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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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.   



Daved van Stralen said:

 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.


...which is a problem that I think some people have. When I think "journal" in the sense of medicine, I think Journal of Emergency Medicine, NEMJ, or Annals, or something similar. When I see JEMS, I see more of a Popular Science type publication than a scientific journal. If JEMS was a scientific journal, shouldn't they be providing the actual research articles instead of having someone else interpret the study for us? Personally, I find myself clashing often with the analysis provided, especially when I go back and reference the original article.
If EMS is a profession (note: current status and what EMS should be are not necessarily the same), shouldn't the professionals be the ones interpreting the studies? If EMS providers have to be one step removed from that, are they really professionals? Granted, though, the need for this is the symptom of a greater disease. After all, what sort of discussion can you have regarding research if a lot of providers don't understand the difference between a P-value and a relative risk value with confidence interval?

Joe, the journals you describe are primary research journals which publish primary or original research while JEMS presents peer-reviewed secondary research (review) articles with paramedics included as peer reviewers.  The primary research journals also publish secondary research that reviews the primary research. A primary research article is very narrow in its scope, becoming even narrower in the 1970s as editors began dividing studies with multiple conclusions into several articles. While familiarity with statistical analysis helps, the most important part of the article, and the part that anyone can grasp, is “Did the authors prove what they said they would prove?” You can do this by comparing the hypothesis at the beginning of the article with the conclusion. The conclusion will be very narrow in its statement.

 

What leads to confusion, not only on this website but in medicine, is the use of the discussion section of the article. The introduction tells us why the study is important while the discussion section presents ideas of how the results and/or conclusion can be used or can explain other phenomena. Some journals allow a broader discussion than others. And, yes, I have done peer review and have been peer reviewed in primary research journals.

 

Think of primary research as a picket fence. The gap between slats is fine until something gets through the fence. If it is important enough that nothing gets through someone will become interested, enough money for the study will be developed, the study will be completed, and an editor will be found who agrees the study should be published. Another slat goes up and the gap between slats narrows. Research has again advanced science. This has nothing to do with what any of us want to have studied or believe should be studied and editors have no control over what is submitted, only what is published.  

 

Becoming an accepted primary research journal is much easier today than when Jim started JEMS. Shortly before he began publishing, the Society of Critical Care Medicine (SCCM) started Critical Care Medicine (CCM) and the National Association of EMS Physicians (NAEMSP) started Prehospital and Disaster Medicine (PDM). Neither was in Index Medicus, the precursor to PubMed. In the 1980s and early 1990s the editors and societies urged members to place their best research in their society journals to achieve the significance necessary to merit placement in Index Medicus. By the end of the 1990s the committee for Index Medicus accepted both journals giving the editors a feeling of great achievement. The Internet changed things so almost everything is now listed in PubMed. Jim did not have a society to support development of JEMS into an indexed primary research journal. He followed the route of creating a peer-reviewed secondary research journal.

 

You have used other peer-reviewed secondary research but maybe with not as critical an eye as you apply to JEMS. All of your medical textbooks are peer-reviewed secondary research sources. For good criticisms of these sources read the book reviews of your primary research journals you use. Look for differences in how they are accepted between fields. Take several books from the same field and evaluate a single topic. Take a single topic and evaluate how books from a variety of specialties address the same material. Most fun, to irritate your Attendings and colleagues, is to find a paragraph that discusses a treatment but has no literature citations and question everybody on its validity. I can almost guarantee the authors made up the material (personal communication from several such authors). Another guarantee for years was to tell an emergency medicine resident that aerosolized epinephrine no more caused rebound croup than aspirin or ibuprofen caused rebound headache – it was fiction. They would even carry 4-5 emergency medicine textbooks to the fifth floor PICU to prove me wrong. Then I pointed out the absence of literature citations. Nor could they find it in Index Medicus or PbuMed. And another yes, I have written chapters for medical books.

 

I compare JEMS more to American Scientist or Scientific American rather than Popular Science. The first two, while not peer-reviewed in the sense of a primary research journal, do require the author to have a body of peer-reviewed research. Jim and I discussed this and he would not abandon those paramedics and EMTs who did not have a college education. A peer-reviewed secondary research journal for people without college – visionary then, unheard of today.



Daved van Stralen said:

Joe, the journals you describe are primary research journals which publish primary or original research while JEMS presents peer-reviewed secondary research (review) articles with paramedics included as peer reviewers.  The primary research journals also publish secondary research that reviews the primary research. A primary research article is very narrow in its scope, becoming even narrower in the 1970s as editors began dividing studies with multiple conclusions into several articles. While familiarity with statistical analysis helps, the most important part of the article, and the part that anyone can grasp, is “Did the authors prove what they said they would prove?” You can do this by comparing the hypothesis at the beginning of the article with the conclusion. The conclusion will be very narrow in its statement.

I think that's good for starting discussions, but if I'm looking to make a serious push to change the way my system/I (arguable difference between the ease that physicians can implement changes than EMS providers, even though EMS providers should be driving change in their systems) provides care (which is ultimately the goal), I think that can be a very dangerous route to go down. An author is free to claim that their study is "significant" even if the "significance" is a RR of 1.01 because the P value is 0.05. Alternatively, if the RR is 1.6 with a huge confidence interval, the author might throw away his hypothesis because the P value ends up, say, 0.09. If all a provider only sees is "not statistically significant" in the conclusion, they may be throwing away something that should be considered, especially depending on what the results of other research articles are. Granted, though, moving past simple statistical significance tests is a problem even at the physician level. I'm willing to argue that most of the people in my class that don't have much of a research background probably aren't able to really look at research articles as critically as they probably should be able to.

You have used other peer-reviewed secondary research but maybe with not as critical an eye as you apply to JEMS. All of your medical textbooks are peer-reviewed secondary research sources. For good criticisms of these sources read the book reviews of your primary research journals you use. Look for differences in how they are accepted between fields. Take several books from the same field and evaluate a single topic. Take a single topic and evaluate how books from a variety of specialties address the same material. Most fun, to irritate your Attendings and colleagues, is to find a paragraph that discusses a treatment but has no literature citations and question everybody on its validity. I can almost guarantee the authors made up the material (personal communication from several such authors). Another guarantee for years was to tell an emergency medicine resident that aerosolized epinephrine no more caused rebound croup than aspirin or ibuprofen caused rebound headache – it was fiction. They would even carry 4-5 emergency medicine textbooks to the fifth floor PICU to prove me wrong. Then I pointed out the absence of literature citations. Nor could they find it in Index Medicus or PbuMed. And another yes, I have written chapters for medical books.


However, there's a major difference between text books and research journals. I expect research journals to be cutting edge. Here's new data. Here's additional data that confirms/contradicts what we currently know. Here's a review article summarizing numerous studies to make it much more usable to the end user.

I don't expect that from Harrison's, Rosen's, Tintinalli's, or even Robbin's (which, granted, is a pathology text book and not a medicine textbook). I expect those to represent the standard of care for when they were written, which generally lags behind the cutting edge even ignoring the time between being written and being published. After all, to change the standard of care to incorporate the newest research requires someone to not provide the standard of care anymore. Review books like First Aid for the USMLE Step 1 ("First Aid") are probably more up to date than Harrison's and Robbin's simply because a new edition of First Aid is published ever year or two, but First Aid lacks the breadth and depth needed as a primary reference. Of course Up-To-Date would be a better source than First Aid.

As far as unreferenced treatments, well that's just because it's the standard of care. Lacking a scientific foundation for the standard of care should be no stranger to EMS providers, nor to medicine in general. Too much simply isn't questioned for a variety of issues, including simply tradition and because the treatment "makes sense" (cough trendelenburg cough)

I compare JEMS more to American Scientist or Scientific American rather than Popular Science. The first two, while not peer-reviewed in the sense of a primary research journal, do require the author to have a body of peer-reviewed research. Jim and I discussed this and he would not abandon those paramedics and EMTs who did not have a college education. A peer-reviewed secondary research journal for people without college – visionary then, unheard of today.


Ok, maybe Popular Science was a little bit harsh. However, now we've reached the true issue. The gap between what college educated providers want/need and what non-college educated providers want/need is vast and results in a "serve two masters" conundrum. With Prehospital and Disaster medicine and Journal of Emergency Medicine (which regularly has a prehospital medicine article in addition to the normal EM studies), do the EMS providers looking for primary research need another journal? Similarly, it's going to be amazingly difficult to cut down an article to the level needed while keeping the more finicky of us happy. Of course then again us finicky providers just need to remember to evaluate the subscription (sample) population to make sure that it adequately meets their needs, even if it doesn't necessarily meet our needs. (On a side note, I'm not nearly as much of a pompous a-hole as this last paragraph probably makes me sound.)
If you want studies go to the NAEMT site an under TCCC materials there is all of the studies on TQ use, fluid resuscitation, torso trauma, some are dated 2011. Another source is health.gov or health.mil one of those has studies also. The best practice or
Lessons learned is a great resourse the Army has a lessons learned and it helps stay up to date with what actually
Works.
 I have about 200 recent prehospital studies
Let me see
What it will
Take
To post
Them 

Hey Paul, the Army's TC3 stuff is actually pretty good.  Reseach on needle thoracostomy depths (cadaveric analysis using CT scans), heat illness, etc. and other stuff has abounded with the giant "laboratory" over there in the sandbox.   What is disheartening, at least with regard to fluid resuscitation which after decades at the "two large bore IVs and loads of fluid", is that we're only relearning stuff which has been around for nearly 100 years or more.  Are we dumb or what?  The studies have always been there...whether new or old...but it seems the trend has been more to Easter Egg the studies rather than taking a really good, humble look for the truth.  It's almost become a game of Chinese proverbs or religious quotes--if you look deep enough, you'll find whatever quote you need to support your side.  Information in a vacuum is no better than watching TV ads to figure out which politician to support.

 

Thanks for the other sources though.

Yes sir I agree but I will out my money on the CoTCCC and their recommendations as a guide. I have sat in a session with the "decision Makers" on protocols and it gets ugly with all the studies thrown around the room. We at the school house utilize hypotensive resuscitation fluid protocols which are basically enough fluid to return radial pulse and/ or increase mentation as an example. It took us years to get past two large bore IV's as I type this we know that some rouge medic is still operating on old atls standards for in hospital fluid resuscitation. 

 

Are you out at Fort Sam?  That was the paradigm we were using in 2007 when I deployed...I was delighted to find the "Army got it right" finally......it still hasn't trickled down to civilian EMS where the "90mmHg" BP has some sort of mystical allure. 

Yes sir I am at DCMT for the most part everywhere i work at maintains around 90 as the standard of care for trauma i do some arm twisting 

 

Tony Ricci said:

What is disheartening, at least with regard to fluid resuscitation which after decades at the "two large bore IVs and loads of fluid", is that we're only relearning stuff which has been around for nearly 100 years or more.  Are we dumb or what?  The studies have always been there...

Anybody remember that old album of EMS songs floating around? All I can think of when I read this is the line from the spoken-word song that goes something like:

I sure had a problem with the state written exam. Half the questions didn't even have the right answers. Since I had experience in government work, I got most of them right anyway. I just picked the answer that someone who didn't know much about physiology, pathophysiology, or current practices in emergency care would think was the right answer.

Although in this respect, I have to spread the blame around to the physicians who were helping organize the first modern EMS services, since EMS didn't have its own ideas about medicine initially, it inherited them, even as modern emergency medicine was simultaneously evolving its own line of research essentially from scratch.

 

To be fair, though, some of those older studies had the disadvantage of not being strong enough research to make it into modern medical journals.

Dr X, I enjoy most all of your comments!  Haven't heard the song but, having done enough government time, that song's lyrics are hilarious!  You can still find some of the same logic floating around in NREMTs skills standards. 

 

The part of the old studies would be true taken from the whole anecdote sense.  As anecdotal evidence isn't study based, it is often dismissed....sometimes with prejudice.  The WWI evidence, anecodtal as it may have been, doesn't seem to have been really explored since in a controlled way until the 1980s/90s animal experiments with pigs (I may have missed earlier ones) and since then in ROC studies (early terminations there due to failure).   In my mind, the scientific approach has at times lost its ability to see the bigger picture?  An example to illustrate my thought on this point:

1) Caveman things round wheel is better than square wheel because it seems obvious that square wheels are easier to push around.

2) Scientist comes along and says "Did you test that in a controlled level I study setting?"

3) Flea-bitten caveman scratches his head "Uhg...Zog no does know what you say.  Round better wheel."

4) Scientist shrugs at caveman's stupidity and says the round wheel won't be used until at least three studies of sufficient power are used to prove validity of round v. square wheel question.

 

 

Tony Ricci said:

Haven't heard the song but, having done enough government time, that song's lyrics are hilarious!  

Try "Every Friday, Saturday, and Sunday Night" here.

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