Monitoring in the prehospital setting

It has always amazed me that the availability of adequate monitoring whilst working as a paramedic is substantially inferior to the monitoring available in other critical care settings.  Consider the following situation……you are responded to a person fallen from a second story balcony.  Your primary survey reveals the following:

A – Gurgling breathing, blood in the airway

B – RR 8/min, poor effort, reduced air entry bilaterally, SpO2 91%

C – HR 130/min, SBP 90 mmHg

D – LOC U (GCS E 1, V 1, M 4 = 6)

You work in an EMS which does not have drug facilitated intubation.  You have a monitor / defibrillator with 12 lead capability, a standalone pulse oximiter and a manual sygmanomometer.  You use colorimetric CO2 detectors for intubated patients.

The patient has their airway cleared, has an oropharyngeal airway inserted, and is requiring ongoing jaw thrust to maintain the airway.  A cervical collar and oxygen therapy are applied and ventilation is supported via mask and self inflating bag.  The patient is promptly loaded.  Lead II ECG monitoring is applied. Enroute  IV access established and IV fluids are commenced.  Your transport time to the nearest trauma centre is 15-20 minutes.

How many sets of complete observations are expected / required / possible?

In my mind, with the stated equipment (very common even in large ambulance services) and available resources, keeping in mind the acuity of this patient and the need for urgent transport (and the safety implications of this) is is my experience that this patient would end up (quite appropriately) with very few sets of complete observations despite paramedic vigilance and diligence   Continuous oximetry is practical, continuous heart rate monitoring is practical (via ECG), some assessment of respiratory rate and effort is possible, assessment of the quality of the radial pulse is possible (depending on whether you are alone in the back sorting A and B), and blood pressures – not very likely / practical.

The key objectives in the care of this patient would be to avoid hypoxia, maintain normocarbia, and to avoid hypotension.  These objectives would be more easily met with waveform capnography (would confirm a patent airway, confirm gas exchange / ventilation, guide ventilation frequency to achieve normocarbia, and to measure / record respiratory rate); non-invasive blood pressure auto-cycling at regular intervals, continuous oximetry with waveform (to give continuous oxygen saturation and an indication of quality of peripheral perfusion).

It strikes me that with technology so readily available that there is not increased effort to ensure that adequate monitoring of patients in the out-of-hospital setting is not more common.

Many argue about the reliability of using technology to monitor patients……my counter argument would be why is this acceptable in an ED, ICU and in the perioperative setting every day?  There are minimum standards for transport of critically ill patients published by the Australian New Zealand College of Anaesthetists (ANZCA), College of Intensive Care Medicine of Australia and New Zealand (CICM) and the Australasian College for Emergency Medicine (ACEM) (PS52) however this policy states “Standards for non-medical prehospital transport are determined by ambulance and emergency services and are not covered by this policy document.”

The increased availability of more sophisticated monitoring would likely also have benefits for non-critically ill patients being transported to hospital to ensure that at risk and deteriorated patients are identified.  Given the knowledge that respiratory rate is a neglected vital sign (Med J Aust 2008, 188 (11), 657-659) it would seem likely that the routine monitoring of ECG and respiratory rate (via thoracic impedance) during transport would improve the detection of at risk and / or deteriorating patients.  Another advantage of routine monitoring would be the availability of a record of the measured vital signs such as included on a printed summary of the patient encounter – this would have benefits for governance and safety, clinical audit and research, and would reduce the practice of “radar” observations.  A definitive record of vital signs for assessed and non-conveyed patients would be desirable.

I am not advocating that paramedics should not directly measure and record vital signs however I am suggesting that as the out-of-hospital setting is an extension of the emergency department and other critical care settings requiring assessment and judgement across the spectrum of acuity, that there needs to be a greater investment / effort in making improved monitoring available for paramedics – I predict that this would result in improved outcomes for patients.

As I reflect on the ANZCA  monitoring standards during anaesthesia (PS18), why should we expect less for critically ill patients in the prehospital setting?  All patients should have access to (as appropriate) monitoring of respiratory rate, oxygenation, ECG, intermittent non-invasive blood pressure and carbon dioxide monitoring. Standards for patient monitoring in the prehopsital setting are urgently needed as is the necessary capital funding to make this possible – this may be a role for the Council of Ambulance Authorities or Paramedics Australasia?

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