Keller Prehospital Ultrasound Study

In the last 30 years ultrasound has contributed greatly to many fields of medicine, emergency medicine has been no exception. In fact emergency medicine is currently one of the fastest growing uses of ultrasound technology. Just as the 12 lead machine was becoming widely popular in many ER's 25 years ago and found its way into the prehospital environment. There were many doubts as to the ability to train paramedics to read 12 leads and the necessity of the prehospital 12 lead. However a recent study showed paramedics to be on par with physicians in their ability to interpret STEMI's. And many paramedics now could not fathom a system without 12 leads. If a paramedic can be trained to interpret something as complex as a 12 lead, then it should be possible to train a paramedic to interpret an ultrasound. With the advances in ultrasound technology creating lighter, smaller, cheaper, and more durable machines, there is no reason not to put this valuable technology into the prehospital field. With its expanded role in the prehospital field, the 12 lead has moved from being a convenience to becoming a real tool with the ability to activate an emergency heart cath team from the field and bypass the ER saving precious minutes in door to balloon times. The ultrasound could soon do the same by alerting the surgical team of positive internal bleeding, ruptured ectopic pregnancy, or operable AAA and bypass the ER to go straight to surgery. This intervention could be life saving in the presence of these injuries. And to add to its usefulness, ultrasound can also help to gain intravenous access, determine endotracheal tube placement, detect pacemaker capture and determine a myriad of other less acute disease processes.

PURPOSE:

1. To determine the utility of ultrasound in the prehospital emergency environment of a suburban city.
2. To determine the ability to teach dual role firefighter paramedics multiple uses of ultrasound in the prehospital environment.
3. To determine the ability of dual role firefighter paramedics to accurately and rapidly perform ultrasounds in the field

HYPOTHESIS:

• The use of ultrasound in the field by dual role firefighter paramedics is poorly studied
• The use of ultrasound in a suburban environment is poorly studied
• Ultrasound will be performed on a clinically significant patient population
• A wide array of ultrasound procedures can be taught quickly and reliably performed by field paramedics with no prior ultrasound experience
• The use of ultrasound in the field will play a significant role in guiding the field presentation of a patient
• Just as the 12 lead did before it, bringing ultrasound into the field will lead to significantly better patient care

DETAILS:

• The study will be carried out in a city with a population of approx. 35000 with a non trauma hospital 15 minutes away and the trauma center 30 minutes away.
• The main priority of this study is that it will not interfere with patient care
• The study will be conducted at Keller Fire Station 4, C shift by Medic 584

PROCESS:

• The procedures will be taught on shift and then tested in a skills lab
• The ultrasound exam is performed by paramedics after patient has been placed in the ambulance.
• Paramedics will record still images of ultrasound views for future review by approved EM ultrasound reviewers. The paramedics read of the ultrasound results will be recorded. If the paramedic feels the ultrasound shows a positive result they will report this in their run report.
• The time it takes for the ultrasound to be performed will be recorded and any difficulty performing the exam will be noted.
• Any hospital diverts that occur, as a result of the ultrasound will be recorded.
• Electronic images will be saved for each scan, and an interpretation log sheet will be filled out. Scans will be over-read in a blinded fashion by a certified emergency medical ultrasound physician. Studies will be scored on technical adequacy as well as image quality.
• The interpretations of the ultrasound director will be compared to those of the EMS providers, and the proportion of adequate studies will be assessed.
• Performance on both a pre and post written and image-based test will be assessed before and after training.

PROTOCOLS:

PRIMARY EXAMS

• We will perform E-FAST exams on all trauma patients with any possible injury to the abdomen or thorax, mechanism indicating a need for the exam, or at the paramedic's discretion
• We will perform pregnancy exam on all female abdominal pain patients of child bearing age
• We will perform ultrasound guided venous access on patients whom IV access is difficult but the patient's condition requires IV access and does not indicate the need for IO, this procedure will be done at the paramedics discretion.
• We will perform AAA exam on all patients with a possible diagnosis of AAA. Measurements will be taken and compared to hospital measurements if available.
• We will perform cardiac echo on patients in cardiac arrest with possible PEA if it does not detract from patient care.

SECONDARY EXAMS

• We will perform renal ultrasound on all patients with flank pain to check for hydronephrosis. Positive findings will be documented.
• We will check for pleural effusion in patients with decreased SpO2 of unknown etiology, especially if known renal or hepatic disease
• We will determine ETT placement via ultrasound on every intubation if possible
• We will check for mechanical capture in transcutaneous cardiac pacing