Myths Busted: Expo Session Questions Traditional Care Protocols
Kenneth A. Scheppke, MD, FAAEM, chief medical officer for Palm Beach County Fire & Rescue, presented a “Mythbusters”-style presentation Thursday afternoon Oct. 19 during EMS World Expo in Las Vegas. Scheppke’s talk, “What’s the Future in EMS,” challenged longstanding traditions in patient care that have not withstood current evidence. Scheppke covered several interventions, including:
For chest pain, nitroglycerin seems to be on its way out. The research shows little benefit for causes other than ischemic chest pain, Scheppke said. Risk of hypovolemia, contraindications with erectile dysfunction medications, and the chance of making the patient worse outweigh its limited benefits.
The verdict: It’s a “risky pain killer,” according to Scheppke.
Oxygen used to be much more widely administered in EMS, and is also being phased out for many patient presentations. Hyperoxia can be toxic in many clinical scenarios, Scheppke explained. For most indications, clinicians should not raise blood oxygen higher than normal oxygen saturation. The goal is normoxia, which could mean transporting a patient on room air only. Possible exceptions include cases of TBI, pregnancy and stroke, Scheppke said.
Spinal immobilization is no longer seen as the go-to mainstay of acute trauma management. Traditional dogma held that additional movement following a fall or impact to the spine may worsen or even cause spinal injury, and that immobilization could prevent it.
However, no randomized controlled trial to date supports this hypothesis, Scheppke pointed out. In early studies supporting spinal immobilization, the “worsening” of symptoms in the absence of immobilization may have actually been caused by post-injury swelling. No well-designed studies support the use of spine boards, and in fact the research suggests that they may actually cause further harm through effects such as respiratory inhibition, pressure sores, and increased pain.
Soft-surface stretchers may be the better choice, said Scheppke, since they conform to the patient’s body and rise to fill in the cavities between patient and surface. Since soft surfaces are not often practical in patient extrication and transport scenarios, Scheppke’s system has shifted to scoop stretchers as a movement device.
If the patient is awake following a fall, accident or other trauma, it’s usually better to direct them to move themselves onto the stretcher under their own power. Self-extrication after crashes results in four times less movement, Scheppke said, adding that patients are better at self-limiting motion than care providers are.
Cervical collars are another EMS mainstay that may not stand up to current scientific scrutiny, said Scheppke. Cervical collars carry the danger of collapsing the jugular vein, thereby inhibiting venous return and increasing intracranial pressure. They can complicate airway management and elevate the risk of failed airway attempts, according to Scheppke.
As such, soft collars are making a bit of a comeback, more as a marker of an uncleared C-spine and a reminder to staff and patients that this is a potentially injured area that should be handled with care.
“There’s no such thing as spinal immobilization,” Scheppke concluded, adding that EMS providers can limit movement at best.
Scheppke is not advising EMS professionals to abandon immobilization entirely. In many cases it still makes sense, and still falls under the “standard of care” mandate in many jurisdictions. But agencies need to change the tools they’re using to achieve it, the scenarios in which it makes sense, and above all, the thought processes that underlie its clinical rationale.