Saturday, November 20, 2010

The Story of Dr. Trendelenburg’s Position

If you look in nearly any EMS text book you will find Trendelenburg’s Position defined as “a position in which the patient’s feet and legs are higher than the head.  This is sometimes known as the 'shock position.'”
Dr. Friedrich Trendelenburg would argue that a “true” form of the position named for him involves placing the patient at a 45 degree angle with the head lower than the patient’s feet, with their legs bent at the knees and hanging off the end of a table. But he was also using the position to keep the intestines out of the pelvis during gynecological procedures and to reduce venous vein pressure during varicose vein surgeries. Little did Friedrich know that his simple to use position would later be called to use in the treatment of nearly all patients with signs of severe shock.
The March to War
It was not until the First World War, when a young American Physiologist, named Walter Cannon, was sent to Europe (with a medical team from Harvard University) that Dr. Trendelenburg’s ‘Beckenhochlagerun’ (Raised Pelvic Position) found worldwide popularity.
Dr. Cannon set out to find ways to combat the effects of shock in wounded GIs. He popularized the use of the Trendelenburg’s position to increase venous return to the heart and thus increase cardiac output (CO). The simplicity of this treatment caused it to be widely popular and easily adopted. As such, it is still taught worldwide to this day.
Unfortunately Dr. Cannon’s announcement, ten years after World War I, was not so popular. After further study Dr. Cannon found the increased CO to be detrimental, along with creating complications with pulmonary function.
How did EMS get stuck with this?
Emergency Medicine’s love affair with Trendelenburg’s Position likely stems from the same place it finds many of its standard practices; military medicine. Through the years war has been the driving factor behind many innovations in emergency medicine including MAST pants and air evacuation. The former has been widely discarded while the latter has saved countless lives.
Since the early days of EMS the “shock position” has been there, always a reliable back up to use if a patient was hypotensive. And many still widely believe it to work, every time, without consequence. EMS, as with much in the world of medicine, will defend dogma vehemently until a respected authority tells them to stop. Or said dogma is specifically banned.
I posed the question, of why Trendelenburg is so hard to let go of, to Sean O. Henderson, MD, via email in 2007. Dr. Henderson was the co-author of a 2003 Canadian Journal of Emergency Medicine piece ‘Myth: The Trendelenburg Position Improves Circulation in Cases of Shock.’
Dr. Henderson wrote to me:
“The ‘shock position’ is very popular. In the allied health professions and we do not have a central clearing house for ‘dogma’ testing. MD’s are bad enough within our own house, but to imagine the tainted information that gets out to nurses and prehospital care providers is frightening.”
That said, a simple internet search will show that there is a movement amongst EMS community discussion forums to stop using Dr. Friedrich Trendelenburg’s famous position. But, there are always opposing views that support the “old tried and true.” Like basic first aid training from the American Heart Association, which still includes “elevating the legs to prevent shock” for a traumatic injury.
At the most basic level Trendelenburg’s Position is STILL being taught as the way to treat shock.
The continuation of this is further perpetrated by the NREMT curriculum and text books. Brady’s 10th Edition EMT-Basic text  advocates the use of Trendelenburg in the event of shock, but is conscientious enough to advise the student not to use the position if the patient has a head injury. This is not only a simplistic, but dangerous view.
There seems to be a feeling of “We have always done it that way!”
Agreed, we have, but my grandparents also used to churn their own butter. Now I go to the store and buy it because it makes more sense.
Show Me the Money…er, Evidence!
-A 1967 study by Taylor and Weil found that Trendelenburg’s Position was associated with retinal detachment, brachial nerve paralysis, and cerebral edema. They also noted an alarming trend in compromised lung volume, which they attributed to the viscera placing pressure on the diaphragm.
- A 1994 study on oxygen transport found increases in left ventricle filling and blood pressure, while end tissue oxygenation was not found to be significantly changed. (So, in short, you’ve increased the blood pressure but, much of the patient’s tissues are still inadequately perfused. Which, last time I checked, is the most basic definition of “shock.”)
- A 1985 study by Bivins, Knopp, and dos Santos is even more alarming. They found that “a 1.8% (99% confidence interval, -1.3% to 4.7%) of the total blood volume was displaced centrally when subjects were placed in head-down position.” This small displacement was eventually determined to be insufficient and not indicative as an effective treatment of hypotension.
-Similarly a co-study between the Anesthesiology and Cardiac Surgery departments of Ludwig-Maximilians University, of Munich, Germany, concluded “Trendelenburg’s Position caused only slight increase of preload volume, despite marked increase in cardiac-filling pressures, without significantly improving cardiac performance.”

 Dr. Sean Henderson summed it up this way, in the conclusion of our correspondence:
“I can’t completely rule out the use of the ‘shock position’ in all cases (such as some cases of cardiogenic shock), but I cannot advocate its use for hemodynamically unstable trauma patients.”
So where does that leave us? Dr. Henderson advocated a “modified Trendelenburg’s Postion with the patient’s legs raised 15-20 degrees while at the same time elevating the patient’s head 10 degrees.” Once an agreed upon alternative to the true Trendelenburg’s Position is reached the national curriculum will need changed. And reeducation of all healthcare providers will be needed.
In the interim EMS providers should consider intracranial pressures, restriction of pulmonary volumes, and increased cardiac workloads before placing a patient in Trendelenburg’s Position.
Old habits are hard to break, and a more thoughtful use of Friedrich Trendelenburg’s position will eventually prevail over simplistic ideas of just “tilting the container.” EOR. - MW

1.) Dodd Memorial Library, Chrisitan Medical
College- Vellore, India (n.d.). Walter B. Cannon: Physiologic Invertigator. Retrieved December 14, 2007, from
Johnson, S., & Henderson, S. O. (2003, August 22). Myth: The Trendelenburg Position Improves Circulation in Cases of Shock. Canadian Journal of Emergency Medicine, 6(1):48-9, . Retrieved
September 29, 2007, from
2.) Limmer, D., O'Keefe, M. F., & Dickinson, E. T. (2007). Lifting and Moving Patients. In E. T. Dickinson (Ed.), Brady Emergency Care (10th ed., pp. 119-120).
Upper Sadle River, New Jersey: Pearson/Printice Hall.
3.)Reuter, D. A., Felbinger, T. W., Scmidt, C., Moerstedt, K., Kilger, E., & Lamm, P. et al. (2005, June 2). Trendelenburg positiong after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. European Journal of Anesthesiology , 20: 17-20, . Retrieved
October 4, 2007, from
4.) (2008, January 5). Friedric Trendelenburg (1844-1924). Retrieved
January 6, 2008, from
5.) Personal email correspondence between the author and Sean O. Henderson, MD,
University of Southern California, were used in the creation of this article. This correspondence was initiated on October 1st, 2007 and continued until October 15th, 2007.
(Note: The majority of this was written in 2007. The author apologizes for any sources that may have been lost in the exchange of file formats and hard drive replacements)

Friday, November 19, 2010


I know why I do what I do.

For years I've always thought that I worked in EMS because it was the default. The default to my less than stellar performance at school. But I finally figured it out. And it was a comment from my brother, of all people, that made me realize it.

A while back he made a comment to a friend of mine that I'm always "Out saving the world." At first I thought of it as a vague reference to my Superman idolization. I then figured out that it had little or nothing to do with Superman.

I've always blamed myself for the death of my grandma.

Before I get into this I don't want any "I'm so sorry" comments or anything. This event in my life made me who I am today. Its carried me into this field and I realize this is where I am supposed to be.

It was 1992 and I was 9 years old. I had come home from school and started on my homework. I remember mom calling my grandparent's house a couple times and getting no answer. She told me to hurry up with said homework and then we'd go over there. I do recall the homework was math. (This might also be some underlying reasons as to why I still hate math to this day.) After nearly 2 hours I finished my homework and we drove the 6 miles to their house.

At the time my grandfather was already terminally ill with cancer, but had decided to stay at home for his final days. The home that sat in front of the business he and his father had started nearly 50 years earlier. Grandma was his primary caregiver and I'm almost certain some form of a hospice nurse came a couple times a week. Time has taken its toll on all of the memories.

I remember having to pee.

As we came in the door I saw Grandma sitting in a chair staring at Grandpa. He appeared to be sleeping. I recall mom saying something to Grandma and getting no reply and then hurriedly trying to get to the phone. I blocked her way, thinking that she was trying to get to the bathroom before me. I ran to it and locked the door.

It wasn't until I heard mom crying that I realized something was NOT right. Everything after that seemed to move so slowly. We waited for the ambulance to arrive and mom kept saying "Momma, no! Please, Momma no!" And I remember Grandpa, in his frail state, standing and walking across the room to touch her face. I don't think I ever saw him stand again. But not only did he stand, but he walked. Walked in the same "Grandpa" gait he had when he was healthy.

I remember the cot.

A flood of vehicles soon arrived at what I now jokingly call the "Gardner Family Ranch". I don't even recall seeing the ambulance but I do remember the stretcher. And I remember seeing my cousin Jeff. As we are all members of the Fire Dept/Ambulance it is still not uncommon for us to have mini-reunions at the scene of a car wreck or our weekly meetings. Though it's rare that I'm home anymore to attend them.

The thing I kept thinking the entire time though was "I wish I'd gotten done with my homework quicker." I now know that most stroke victims have about 3 hours to get to the hospital. After that 3 hours most "clot busters" won't work or permanent brain damage has already taken hold. And as I sit here and type I think about the state of my grandma's health. Surely she wasn't taking care of herself to well because she was worrying about Grandpa.

I can't remember the exact time frame, but it seems like she died about 4 days later. She did wake up in the hospital. I do remember that. I remember mom telling the story of my great aunt coming in the room and the nurse asking "Do you know who this is?" And my grandma giving the nurse a "Duh!" look. She wasn't able to speak, that is the other thing I remember.

Lastly I remember dad picking me up at school and telling me she had died. A task which he was forced to repeat almost exactly a month later when Grandpa died.

But overall I remember that damn math homework.

Math has long been the bane of my existence. Its not that I'm actually that bad at math. Most of the time while studying it and doing practice problems I'm fine. But the pressure of a test was normally too much for me to take. I'm likely to just put an answer down so I can get done.

But I digress. The reason I do what I do is this:
I never want to delay the care of anybody's loved one for any length of time. I've dedicated myself to working at places where time is of the essence. Minutes count and so does the treatment.

The outcome of my Grandmother's stroke would not have been any different had I not had least I think.

And that inkling of doubt is what makes me do what I do.

Many years later I worked in a nearby ER, as a tech. One day my Grandfather's uncle's wife came in. Technically Great-Great Aunt (I think). She was confused and upset. Shaking uncontrolably. As I triage her in I noticed her last name was the same as my grandparents. I made comment to her son (a cousin of some form?) that their last name was my mom's maiden name. After telling him who my mom was he informed me of the family connection.

My grandpa had 3 uncles who were much younger than his father (my Great Grandfather). Of the three of them one is still living and WELL over 100 years old. The other two died in 2000 and 2003. One in his late 90's and the other was about 102.

The Great Great Aunt, who was hard of hearing, was assured that she was in the hands of family and we'd take care of her. Later that night her son had to go home and I sat beside her bed to talk to her. I asked her if she knew Earl, my great grandfather.

She replied: Girl Scout Cookies!?!?!
M: No...Earl G***** (louder so she could hear it)>
GGAunt: Yes, he was my brother-in-law.
M: Do you remember Raymond and Verna Vee?
GGAunt: *Smiles really big and says* We used to play cards with them!
M: They are my grandparents. I'm their last grandchild.
GGAunt: "Oh...goodness. I'll bet you are a good boy. They were good people."

Yes. They were.

I hope I am.