Study questions the standard of C-Collars

Baylor study doubts neck brace standard
In some cases, device might hurt accident victims

By TODD ACKERMAN
HOUSTON CHRONICLE

1/25/10

   Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.

   Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive, a finding that could upturn the way emergency medical personnel and doctors act to stabilize and protect the upper spine in potentially fatal neck injuries, such as those that commonly occur in bad automobile accidents.

   "This study is a proof of concept that in cases of severely unstable neck injuries, cervical collars are not only not helpful, but harmful in many situations," said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and the study's lead author. "More research needs to be done, but it might be that we can prevent some of the deaths and quadriplegia that occur in these injuries."

   The study appeared this week in the Journal of Trauma.

   Dr. David Persse, medical director of Houston's Emergency Management Services, called the study "compelling" and "concerning" and said it will come up for discussion at the annual meeting of the nation's 30 largest EMS departments in Dallas next month. But he also said he doesn't want to overreact.

   "We need to look at this thoughtfully before we change the standard of care," said Persse. "It concerned a particular kind of injury. It may apply to other injuries as well, but we don't know that yet."

   But Persse added that he understands the need to act quickly, that "it's not like a lot of areas where there's not as serious downside to waiting for the next study."

Car-crash victims

   Ben-Galim said cervical spine injuries are found in the autopsies of up to 94 percent of people who die in car crashes, which claim about 44,000 U.S. lives annually. There are about 11,000 people annually who survive spinal cord injuries.

   There is no obvious alternative to cervical collars, though hospitals often place sandbags under the back of the patient's head and, less commonly, some EMS teams at the scene of the crash wedge the head of the patient between foam bolsters on the backboard.

   The injuries in question involve the area where the brain connects to the spinal cord. Doctors treating such injuries work to stabilize the ligaments, muscle and bone to prevent secondary injury and to protect the brain stem and cord.
  
   Baylor researchers undertook the study after a case in which a broken jaw precluded the use of a cervical collar on the survivor of a car wreck brought to Ben Taub. When the doctors started to put a collar on the patient, fluoroscopy showed two of the patient's vertebrae separate, causing doctors to immediately remove the collar. The treated patient ultimately walked out of the hospital on his own.

   Ben-Galim noted that there are other such case histories in medical literature.

   To study the phenomenon, Baylor researchers made an incision in cadaver neck ligaments based on patient X-rays, then simulated clinical scenarios by applying cervical collars and putting the bodies in ambulances and driving a distance.

   In all of the cadavers, imaging technologies found that the collar increased the rupture.

   In effect, the collars pushed the head away from the shoulders, Ben-Galim said.

   He said the rupture stretching occurs because of both the application of the collars and their continued use.

   One national expert called the study interesting but said he wasn't sure it would one day change the standard of care.

   "There are certain cases, like the ones in this study, that can be dangerous, but they're rare -- most people who suffer high neck injuries die immediately," said Dr. Tom Scaletta, the past president of the American Academy of Emergency Medicine. "I think the study's importance will be to raise awareness about the special care that must be taken -- preserving patients' normal head position, making sure they're not having difficulty breathing."

Anecdotal cases

   Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute and team physician for the Houston Texans football team, said the study wouldn't change the care of injured football players removed from the field in collars and on stretchers because those injuries tend to involve lower areas of the spine.

   Ben-Galim said that since the study was undertaken, Ben Taub doctors have saved patients with severe neck injuries by loosening or removing cervical collars early and rushing them to the operating room, but he acknowledged such cases are anecdotal.

   He said the research team looked at 400 articles and found no scientific evidence that cervical collars can stabilize severely unstabilized spine injuries.

Original source: http://www.seattlepi.com/health/414631_Neck25.html

CAMTS Accreditation - Blessing or Curse?

NOTE: This is my commentary/response to the original article which appears at:

VerticleOnline and published Oct 21, 2009

MY COMMENTARY:

CAMTS accreditation has become double edged sword.

On one hand your HEMS program may not be able to live without it (either by regulatory requirement of your state, OR by lost revenue via third party insurers who require accreditation), but on the other it may be hard to live WITH it too! -recurring site visits, 3 year applications for reverification, continually updating standards etc.

One of the big problems with CAMTS accreditation is that in some circles it is legislatively mandated (see the 8 states that require it) and by definition, accreditation conflicts with "mandatory" -- so which is it? Mandatory or voluntary???

Personally I believe the original intent of CAMTS was good for the following reasons:

1) It's not governmental: for those of us who dislike big brother running everything. (This is a HUGE plus in my book)

2) Technically, it's still voluntary (debatable)

3) Nursing/carregivers: involvement with heavy focus on requirements for the medical crews, in my opinion, is good. I believe the industry is moving towards recognizing the medical crews as AIRCREWS. I think there will be needed discussion when/if this happens (I hope it does) because then there is more FAA oversight in that aspect.

4) CAMTS uses widespread representation. Argue if you like about how the pilots are not as strongly represented, but there are a few other "non-specific" seats on the CAMTS board of directors which could be occupied by qualified pilots as well.

---->NOTE: if the HEMS pilots do not feel they are represented adequately by CAMTS, then they should lobby their professional organizations to develop some type of accreditation program as well, OR, get their representative body to work more collaboratively and intertwined with CAMTS

5) In my personal opinion, in what I have read and researched over the years, I feel CAMTS strives to stay "ahead of the curve" in as much as incorporating or leaning towards industry leading "best practices" as well as those practices which may be recommendations by federal investigative/review committees. I have always felt that CAMTS was dynamic and responsive to the HEMS community.

I realize there are more problems and concerns with CAMTS which I have not listed here; I will look for part two of this article to help stimulate more discussion.

My bottom line however, is directed towards the skeptics and nay-sayers.. and I say to those that are (1) unhappy, (2) dis-enfranchised or (3) mis-represented by CAMTS - "sorry", CAMTS has ONLY become so influential and powerful by the VOLUNTARY submission to it's program requirements and accreditation processes by programs across the US... The more programs that seek the CAMTS "Merit Badge", give the CAMTS machine more influence, power and presence....

Taxi vs. Ambulance

Any chance they are "Transformers"????

Too Many Cooks in the Kitchen?

A recent discussion over at Jems.com was started in which the original poster (OP) threw out the question about what drives EMS staffing, Cardiac Arrests (ALS) or Medical Care, and what the mix of EMT's to EMT-P's should be utilized. (http://connect.jems.com/forum/topics/cardiac-arrest-or-medical-care)

An interesting discussion ensued with many people voicing their opinions and experiences. After reading through a majority of the posts I could pick up on a couple of themes which seem to predominate...

One of the strongest themes is that if we are basing our EMS staffing on ALS calls, then increased EMT-P's are needed, sometimes even dual EMT-P crews. This is further facilitated by the growing use of and demand for EMT-P qualified "first responders" as part of the fire service and a responding engine or rescue company. Unfortunately, with this increased use of EMT-P's by the fire service, it has mandated or "encouarged" many who would not otherwise consider going to EMT-P school to go to get the increased education and medical credentials. Many men/women entering the fire service are now being called up on to change/alter their career paths to incorporate this EMS training to meet the demands/desires of their municipality public safety administrators.

So the thought process goes that we need more medics (EMT-P's) to be able to effectively cover more ALS calls, more readily.

While this sounds good in principle the numbers don't pan out as well.

Having more medics on duty means each medic gets less calls. Huh you say? What's that got to do with the price of diesel?

Of those ALS calls that require medic level skills (IE: non-BLS), each medic will have less opportunities to "play" and get the ongoing job/real-life experiences which add to and build upon their experience repertoire'. When one considers critical ALS skills, like, er, uh, lets say "INTUBATION", you see where lack of "practice" can lead to lack of success.

Ultimately this leads to an EMS/Fire Service with lots of medics who each SELDOM get intubations on live (er, uh, "barely alive") patients. So when it REALLY counts, they lack the field experience and have to base their skill set on those manikins and OR rotations for recalling the psychomotor skills.

Add to this the current recommendations by the American Heart Association and the EMS/Pre-hospital system as a whole; to forego intubation if BVM will suffice. So now you have even less opportunities for intubations amongst and increasing number of medics.

It's not uncommon to read about medics in some systems these days who are lucky to get even just ONE opportunity to intubate annually - that's OPPORTUNITY, we're not even talking successful intubation yet!

So now to explore this we respectfully have to look at the other side of the equation or assume the other possible outcome - to DECREASE the number of employed medics and increase the number of EMT's (basics) out there.

Well, up front the numbers would support this. Overall, a majority of all EMS calls are BLS in nature and don't require ALS skills at all. So it would make sense to have an EMS system that is heavy on the EMT-B side of providers. This would, however, beg the question: what to do with all those medics?

Some proponents have suggested staffing with medics where they are needed, or centralized or via the QRV scheme.

Looking at demographics, transport times, distances, a service could strategically look at where to maximally staff their medics. Maybe they would put them in areas that were longer transport, higher acuity traumas or more rural where experienced providers were limited in availability.

One could conceive of even putting more EMT-B's in some of the urban areas where even with a "trauma" a load-n-go might only be 2-3 minutes from a trauma center.

Some systems have already incorporated the medic QRV concept. Contemporary implementations of this usually have a shift supervisor (medic) readily available to respond to a wider area quickly to "back up" the EMT-B's on scene and bring that higher level ALS skill set when necessary. Most systems that are using this however are using their supervisors; the new evolution of this position would consider merely a street level paramedic who is unencumbered to respond as needed to scene calls and not tie up a supervisor. If no ALS needed on a particular scene, then the medic could get back "in service" and "available" for the next one.

These are only limited solutions to bigger system problems. In an era of increasing cost containment, decreasing reimbursements, increased operating costs and increased litigation risks the overall principle is COST. The costs of labor, training and effective resource utilization all add up. New and novel ways to staff and provide effective community level EMS services continues to be a challenge even for the most experienced administrations.

It is interesting however to note that we spend way too much time focusing on "the big one" when the "big one" occurs a whole less often than previously considered. But....would anyone want to tell THEIR community that they are cutting back on Advanced Life Support (IE: Paramedic) level care???? Political suicide for sure!






~"KMG-365, Clear..."

CCC Class Wake Med - Day 1 Report

What a day!
Just finished day 1 of a 2 day CFRN/FP-C course here in Raleigh NC at Wake Med. This was a 2-day certification review course produced by Critical Care Concepts and Rick Patterson. I was assisting Rick in teaching for his company during this class.

Their conference facility was THE BOMB. Rick even compared it to some conference hall. He said "man this is like JEMS" the EMS today national conference. Wake Med (WM) has this AWESOME conference center across from the main hospital. It's got several multi-size rooms with sweet A/V setups in each. Nice central lobby, reception areas and a juice/soda/coffe bar (self serve)....it's freakin sweet! Just being in such a nice place, made us feel like some special guest speakers and such!

Class went pretty well on day 1. We ran long and didn't cover as much as we wanted. We hit most of the big topics, but probably ran a little long winded for most of the audience.

After course introductions and "settng the stage". We kicked it off with me doing the cardio lecture. This cardio lecture is always a tiring one. The one we do for Rick's classes is a bit longer (about 80-90 minutes) than the stand alone one I do for my "CEN-only" classes. I think it's a good starting point however, and it DOES lend itself to some minor alterations depending on class prior expeience and knowledge level. Today's version we cut a bit short due to time and we dropped off the 15 or so, ACLS review slides. Instead of slides we closed out the ACLS with a 20 minute "core" ACLS review and Rick went impromptu as he finished the cardiovascular by hitting on the main ACLS bullet points. And, as always, reminded the students that if they hadn't attended an ACLS provider class within the last 6-8 months, that it's probably a good idea to hit that before taking the cert exams (CEN, CFRN, FP-C).

Then we jumped over to the flight portion of the class. Rick jumped right in and ran through the flight principles and concepts (gas laws, stressors of flight etc)..and as always, while I was sitting back watching/listening - I once again was quite engaged when Rick "does his thing"! Shortly later, we went to aircrew safety, survival and regulation to complete most of the dedicated flight content. And once again, Rick gets right into his "zone" and runs through this, lecturing effectively while inserting his anecdotes and war-stories as appropriate. Pretty cool this time working through the survival/shelter part using the big graphics on the LARGE screen; cool to see the "big picture".

Due to time concerns we carried the neuro lecture on into and through lunch this time. I was giving this one and probably where we started to see the early signs of the diverse audience starting to loose their learning thread. You start to see it when we start talking about some more "general" neuro stuff like Multiple Sclerosis or Lyme disease -- the people there for flight certifications are probably starting to think like "why do I need to know this"... So it's always a challenge to try to deliver it and at least make some relevancy to the entire audience. Interesting, at the beginning of the neuro lecture we review the cranial nerves (Nursing 101 right?)....well when I threw up the "Old Olympus Towering Tops" slide, I got so many blank stares...? Kind of made me stop and think. However as this was not a "teaching class" but rather a "review class" - I just referenced it and pointed out that some people may want to spend some time reviewing this on their own before sitting for their exams. So I knocked out the neuro lecture and then we took a break for fresh air and a leg stretch.

We proceeded to head across the parking lot to the helipad. We all posed around the Wake Med hel0; a beautiful machine -- the EC 135 with their appealing crimson and white paint scheme. It really is an appealing piece of equipment - I hope the class photos came out okay!

Afterwards we headed back in for another lecture. This time it was back to Rick for his ABG lecture. Now since I've known Rick, and since the first time I've seen him do this lecture; I am continually amazed and blown away how he does this. The first 15 min or so arethe groundwork for the topic; looking at some basic ABG concepts, pulmonary function/gas laws etc. Once that's done, the "show" begins. Rick starts to run through these ABG "problems" on the board. He starts off like a kindergarten teacher, holding the student's hand through the first few examples, prompting them along the way. Then he backs off a bit and starts letting the class work through the problems more independently.

Towards the end, the students are engaged and interacting. There were a few people however that just "didn't get it" completly and a few who were aking the time honored "calculus question: but what will I do with this in the real world?"... We had to try to explain to them that it's not so much that you'll be doing calculations like this bedside or stretcher side, rather it was a learning curve to start to drive home the relationships between the components and the principles there which lent themselves to overally pt management.

There wasn't a person who told us they had looked at the whole ABG/respiratory function like we just did here - I'm sure there were SEVERAL seasoned people who left that room feeling like they actually LEARNED something!

That pretty much wound it up for the day, it was close to 5pm and people were tired.

We'll be back hitting it early Sunday morning...bright and early at 0800!
Gonna have to step it up and get in our "zone" to keep this puppy on track.

Full day tomorrow, topics include...
1)Airway/respiratory/vents
2)Toxicology
3)Burns
4)Thoracic/abdominal trauma
5)OB/Neonatal
6)Peds
7)General medical

Gonna sign off for now, it's late and I gotta review some notes!
http://www.bemetweb.com
"...KMG-365, Clear..."

Know your author....

My personal review of
"Paramedic Practice Today - Above and Beyond"
by Barbara Aehlert (Author)

• Publisher: Mosby/JEMS; 1 edition (January 30, 2009)
• Language: English
• ISBN-10: 0323043747
  

"More info on the editor please....."
"February 11, 2009

By	Mark W. Boswell "www.BEMETweb.com"- See all my reviews on Amazon.com

As an educator and author I support my colleagues and peers in their professional publishing endeavours and I applaud Ms Aehlert for this most recent publication she has worked on.

Given the scope and breadth of her prior works I feel this will make a good core textbook for EMT/Paramedic programs, HOWEVER - I do not see Ms Aehlert's credentials relevant to her published work.

I would like to make it clear that Ms Aehlert is a Registered Nurse, and she is listed as the author/editor for a PARAMEDIC course textbook. I have researched her background and I cannot find her to have Paramedic or National Registry credentials. If I am wrong in this, and someone shows me some references, I will humbly stand corrected.

My personal feeling is that if you are going to put yourself so visible as an educator, author, editor then you should at a minimum state clearly the relevant credentials. In the classes I've authored and taught as well as my own publication, I clearly and unashamedly cite my credentials and I will never try to stand myself up as an authority figure on topics/material that I don't hold the appropriate credentials.

To the reader of this review, please be aware that I am not trying to bring any ill-will to Ms Aehlert nor to adversely affect her professional publishing, editing or authoring venues; I am only trying to point out something which I felt was lacking in reviewing this text and trying to help other potential purchasers as well due to the limited information presented in Amazon's product page.

Web citation regarding Ms Aehlert's background...

"Barbara Aehlert Is The President Of Southwest Ems Education, Inc. In Phoenix, Arizona And Pursley, Texas. She Has Been A Registered Nurse For More Than 30 Years With Clinical Experience In Medical/Surgical And Critical Care Nursing And, For The Past 18 Years, In Prehospital Education. Barbara Is An Active Cpr, First Aid, Acls, And Pals Instructor And Takes A Special Interest In Teaching Basic Dysrhythmia Recognition To Nurses And Paramedics. She Is A Consultant With The Southwest Ambulance Paramedic Program In Mesa, Arizona, And An Active Member Of The Pursley, Texas, Volunteer Fire Department" (www.eruditor.com/books/name/barbara_aehlert.1019422.html.en)

The EMS Truth Detector

Ever wonder if your patient is telling the truth or not? Often this is a dilema for pre-hospital and ER folks. Now after EXTENSIVE research and LABORIOUS review I have compiled some common patient sayings and given you a way to weigh the possiblity if your patient is speaking the truth or not. Look down the LEFT side to find your patient's statement, then look ACROSS to find the PERCENTAGE CHANCE THAT THIS IS THE TRUTH. Good luck and BE SAFE.



-KMG-365, Clear

How to predict injury severity

Okay, now we have a tool so you can predict just how serious/severe your next dispatch will be. Look on the bottom for any pertinent dispatch information given to you by your 911 Center, then cross reference it with the severity/seriousness description on the left side. ENJOY!

-KMG-365, Clear

The REAL reason for spinal precautions!

-KMG-365, Clear