospital Emergency Care...had I found it, I would have noted cost to subscribe, not difficulty to access. If you wouldn't mind posting a link for me and one else following this discussion, it would be appreciated. Thanks.

I am feeling profoundly igernunt right now....never thought in terms of Trade journals or whatever else. I subscribed to PEC for a while as well as a few others. Had stopped JEMS due to preponderance of fluff. Nevertheless, for the sixth grade level readers out there, info put out by JEMS does have an impact. Some of it is quite useful. I can recall cadaveric studies on securing the airway via cervical spine stabilization post intubation which changed the way I did business and which has now been implemented in our county (placing cervical immob device on all intubated patients) . I believe another was a great runaway of hip showing superiority of inline traction via sager-style versus half-ring splint. Peer reviewed or not, JEMS does put out plenty of influential information....and I'd like to see its quality maintained or improved.
NAEMT members get a PEC discount, too.

The trick is the right Google search. This one led me to PEC (or a splash page) on the first 3 links (and Prehospital & Disaster Medicine was the 6th).  Or you can just go here.

 

Ways to get it:

Become a "professional" member of NAEMSP: $160/yr

Institutional subscription through Informaworld (if you can talk your employer into it): $215

NAEMT member discounted price: $56/yr

 

Needless to say, if you have a few friends interested, it's easy to split the cost and pass the print version around; subscription includes electronic access as well, just be careful not to log on at the same time as each other. :)

Hello everyone! I'd like to address the issue of reviewing articles. While we are a trade journal, we certainly do not accept content lightly. We have an Editorial Board of talented EMS professionals who work in a variety of areas in the EMS industry, and we're lucky enough to have two wonderful technical editors and a medical editor. We reach out to these people to help us review articles for the magazine and website.

And I should also explain that the reason the JEMS staff hasn't been very involved in this discussion is because we're publishing Tony's response in our June issue (as Tony knows), in the Letters section, with a response from Dr. Fox, the author. We would like to let Dr. Fox speak for himself and address many of the concerns raised in this thread.

 

Thank you everyone for the feedback! Good and bad feedback is always appreciated.

 

Skip Kirkwood said:

I can't answer that question.  Let's ask the staff:

 

Hello friends at the JEMS/Elsevier end of the internet!

 

Can you tell us how (or if) articles submitted to JEMS for publication with a "clinical nature" are vetted for medical appropriateness?

 

Thanks!

I was very disapointed by the article also.  Giving so much fluid and intubating a patient before external bleeding is controlled is poor practice. 

 

It would certainly be nice to have a standard format for EMS cases like the case reports in the medical literature. I, too, have had problems with the scenarios used in EMS education and do not understand why the authors do not use real cases. Except, EMS situations are complex with scene influences, local protocols and teaching, and variable quality of teamwork on scene. This makes them difficult to reduce to one element for instruction or discussion. So, maybe they are real cases but sanitized for instructional reasons. In conversation we can interact with each other to discuss what is missing but on the written page, sent to people with immensely different backgrounds, educational levels, and experiences, it is nearly impossible. That is the purpose of the letters to the editor, to bring your view to the authors for clarification.

 

Jim Page used journal in the title of JEMS for a purpose. In one of his publisher’s pages he castigated someone who called JEMS a magazine, explaining the reason for “Journal” in the discussion of his anger. Jim wanted a journal for paramedics similar to those for physicians and nurses. It would be reviewed for scientific merit and accuracy by a panel of physician and paramedic reviewers similar to the peer review system for medical journals.

 

As is the standard for medical journals, JEMS would remain neutral in controversy, giving the science for both sides of the controversy. Though his background was in the fire service, as publisher Jim Page kept JEMS neutral in the eternal battle between fire and private. He believed educated and informed paramedics were the best defense for good EMS against those who wanted micromanagement for a field that, from its very nature, cannot perform under micromanagement. Because of Jim we have the paramedic journal JEMS.

 

He did advocate openly using his lawyer hat. His advocacy for due process and support of the individual paramedic was strong and seems to have not been picked up with the same enthusiasm by other national advocates, particularly the medical community.

 

Before you let your hair catch fire about the statements I wrote they all came verbally, first hand, from Jim directly to me in discussions we had. I met Jim on scene in 1973 when Squad 39 opened as paramedic covering Bell Gardens. We met again in 1990 and had many conversations, some confidential and some open, about EMS and what we can do. As an advocate he gave pro bono legal services to paramedics in our region and he called on me as his medical expert witness. He did this as I would work with him pro bono. He also told me no other physician in the larger Los Angeles area would help in career damaging cases, paid or not. He recognized what he could do effectively and what he needed others to do with him or sometimes not associated with him. But above all, he made JEMS a professional, peer-reviewed paramedic journal.

Daved van Stralen said:

But above all, he made JEMS a professional, peer-reviewed paramedic journal.

I would argue for a "tried to" in that sentence, if for no other reason than "Sirenhead."

Point well taken. They once changed the title to one of my articles to less than professional wording and would not do an article on oxygen delivery as there was a doctor in San Diego who went to people's homes (house calls) and brought oxygen. I spoke to Jim about this approach and he has market forces. Scientific journal yes; has to be marketable to some people with little science on their mind. AJ has been a great improving force at JEMS.

 

I wanted to do a column of my experiences in past times. What do you think of Sgt. Save-a-life - here to serve you day or night.   

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