Dear all,

As I read through Jon Nicholls, Sue Hughes, Janet Turner & David Yates
report 'The costs and benefits in paramedic skills in pre-hospital care'
published in the Health Technology Assessment 1998 - I question my current
working practice and try to solve the shortfalls which have been brought
into question from the report. Like many people in our profession you see a
problem and one seeks ways around it or confront it head on.

I am going to put forward a concept, not new to some, which goes against
historical teaching and patient care. I would like both acad-ae-med and
999listserv to advise me why this won't work or why it would be detrimental
for the patient / receiving doctor.

Please - I do not wish to debate the report in general, or the weakness in
this report. I realise there are many questions to be asked from the
report - why is there IV access with no fluid administration. Is mortality
down to the ambulance crews or patient care in the AEU - hypotensive
therapy - cannulating en-route etc, etc - these and many other things have
been suggested to me. We can address these at some other time.
I just want to discuss reducing 'on scene' times with a slightly different
approach to fluid administration.

THE REPORT CONCLUSIONS
1. No evidence to suggest that a substantial number of pre-hospital deaths
are avoidable.
2. Protocols used by paramedics increase mortality from serious trauma
involving bleeding.
3. An increase in mortality may be due to delays on scene or inappropriate
pre-hospital infusion.
It is number three that I wish to address. How do we reduce on scene time
and hopefully reduce mortality?

THE ONLY PRE-HOSPITAL INTERVENTION AVAILABLE TO PARAMEDICS (figures from the
report)
Intervention		No. of Cases	Percentage
Cannulation
Attempted			293			33.8
Successful			274			31.6
Fluids			160			18.4
Intubation
Attempted			16			1.8
Successful			10			0.7
Given drugs			87			10.0
All patients with PRF	868			100.0


EXTENDED TIME ON SCENE
Paramedics took an extra 12 minutes on scene to perform intubation or
cannulation*
*Results on executive summary
If we address cannulation first we can look at intubation at some time in
the future.

QUESTION:
Would a smaller cannula reduce on scene time and still give the necessary
fluid needed for trauma?
14g vs. 18g Cannula

HISTORY
In days gone by (pre evidence based medicine)we were told to that for
hypovolaemia we should stick the patient with a wide bore cannula for
infusion. I am not sure how widespread this still remains in protocols up
and down the country but I see many paramedics attempting to achieve this
with different degrees of success. I have just over a 60% success rate for
first time 14g insertions (64% based on last years personal stats).
I question the need for such a wide bore cannula.


POTENTIAL PROBLEMS WITH LARGE GUAGE CANNULATION
Requires greater skill
Sometimes, too big for distal veins
More difficult with shut down veins
It is very painful for the patient
More fluid can be run through (good or bad??)

BENEFITS OF SMALLER CANNULA
Easier to introduce
Less painful for the patient
Higher success rate of patent cannulation
Larger veins remain intact for the AEU’s
May result in less time on scene
Maximum fluid administration maintained (see below)


APPROXIMATE FLOW RATES
Size		ml/min
22g		31
18g		80
16g		170
14g		213

NORMAL TOTAL FLUID ADMINISTRATION BY PARAMEDICS (on own initiative)
Total fluid allowed to be administered by paramedics is 2 litres (in most
areas, without doctor intervention)

THE REPORT IDENTIFIED
Intravenous fluids were given in 160 out of the 274 cases which were
successfully cannulated (58%)
Of those given fluids 68% had less than 500mls.

QUANTITY vs TIME
	10 min	20 min	25 min
18g	800ml		1600ml	2000ml
14g	2130ml	4260ml	5325ml

How fast can we get through our 2000mls
14g = 2130 mls in 10 minutes
18g = 2000 mls in 25 minutes

PARAMEDIC/PATIENT CONTACT TIMES
It would not be unreasonable to say that most on scene times are 15 minutes
or over (recent Sussex audit states 17 min average on scene time) and the
running times to AEU is probably about 10 minutes (similar figues are
reflected in the report). This gives a total paramedic/patient contact time
of 25 minutes. With this figure in mind it is possible to suggest that we
can infuse the maximum fluids available to us within the contact time with
the patient of 25 minutes (on scene to arrival at hospital).

Would this be in the best interest of the patient?
Would this reduce on scene time?
Are there any reasons anyone can think of that we shouldn't go down this
road?
Any other thoughts on the subject.


Mike Bjarkoy
Paramedic
Sussex



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