Pericardial centesis for trauma arrest patients?

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Permalink Reply by Mike Lesher on January 13, 2009 at 8:02am

More waste. Take the thousands of hours it would take to train the clinicians to do a centesis, then the money it would take to implement this into protocol. I believe it is a good thought that keeps the best interest in the patient, but I think it wouldn't be worth it in the long run.

It is yet another strain on the providors to contend with. This field needs to work a lot smarter to survive. I say take all the money we would put into this very rarely used/successful/needed skill and put it back into the paychecks of the providors that are doing the calls that matter.

Don't get me wrong. Doing the new/cool things are fun, but this isn't a time to be making more demands on the already limited staff/budget. I say save the money and get another medic on nightshift.

Mike Lesher

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Permalink Reply by John W. Magyar on January 13, 2009 at 1:08pm

Speaking from the sidelines, I would just like to add "What would it hurt" if there is no other option but death for the pt.?
From my past experience as a Navy Corpsman (prior to the birth of civilian Paramedics) we did many things that were "unheard of" outside of the military setting. If some intelligent beings back in the 60's didn't think outside the box back then, we might still be delivering "first aid" with a J&J kit, a bedpan and a bible in the back of a Cadillac ambulance today. I'm with Hulsizer on this one.
Here's a thought. Why is it that a military medic is good enough for our troops in combat but not good enough when he/she gets out of the service to treat civilians without additional training and certification? Would this help our EMS manpower shortage? Maybe this is food for another discussion.
Who is your little friend on your shoulder Mike?

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Permalink Reply by David Bardo on January 14, 2009 at 8:44am

For someone who lives in the middle of "BFE" or "the sticks" as many Medics have told me! this is a skill that is nice for a medic and i would have to agree with the other two posts it is to expensive at this time for everyone to continue to put money into retraining the medics.

As far as Mr. Magyar's post Military Medics and Corps men comming out of the Battlefeild and into the civilian field it is proven that, and now i can only speak for the US. Army trainning at FT. Sam Houston, they do not teach the things that a Civilian medic needs to know ie: Cardiac rythims, most drug administrations, Intubation. these are only a few of the things that Military training leaves out, only due to the situation of clearing the battle fields of the wounded and those who can sustain life. Yes, a Battlefield medic trys his best to save everyone there are times he or she has to play god and say "you're not going to make it but your battle buddy can," ethicaly wrong in this field, but right for their situation.

now back to the topic at hand, Paracardial senthesis in my area would be a waste unless the medic is right there, yes we have life flight but even for them to get to us is a good 10 - 15 mins from skids up, so i do not see a point to it like Mr Lesher .

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Permalink Reply by John W. Magyar on January 14, 2009 at 10:15am

Lets take another look at this topic from a different point of view. Could it save lives if properly performed in the prehospital setting? Could it harm the pt. who is already dead? How long would it take to train a medic to do this procedure? How much would the supplies cost to do the procedure? I hope these questions stimulate more discussion on this topic.
I recently spoke with a Physician's Asst. who is actively involved in EMS as a seasoned and experienced Health Care Professional. A case was discussed where a young pt. could have possibly been saved if this procedure and equipment would have been available. Unfortunately, this skill is not currently available or in the scope of practice for a medic.
What is the role of a medic and what are their boundaries? Are medics limited to learning and retaining only what they know today? Medicine and prehospital medicine changes every day and is not static. (thank God)
Lets look at the real "meat and potatoes" here. If a medic can learn to read a 12 lead EKG and give appropriate Rx for the condition, why couldn't he/she learn to effectively do a pericardial centesis? Its not like we are trying to teach the medic to do brian surgery in the field.
And now back to the cost factor. Thats an issue for the administrators, politicians and the bean counters. But, for the sake of discussion, what would the supplies cost for this procedure? How long would it take to train a medic to do this procedure?
How much is a life saved worth? Because we are in a "financial" recession, should we use that reasoning to stop trying to improve EMS?
I look fwd. to reading more input on this topic. Be safe out there!!!

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Permalink Reply by Michael Hulsizer on January 14, 2009 at 3:41pm

I'm in the buisness of saving lives, or at least the buisness of trying to save lives!!! The cost of something I guess does come into play but really didn't play into my thought process when I started this post. First...We already carry everything needed to do the proceedure (needle and syringe), secondly...the process of the procedure is relative to a chest needle decompression. Who would have thought that we would actually be doing surgical airways verses a needle chricothyrotomy today!! It took someone to prove that it was a better process!!

John, the 12 lead EKG was a great example of progression in this field, and I see in the near futher similar advances in CVA treatments for pre-hospital care providers!! We are talking here about a last ditch effort that could or has the potential to change the entire outcome of a patient. We who take and teach ACLS and PALS know what the H's and T's are...guess what one of the REVERSABLE CAUSES are for PEA....cardiac tamponode!! Reversable being the key word here!!! I have copied a sample protocol for those who would like to actually see what the proceedure consists of.

SAMPLE PROTOCOL (Ada County, Id)
I. BACKGROUND:
Pericardiocentesis is an emergency lifesaving procedure. It can be performed on
standing order in cardiac arrest situations; otherwise it is to be performed only on the
direct verbal order of the medical control physician (See General Guidelines for
exceptions). It is an invasive technique that may allow restoration of adequate cardiac
output by relieving pericardial tamponade.

II. INDICATION:
Emergency relief of pericardial tamponade with:
- Severe hemodynamic compromise.
- Shock state refractory to fluid loading, chest decompression, and
pharmacological intervention.
- Cardiac Arrest (standing order)

III. CONTRAINDICATIONS:
None

IV. COMPLICATIONS:
1. Cardiac Dysrhythmias:
• -Ventricular Fibrillation
• -Asystole

2. Cardiac Trauma:
• -Laceration of coronary artery
• -Laceration of cardiac chambers

3. Pneumothorax

4. Hemothorax

V. PROCEDURE:
1. Place patient in the supine position or torso elevated 20-30 degrees.

2. Prepare site with Betadine.

3. Select a 4-inch 16-gauge needle with 35 cc syringe attached.

4. Insert needle between the xiphoid process and the left costal margin at a 30-
45 degree angle to the skin.

5. Advance the needle toward the left shoulder, aspirating constantly. A distinct
“give” or “pop” may be felt as the needle enters the taut pericardium.
Contact with the epicardium may produce a “scratchy” sensation, or
dysrhythmias.

6. Grossly bloody fluid from the pericardial space should not clot.

7. Reassess the patient.


I just feel that we should be doing everything possible for our patient, and really do not like leaving something on the table when there is something else that could have been attempted before saying "that's it"

Thanks for those who posted!!

"Personally, I believe that if we write our CE, text books, and curricula at the physician level instead of the kindergarten level, our paramedics and EMTs will rise to the occasion and meet the higher standard....." (unknown author)

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Permalink Reply by JJ Magyar on January 14, 2009 at 3:42pm

I have to agree with Hulsizer. He is suggesting this procedure for a trauma arrest with a PEA. In this situation a the patient is dead and only stands a chance if a reversible cause is treated. In this situation the benefit far outweighs any risk to the patient.

Mr. Lesher I dont think you understand what would be involved in implementing such a procedure/protocol. The cost for equipment would be limited to a syringe and needle. Considering the infrequent cases where this would be used cost is not an issue.

In regard to training it wont take thousands of hours. I was trained to do this in paramedic training. Review the procedure for this emergency procedure, it is not chest surgery. A few years ago I did the procedure on a live animal in a comparative medical lab without difficulty. I had a 5 minute review of the procedure and landmarks under the supervison of a physician.

The attitude of do work smarter by doing less is an area I dont support. In a competitive world you need to make yourself more valuable. I come from a world where we dont say "cant" we say "ok" and get it done.

In regard to putting money back into the provider I share some of your thoughts but disagree with some of the notion that money is just deserved. First you must understand wage is driven by the market. I think everyone in all jobs/professions would like more money. If there is high demand for what you do there will be a competitive wage( re: nursing). When there is an abundance of supply the wage will be lower. In our world reimbursement is the issue plaguing most services. I do know paramedics resisting advancment does not add value therefore no increase in pay.

I resent the attitude about comments like "doing new and cool things" and referring to emergency procedures as fun. I never once thought a procedure was fun. All procedures even the very basics should be viewed as something that may impact the life of the patient forever. Simply not cleaning an IV site could lead to infection that could prove deadly to an immune suppressed patient. The human body should be respected and anything we do to someone else should be viewed as a serious responsibility. If I was a physician who heard a paramedic refer to emergency procedures as "new and cool things" I wouldnt trust my license to those providers. To me that screams problem provider and this attitude is exactly why our profession is stuck.

What I hear is medics on both ends of the spectrum. We have some that want to advance their profession and increase their potential benefit to patients. We have others content with the status quo. I understand both sides. This post has proven my theory that all medics are not created equal and a one size fits all wont work.

Interesting topic and I look forward to some debate and further discussion.

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Permalink Reply by Mike Lesher on January 16, 2009 at 7:47pm

Mr. Magyar,

You bring up too many points in your post to "personally" address.

To make it more simple: I simply don't agree that a centesis is something WE as a PROFESSION should be spending energy on.

How about those EAGLES!


p.s. don't judge a book by it's cover. We have lots in common. Some people just don't know me........yet.

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Permalink Reply by Michael Hulsizer on January 17, 2009 at 11:55am

Mike,

That is what this site is all about.....personally addressing these situations and comments left by others!! just stating you are for or against something doesn't carry any weight!! I would think in your situation, at your full-time employment...you may have the opportunity more than others to use this procedure possibly saving someone’s life, or are you one of those guys who just collects the federal paycheck and doesn't care about anything else?

I thought we were supposed to spend energy, time and resources on attempting to save lives!! I don’t see anybody standing in the way of spending 10's of thousands of dollars on the new LP 15's!! Do they do anything different than what we can do now...the answer is no!!! They may do it better, they may do it lighter, and they may have some nicer features, but the answer remains the same!!! I for one love working with the best equipment but if you are going to state cost and energy as reason not to do something than know the costs before you state it.

Look at all the procedures and or medications over the years that we have not been either allowed to do or were too expensive to carry and use!!! Times have changed and we now have those on our trucks!! Why, one because standard of care issues came into question and monies became available!!

Sitting back and watching doesn't change anything!!!! Attitudes need to change!!! Motivation is the key!!!

I don't think JJ was judging you at all!!

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Permalink Reply by Allen D. Slotterback on January 17, 2009 at 2:49pm

For the sake of a syringe and a needle.....why the heck not. If we're going to intubate, push meds, do CPR, and decompress chests then why not perform a procedure that is in no way going to harm the patient? Given the scenarios that this procedure would be done it really shouldn't matter if 50% of the time the provider royally screws it up. What's worse than certain death? I'm not saying it's acceptable for it to be done improperly, but that's just an example to put this in context. If it has the possibility of saving a life then nothing should be outside the realm of what we should do or can learn to do. You rise to the occassion and meet the challenge, or you let some one step in and do it who is willing.

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Permalink Reply by John W. Magyar on January 17, 2009 at 6:26pm

This has been a great discussion topic. I wonder what our Medical Directors think. It would be interesting to hear their take on the subject.

From everything I have heard so far, I would have to conclude that:
1. The procedure is simple, safe and can't hurt a pt. who is otherwise dead
2. It is not cost prohibitive
3. It can save more lives and "THAT" is what EMS is all about !!!

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Permalink Reply by JJ Magyar on January 19, 2009 at 8:43am

Thanks Hulsizer. I am not judging just stating my opinion from a person who chose to make this my career and takes it very seriously. I am all about raising the bar to better our profession and the care we give to others. We need to know personal feelings on these issues so we can balance everything.

It is ok to have a difference of opinion and I like to defend my opinion but please dont take it as anything other than constructive for the good of the discussion.

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Permalink Reply by Doug Keefer on January 22, 2009 at 1:19pm

Good topic Mouse.

1.) New skill to potentially save lives during a trauma arrest which, if you research the literature has a survivability rate of 1%. Adding centesis to the skills for ground providers is a good thing, if that would in a sense raise that percentage up. Good patient care is what it is all about, and if it is going to be a benefit for the pt, then we move forward. Hulsizer brings very good educations points, and others have also added some QA and other points to ponder.

2.) Cost is not an issue, and it was taught in the paramedic curriculum. Could be added to the yearly skills review that is done or to check provider performance every year. We already have the syringes and the needles we have, but just getting this size should not prohibitive in any means. Why should the ground medic's have to wait for an aeromedical service to land and provide this before cessation of all other efforts.

3.) Bringing the medical director's into this is a great idea to get more input.

I have seen this done a hand full of times, in the ED, and in the field by aeromedical personnel. Did it change the outcome on the patients that it was performed on. No. But, could it, Sure. Move forward and get more CQI, CQA information and lets expand our skills, and education levels, and service that we provide to a higher level.

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