Vaccine-Preventable Outbreaks

This map(1) isn’t prehospital medicine-related, but it’s just so striking that I had to share it.

1. Council on Foreign Relations. Map: Vaccine-Preventable Outbreaks [Internet]. Council on Foreign Realations. [cited 2014 Oct 25]. Available from:–link2-20141023&sp_mid=47257856&sp_rid=ZWFuZHJld0BsYWJ4LmNvbQS2#map

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Two Part Article on Evidence Based EMS

I’ve got a two-part article on understanding evidence based EMS over at “Evidence Based EMS” is a hot topic in our industry right now, but it’s more of a buzzword than anything else in a lot of quarters: if you’d like a deeper understanding of the concept, I’d invite you to take a look:



Last updated: February 1, 2014 at 19:20 pm

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Research Review: Oxygen therapy for sepsis patients in the emergency department: a little less?

There’s a small observational study currently in pre-press at the European Journal of Emergency Medicine on oxygen therapy in the initial resuscitation of sepsis patients. The authors looked at 83 septic patients in the emergency department, examining their arterial blood gasses during initial resuscitation using the standard sepsis protocol of the hospital where the study was conducted. Unlike most initial resuscitation protocols for sepsis which I’m familiar with, this particular institution calls for 40% oxygen by venti mask and only gives 100% oxygen by NRB in the event that a patient is actually found to be hypoxic. Despite this relatively conservative oxygen protocol, the authors found that the vast majority (77.9%) of those patients who received 40% oxygen by venti mask were hyperoxic.(1)

I’ve talked about the harm of blowing high-concentration oxygen at everyone who looks vaguely uncomfortable before: the way we keep doing this in EMS is harming patients by making them hyperoxic.(2–4) This study small and not nearly powerful enough to examine mortality in hyperoxic patients vs. normoxic patients, but it would be nice to see some follow-up research covering the topic. In an ideal world, this data would be another nail in the coffin of the practice of giving high-flow oxygen to anyone and everyone who is really sick and gets loaded into an ambulance, but we’ve had high-quality evidence that this is a harmful practice for a long time and one small observational study seems unlikely to change anything. Suffice to say, I won’t be holding my breath.


1. Stolmeijer R, Ter Maaten JC, Zijlstra JG, Ligtenberg JJM. Oxygen therapy for sepsis patients in the emergency department: a little less? Eur J Emerg Med Off J Eur Soc Emerg Med. 2013 Apr 21;

2. Corsonello A, Pedone C, Scarlata S, Zito A, Laino I, Antonelli-Incalzi R. The oxygen therapy. Curr Med Chem. 2013;20(9):1103–26.

3. Richard D Branson, Jay A Johannigman. Pre-Hospital Oxygen Therapy. Respir Care. 2013 Jan;58(1):86–94.

4. Sjöberg F, Singer M. The medical use of oxygen: a time for critical reappraisal. J Intern Med. 2013 Dec;274(6):505–28.


Last updated: February 1, 2014 at 12:35 pm

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Research Review: Volume replacement with Ringer-lactate is detrimental in severe hemorrhagic shock but protective in moderate hemorrhagic shock, studies in a rat model

Critical Care recently published a small study on hemorrhagic shock and fluid replacement using rats entitled Volume replacement with Ringer-lactate is detrimental in severe hemorrhagic shock but protective in moderate hemorrhagic shock: studies in a rat model. The study authors compared fluid resuscitation outcomes for Ringer’s Lactate and Ringer’s Saline in rats with moderate and severe shock. Except for a control group of 6, the rats were divided into groups of 8, put into shock by removing a predetermined amount of blood from them using a syringe, and then treated using either Ringer’s Saline or Ringer’s Lactate.(1)

Of the rats in the study:

  • 2 out of 8 rats with moderate shock survived when given Ringer’s Saline.
  • 8 out of 8 rats with moderate shock survived when given Ringer’s Lactate.
  • 2 out of 8 rats with severe shock survived when given Ringer’s Saline.
  • 0 out of 8 rats with severe shock survived when given Ringer’s Lactate.
  • 6 out of 6 rats in the control group survived.

The authors did some relatively sophisticated statistical analysis that was also not really completely reported, possibly because the study is still in provisional stage and doesn’t have its graphs yet. They also drew some pretty expansive conclusions from their data, saying:

The present study clearly demonstrates that (Ringer’s Lactate) is toxic in the resuscitation of severe hemorrhagic shock but protective in the treatment of moderate hemorrhagic shock. . .

This is the kind of laboratory-based study that has to be handled with care in a lot of ways. For one thing, it’s tiny: each study group only contained 8 individuals. That’s not large enough to make changes to what we do in the clinical setting on. It’s also an animal model study, and just because something works one way in rats doesn’t mean it works that way in humans. Finally, the study also has some pretty hairy design issues: instead of instead of a moderate shock control group and a severe shock control group which wouldn’t receive any treatment, the authors just kept six rats in a cage and called that their control. We don’t know how many rats would have survived from either group without any fluids being given.

The results they got at the moderate shock level are really intriguing. 8 vs 2 is a big enough difference to suggest a real difference in outcome between Ringer’s Lactate and Ringer’s Saline. That said, we can’t say anything useful about fluid resuscitation in severe shock because this study is just too small and so are the differences in outcome (2 vs 0 out of 8 rats surviving), despite the authors’ statistical analysis and conclusions. Given the huge difference in outcomes for moderate shock, it would be really nice to see some larger, better-designed follow-up research on lactate vs. saline.

Even though this small study reached a negative conclusion about Ringer’s Lactate in severe shock, several previous studies have found Ringer’s Lactate is superior to Normal Saline for fluid resuscitation in both moderate and severe shock,(2–4) In prehospital care, especially at the BLS level, we tend to just say “Normal Saline and Ringer’s Lactate are basically the same thing” and leave it at that, but understanding crystalloid volume replacement is something the NOCP puts within the scope of what BLS providers are expected to understand.(5) Even if the ultimate decision about which fluid we carry is made by our medical directors, it might be time for us as a profession to start paying more attention to the differences.



1. Hussmann B, Lendemans S, Groot H de, Rohrig R. Volume replacement with Ringer-lactate is detrimental in severe hemorrhagic shock but protective in moderate hemorrhagic shock: studies in a rat model. Crit Care. 2014 Jan 6;18(1):R5.

2. Healey MA, Davis RE, Liu FC, Loomis WH, Hoyt DB. Lactated ringer’s is superior to normal saline in a model of massive hemorrhage and resuscitation. J Trauma. 1998 Nov;45(5):894–9.

3. Phillips CR, Vinecore K, Hagg DS, Sawai RS, Differding JA, Watters JM, et al. Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer’s: effects on oxygenation, extravascular lung water and haemodynamics. Crit Care Lond Engl. 2009;13(2):R30.

4. Todd SR, Malinoski D, Muller PJ, Schreiber MA. Lactated Ringer’s is superior to normal saline in the resuscitation of uncontrolled hemorrhagic shock. J Trauma. 2007 Mar;62(3):636–9.

5. Paramedic Association of Canada. National Occupational Competency Profile [Internet]. 2011. Available from:

Last updated: January 8, 2014 at 23:35 pm

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Anaphylaxis Presentation at Training For Life in Gander, NL

I’m presenting on anaphylaxis today at the St. John Ambulance NL Council’s 35th annual Training for Life Conference in Gander, NL, and the slide-set and references for this presentation are available here.

Anaphylaxis is a topic which doesn’t get extensive coverage in standard first aid (St. John Ambulance presently devotes two slides to it, and the Canadian Red Cross devotes one), but it’s an increasingly common problem in our society.(1) This slide-set covers the topic more extensively from a first-aid perspective, and is available for free under the Attribution-ShareAlike 2.5 Canada license. (Please contact me if you’d like to use it without the attribution or “share alike” requirements.)

The slides are in Open Document format, and can be opened using LibreOffice, which is available for free at


1. Tang ML, Osborne N, Allen K. Epidemiology of anaphylaxis. Current Opinion in Allergy and Clinical Immunology. 2009 Aug;9(4):351–6.


Last updated: October 19, 2013 at 16:57 pm

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Research Review: Identification of Adult Septic Patients in the Prehospital Setting

A new retrospective chart-review study comparing two prehospital sepsis screening tools entitled Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment has just been published ahead of print in the European Journal of Emergency Medicine.(1) The authors did a retrospective study comparing a previously-unvalidated sepsis screening protocol published by Robson, et. Al in 2009, an also previously unvalidated sepsis screening protocol in use in Sweden, referred to as “BAS 90-30-90,” and provider clinical judgement, which was defined as when a prehospital practitioner recorded a clinical impression of sepsis or a similar term. The authors looked at a retrospective cross-section of 353 patients, and found that the Robson tool would identify 75% of patients later found to be sepsis, BAS 90-30-90 would have caught about 43%, and practitioner clinical impressions only caught about 12% of septic patients.

This study makes the Robson criteria look like a very nice option for prehospital sepsis detection. According to the current authors’ adaptation of that tool, whenever any of the following are present in a patient with a history suggestive of infection, a patient may be considered septic:*

  • Temperature > 38.3º or < 36.0º
  • Heart rate > 90 bpm
  • Respiratory rate > 20 breaths/min
  • Acutely altered mental status
  • Plasma glucose > 6.6 mmol/l (119 mg/dl) unless diabetic

The 75% detection rate found with the Robson criteria even puts it ahead of Guerra et. al’s tool, which required point-of-care lactate testing.(2) Those are impressive numbers, and they don’t even require a fancy new toy. I also like that this tool includes hyperglycemia as a criteria: that’s one of the canonical signs of sepsis according to the international consensus criteria,(3) but even though we all carry glucometers it’s a sepsis sign we usually overlook in the prehospital environment.

The finding that prehospital practitioners aren’t good at identifying sepsis is unfortunately not surprising, given the research that shows we as a profession don’t have a very good understanding of what sepsis is,(4) but it is fairly disturbing to see numbers this low. It indicates a crying need for EMS practitioners to have more education on this topic. Can you imagine if EMS only picked up on 12% of CVAs or AMIs in the field?


* The authors of the current study include a fairly heavy-handed statement with their adaptation of the Robson criteria that “to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.” However, I believe my recounting it here is an insubstantial infringement, and even if it were found to be a substantial infringement by a court I believe that this blog article, which is a critical review of the authors’ article, would be protected as fair dealing under the copyright laws of Canada, where this blog resides, the UK, where the European Journal of Emergency Medicine is published, and/or as fair use in the United States, where the European Journal of Emergency Medicine’s website resides.


1. Wallgren UM, Castrén M, Svensson AEV, Kurland L. Identification of adult septic patients in the prehospital setting: a comparison of two screening tools and clinical judgment. Eur J Emerg Med Off J Eur Soc Emerg Med. 2013 Sep 30;

2. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early Detection And Treatment Of Patients With Severe Sepsis By Prehospital Personnel. J Emerg Med [Internet]. 2013 Jan [cited 2013 Jan 14]; Available from:

3. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003 Apr;31(4):1250–6.

4. Báez AA, Hanudel P, Perez MT, Giraldez EM, Wilcox SR. Prehospital Sepsis Project (PSP): Knowledge and Attitudes of United States Advanced Out-of-Hospital Care Providers. Prehospital Disaster Med. 2012;FirstView:1–3.


Last updated: October 6, 2013 at 22:30 pm

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October 28-November 1st is Canadian Patient Safety Week

Image Copyright 2013 Canadian Patient Safety Institute. Used by permission.Coming up at the end of next month is Canadian Patient Safety Week (CPSW), from October 28th until November 1st, an event sponsored since 2005 by (rather appropriately) the Canadian Patient Safety Institute (CPSI). Medication safety is this this year’s CPSW theme. According to CPSI, medication errors play a role in about 10% of all hospital admissions in Canada, and 25% of all hospital admissions for elderly patients.(1) That translates into a pretty significant chunk of the people we care for.

EMS practitioners don’t always see a lot of the work that goes into home medication safety, but there are a few things we can do to help keep our patients safe medication-wise. First and foremost, whenever possible we can take the time to get a thorough medication list including whether the patient is complaint with his or her medications. Oftentimes we are the only health professionals who will see our patients in their own home environment, and that puts us in a unique position to pick up on a variety of safety issues which other providers might not be aware of, including medication issues. Canadian Patient Safety Week might also be a good time to find out if your community has a Vial of Life program, and to get familiar with it if there is one.

During Canadian Patient Safety Week, CPSI is also sponsoring a free program called “Canada’s Virtual Forum on Patient Safety and Quality Improvement,” which is about twenty hours worth of free presentations and panel discussions. While most of the sessions are focused on inpatient and ambulatory care, there are a couple of items which may be interesting to prehospital practitioners including a panel session on infection control entitled “Stop Infections Now Collaborative Team Rapid Fire” and a professionalism-focused presentation entitled “Changing Attitudes and Prejudice in the Workplace.” There’s no word yet on whether or not certificates of completion will be available to claim CME credit, but I do have an inquiry in to the CPSI and will post an update when I find out.

You can register for Canadian Patient Safety Week and Canada’s Virtual Forum on Patient Safety and Quality Improvement at

1. Canadian Patient Safety Week Communications Toolkit 2013. Canadian Patient Safety Institute; 2013.

Last updated: September 30, 2013 at 17:46 pm

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Research Review: A Study into Pre-alerts to North East Hospitals for Sepsis

©2013 MA Healthcare Ltd. Use believed to constitute fair dealing.

A few months ago the Journal of Paramedic Practice published a time-control cohort study on the impact of a Sepsis Screening Tool (SST) introduced in Northeast England in 2012.(1) The authors examined patient care reports for patients transported by the North East England Ambulance Service during various months between October 2011 through March 2013 and tallied the number of times EMS pre-alerted the emergency department about an incoming sepsis patient each month. The authors used textual analysis of the electronic patient care reports to capture their data. The ambulance service being examined introduced a program of sepsis education consisting of a one-hour class available and to and mandated for its staff between March 2012 and April 2013, put out a “patient care update” on sepsis in July of 2012, and launched its sepsis screening tool in March of 2012. The authors found a statistically significant, actually fairly large, difference in the total number of sepsis pre-alerts issued before and after the introduction of the screening tool. They also found a somewhat more modest difference increase in the proportion of cases meeting the authors’ sepsis screening criteria which were pre-alerted after the introduction of the SST, from 87% to 94%, and they did not report on the statistical significance of this change.

The methodology in this study is problematic. There are a lot of reasons, but one of the most important is that the authors a priori deemed that the criteria in the SST they’re using defines sepsis, saying “The introduction of the SST has changed sepsis from a vague and nebulous concept to a defined, therefore measurable, condition with a specified treatment bundle,” and from there they essentially studied whether or not paramedics were able to use it or not. Secondly, the time-control design that coincides with a program of sepsis education means acts as a confounding factor which makes it impossible to differentiate the effects of the sepsis education from the effects of the SST; the study looks more appropriate for an observational study than a time-control study. Finally, while the authors used textual analysis to capture their data they don’t address inter-rater reliability, and their data collection process changed towards the end of the study “due to changes in IT capabilities.” The authors recognize many of these limitations, particularly the need for their SST to be empirically validated, but the limitations make it difficult to generalize any conclusions from this study.

Even though the sepsis screening tool introduced in this study is not actually validated I think it’s probably the most valuable tidbit that can be gleaned here. While a validated prehospital sepsis screening tool does now exist in the literature(2), that tool requires the use of point-of-care lactate testing. In the present study’s SST point-of-care lactate testing is optional, but not required. While this present study’s tool needs to be validated and therefore can’t be considered evidence-based yet, I think it’s nice that it’s at least gotten into the literature.


1. McClelland G, Younger P. A study into pre-alerts to North East hospitals for sepsis. J Paramed Pr. 2013 Jul 1;5(7):408–15.
2. Guerra WF, Mayfield TR, Meyers MS, Clouatre AE, Riccio JC. Early Detection And Treatment Of Patients With Severe Sepsis By Prehospital Personnel. J Emerg Med [Internet]. 2013 Jan [cited 2013 Jan 14]; Available from:

Last updated: September 27, 2013 at 21:07 pm

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Short YouTube Video of a Flail Chest

I was on YouTube looking for something else, and I just came across a really cool video of a patient with a large, obvious flail chest segment. It’s been up for a while (posted in 2010), but it’s still worth a quick watch.



1. Medical Tube- Flail Chest [Internet]. 2010 [cited 2013 Sep 16]. Available from:


Last updated: September 16, 2013 at 20:14 pm

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Research Review: Two Studies on Supraglottic Airways

There’s a really interesting pair of studies in the European Journal of Emergency Medicine right now on lay rescuers and supraglottic airways. One is entitled Laryngeal tube placement on manikin by laypersons: is there a possibility for ‘public access airway management’? And it examines King LTs in the hands of lay rescuers. The authors rounded up 71 patients and visitors from a large German hospital, none of whom had any medical training beyond first aid, gave them a King LT and an instruction card, and asked them to insert the device into a manikin. Next, the researchers demonstrated how to insert the King LT, and had the participants try again. The study participants inserted the King LT correctly 53% of the time with only the instruction card, and once they had been shown how to do it they inserted the device correctly 98% of the time.(1) The other study is entitled Evaluation of advanced airway management in absolutely inexperienced hands: a randomized manikin trial, and it examines a number of airway devices. The authors took 50 Viennese medical students in their first month of training, none of whom had any previous airway management or resuscitation experience, gave them a one-hour lecture on airway management. The study participants were then asked to perform mechanical ventilations using a variety of supraglottic airways, traditional endotracheal intubation, and traditional bag-mask ventilations. At that time, the students successfully managed the airway 74% of the time using an ET tube, 86% of the time with bag-mask ventilations, and 100% of the time with all the supraglottic airways. The participants were re-evaluated after three months, and achieved 64% success rates with ET tubes, 84% with bag-mask ventilations, and 100% with the supraglottic devices.(2) Both of these studies look like fairly solid science, with reasonably good study designs and large-ish sample sizes for the topic being studied.

With the caveat that the use of medical students in the Viennese study probably limits how much we can generalize from it, as these participants aren’t very representative of the first-aid-giving public, the take-home message from this data seems to be that supraglottic airways should be much more widely available than they are now. This isn’t the first time a study has found that lay rescuers can insert supraglottic airway devices with a minimum of training. A few years ago, another German study was published involving several different airway devices, including King LTs and LMAs, which found that lay rescuers successfully inserted the devices more than 95% of the time after a three-minute training session.(3) Three minutes of training could easily be added to Standard First Aid, though if the history of public-access defibrillation in Canada is any guide, there would be probably be significant legal obstacles to implementing intermediate airway management as a first-aid measure here.

This data which makes supraglottic airways look like a feasible first-aid measure really does make me wonder why they’re not more widely available to BLS providers in Canada. Unlike first-aiders, we have the legal regime to insert supraglottic airways already in place. The King LT is roughly a $40 device, so it’s not expensive compared with a lot of EMS equipment.(4) Now we’ve seen that if you grab random people essentially off the street and show them how to insert a King LT once, they’ll be able to do it correctly 98% of the time. It’s mind-boggling that there are places where these tools aren’t available to every EMR who has some form of medical control, let alone every primary care paramedic.


1. Jänig C, Marquardt S, Dietze T, Nitsche T. Laryngeal tube placement on manikin by laypersons: is there a possibility for “public access airway management”? Eur J Emerg Med Off J Eur Soc Emerg Med. 2013 Jul 24;

2. Goliasch G, Ruetzler A, Fischer H, Frass M, Sessler DI, Ruetzler K. Evaluation of advanced airway management in absolutely inexperienced hands: a randomized manikin trial. Eur J Emerg Med Off J Eur Soc Emerg Med. 2013 Oct;20(5):310–4.

3. Schälte G, Stoppe C, Aktas M, Coburn M, Rex S, Schwarz M, et al. Laypersons can successfully place supraglottic airways with 3 minutes of training. A comparison of four different devices in the manikin. Scand J Trauma Resusc Emerg Med. 2011;19:60.

4. King LT-D Supraglottic Airway [Internet]. Remote Med. Int. [cited 2013 Sep 4]. Available from:


Last updated: September 4, 2013 at 23:23 pm

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