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Busting EMS patient care and medication administration myths

EMS physicians debunked long-held beliefs about shock positioning, IV medication administration, and pregnant patient positioning

SAN DIEGO — While much progress has been made in using research to guide field patient care practice, we continue to perform daily activities according to tradition and expert opinion. Such were the topics of discussion in an EMS Mythbuster forum at the National Association of EMS Physician’s Annual Meeting.

John Gallagher, MD and John Lyng, MD, NREMT-P, FACEP described several practices that didn’t hold up to scientific scrutiny, but also spoke to the usefulness of debunking such processes.

Shock position
The Trendelenburg position doesn’t do anything to improve perfusion. However, placing the patient in shock in a leg-raised position can help identify patients who may benefit from rapid volume replacement. Moreover, there is good evidence to elevate the head of patients with traumatic brain injuries.

IV medication administration
Some EMS practitioners choose an IV administration port closest to the fluid bag to administer medications; sometimes referred to as the high port injection method. The rationale is that the fluid within the administration set will dilute the medication and it would administer more slowly. A simple test in a laboratory setting seemed to disprove that theory. Using a video, Gallagher showed that a small bolus of dye introduced into an administration set at the high port did not appear to dilute before entering a simulated vein.

Rapid adenosine administration
Some health care practitioners use elaborate setups to inject adenosine rapidly. Arm raises, stopcocks and other mechanisms are used to speed up the bolus injection. Using the same testing method Gallagher demonstrated that none of those methods worked. Using a stopcock actually split the dye bolus into two distinct doses.

Pregnant patient position
Nearly every EMS practitioner has been taught to lay a third trimester pregnant patient on her left side during transport to relieve assumed pressure on the aorta and vena cava. The literature would seem to indicate otherwise. While compression does occur, most patients have little to no symptoms. Moreover, in order to achieve a thirty degree elevation of the right hip and shoulder, the patient’s body would need to be lifted about ten inches off the cot, not an easy feat. For patients with no symptoms, transport them in their position of comfort. If there are symptoms, perform a manual left uterus displacement.

Cold and dead
The adage, “You’re not dead until you’re warm and dead” has been applied to hypothermia victims as a rationale for prolonged resuscitation. A patient hypoxic before hypothermia is dead. Hypothermia before hypoxia may confer a survival benefit due to a reduction in metabolic oxygen demand secondary to cooling and slowed metabolism. Moreover, administering shocks and epinephrine in hypothermic resuscitation appear to not be harmful.