Medical Director’s Update

by Dr. Chris Register

No Transports – The Myth, the Legend and the Protocol 

Recently a new protocol has been put into action in Pitt County which requires very specific documentation of a patients request for no transportation to a medical facility.  This protocol is designed to not only verify proper handling of the emergency call administratively, but provide adequate coverage and verification of proper medical care and disposition.   “No Transports” have become an issue not only locally but nationwide with several studies performed and numerous papers written.

     The findings range from death of 1 in 100 no transports, to a second request for 911 assistance and significant hospitalization.  Several studies have cited release of patients by paramedics without physician assessment as an area of controversy.  In one report, 2% of patients who initially refused transport against medical advice called 911 within 48 hours with a related chief complaint.  These patients tended to be over 65 and over half required admission, with one death enroute to the hospital [1].  Similarly, a study in a rural area showed that 48% who initially refused transport sought care at a later time, with 25% requiring admission and one in hospital death [2].  Patient refusals also pose significant medico legal concerns, with non-transport occasionally resulting in litigation [3].

continued    

County Update

by Jack Cote

Greetings from Pitt County Emergency Services;

Here is some news from our department.  The Pitt County Emergency Services Department has hired a full time fire inspector to fill a long vacant position.  Expect a formal announcement in early June.

We expect the the new EMS stations in Bethel and Bell Arthur will be completed and occupied by July 1st.  There is great excitement concerning the opening of these new stations in our department and in the EMS community.

Any squad using an M series Zoll Monitor/Defibrillator that desires training from Zack Taylor, the Zoll Sales Rep., can contact Zack directly.  If you don't have Zack's contact information get in touch with Jack Cote, Pitt County Paramedic Supervisor, for assistance in coordinating  a training at your squad's facility.

Lastly, according to Craig Forlines, Deputy Director Emergency Services and EMS Coordinator, look for some new computers and software updates early in the fiscal year for PDA Medic program.  Call the Emergency Services Office with any questions, and be advised we recently got a new phone system and new phone numbers.  The main office number is now 902-3950.

Jack Cote
Paramedic Supervisor
Pitt County EMS
902.3950 office
830.6348 fax

ED Update

by Gwen Wilson

Construction Update: Renovation of the old A-side of the ED continues. The current time line is to move into this space sometime around the beginning of August. At this time, a temporary trauma room is being built so the B-side can be closed for renovation starting in mid-August. 

Reminders: All EMS units are requested to take their extra backboards with them each time they come to the ED. The ED is the "front entrance" of the hospital for many people. The goals is to have all areas clean. With 30-40 EMS units arriving daily, there is not enough space to store extra boards and belts. 

Thank You: Just recently, EMS week was celebrated in honor of all EMS workers. PCMH supported the EMS seminar as a way to say thank you. In the rush of each day this appreciation may not be voiced or demonstrated. Each of your contributions are greatly appreciated. I cannot imagine what this county and our hospital would be like without the response of EMS!

Meetings and Events

QI Mtg – July 8, 9am Division of EMS

Pitt County Rescue Assoc. Mtg – July 13, 7pm

Emergency Services Center

EMS Advisory Committee Mtg – July15, 7pm

Emergency Services Center

EMS Con Ed Committee Mtg – July 28, 7pm

Emergency Services Center

ERAC Mtg – August 20, 10am

Monroe Building

Trainings

EMS Con-Ed June 16th @ PCC

(Pediatrics)

EMS Con-Ed July 21st @ PCC

(Toxicology)

Medical Director's Update - continued 

The No Transport protocol has been designed to streamline and alleviate some of the post call difficulties which may come into play if not followed.  Implemented October of 2003, the “No Transport” protocol on page 157 directly requires the provider to contact medical control after making an appropriate assessment of the patient and the scene.  The only time that medical control need not be contacted is in the event of a minor MVC with absolutely no injuries.  If any question arises as to the appropriate action needed, never hesitate to contact medical control for guidance.   It is imperative for the individual as well as the service that these protocols be followed.  Just think, 1 death in 100, where are you on that spectrum?  Be safe and remember – we are all in this together.

Dr. Chris Register

registerch@mail.ecu.edu

Clinical Faculty, Department of Emergency Medicine

East Carolina University School of Medicine

References:

1. Moss ST, Chan TC, Buchman J, Dunford JV, Vike GM: Outcome study of prehospital patients signed out against medical advice by field paramedics.  Ann Emerg Med 1998; 31:247-50. 

2.Burstein JL, Henry MC, Alicandro J, Gentile D, Thode HC Jr., Hollander JE: Outcome of patients who refused out of hospital medical assistance.  Am J Emerg Med 1996; 14:23-6 

3. Golberg RJ, Zautke JL, Konigsberg MD, et al: a review of prehospital care litigation in a large metropolitan EMS system. Ann Emerg Med 1990; 19:557-61

Final Thoughts

by Chris Starbuck

Emergency Medical Services in Pitt County have recently started using quantitative End-Tidal Carbon Dioxide(ETCO2) devices that displays a waveform. We have long been using colorimetric ETCO2 devices for endotrachial intubations. The addition of the numerical value and waveform will allow for continuous monitoring of tube placement,  ventilation, and even dianogistic applications in the future. Some researchers are even looking at using ETCO2 to predict the outcomes of patients in full arrest{3,4}. ETCO2 has even been studied for use in termination of CPR{5}.

"Capnography has not been embraced by clinicians as pulse oximetry has for several reasons. Historically, the equipment used to monitor ETCO2 was bulky and was cumbersome to use. The mainstream airway adapters were heavy and could easily displace a neonatal endotracheal tube. Mainstream cables were costly to replace, and windows clouded by condensation incapacitated the monitor. Some equipment could be used only for intubated patients (or required further calibration and manipulation before it could be used for nonintubated patients)"{2}.

"Sidestream sampling had its problems as well. Secretions and condensation caused constant occlusion alarms. Tedious calibration was necessary when other anesthetic gases were used or when the Fio2 was raised above a certain percentage. High sample flow rates in sidestream monitors also competed for tidal volume in the low-weight patient. Clinicians had to be cognizant of proper sample techniques or mixing would occur, rendering the resulting number and waveform useless"{2}.

"Third-generation capnographs are now available, and many of the past’s problems have been resolved. Several manufacturers make small monitors that are ideal for use in prehospital or intrahospital transport situations. Multiparameter monitors are also available with the latest technological advances. The technology does not require cumbersome calibration in the presence of other gases, and a spontaneously breathing patient can easily be monitored via nasal cannula or mask interface. If the same patient deteriorates and requires intubation, continued monitoring is accomplished by simply changing the interface connection at the monitor"{2}.

With a numerical display and the waveform, the provider can determine if they are adequately ventilating the patient and/or maintaining tracheal intubation{7}. The use of the waveform can also be used in determining bronchospasm{8}.  Check out the link below for the waveform review website.

Both litmus and digital devices have their draw-backs. The colorimetric devices requires the user to bag six full breaths and  it cannot detect hyper-or hypocarbia{1}. Mainstream ETCO2 requires calibration and expensive cables, while side stream devices require a large sample size{2}. Microstream, like side stream, tubes can become occluded{7}. 

As always, new technology in health care, leads to new research and improvements in patient care{9}.

Whichever device is available, having it will provide an adjunct to your assessment.  With groups like the AHA, ACEP, and the NAEMSP publishing it's recommended guidelines for ETCO2 use, it has become a standard of care{9}. Just as rhythm strips defend your assessments and treatments, capnography strips will defend your intubations. Hopefully, this will improve the monitoring and one day the diagnosis of our patients.

ETCO2 links

1. http://www.jpgmonline.com/article.asp?issn=0022-3859;year=

1994;volume=40;issue=2;spage=78;epage=82;aulast=Bhende

2. http://www.rtmagazine.com/articles.ASP?ArticleId=R0012A04

3. http://www.enw.org/ETCO2inCPR.htm

4. http://content.nejm.org/cgi/content/short/337/5/301

5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=

Retrieve&db=pubmed&dopt=Abstract&list_uids=9498946

6. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=

Retrieve&db=PubMed&list_uids=8273953&dopt=Abstract

7. http://www.capnography.com/Homepage/HomepageM.htm

8. http://www.medtronicphysiocontrol.com

/documents/WP-Capno3202397.pdf

9. http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=

searchDB&searchDBfor=art&artType=fullfree&id=ajem0301028

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=

pubmed&dopt=Abstract&list_uids=11376503

Nice site with waveforms for review:

http://www.capnography.com/find.htm

Follow this link to take the Capnography Quiz:

http://www.nepeanicu.org/Capno.htm