First TOTWTYTR –
Missing a flail chest won’t be corrected by blind adherence to mechanism of injury. It will be corrected by doing a complete assessment.
If we were to blindly adhere to MOI (Mechanism Of Injury) criteria, we probably would transport almost all of the patients with flail chest. The trauma center staff would need to perform assessments on thousands of uninjured and mildly injured patients for each flail chest they would find.
That is for each flail chest they would find by actual patient assessment.
The differences will be the location of the assessment, the cost of the patient care, and the decrease in competence. The decrease in competence will be not just for EMS, but also for the nurses and emergency physicians at the local hospitals which would otherwise assess and treat these patients.
The less experience they have with assessment and treatment of minor to moderate trauma, the more their skills will deteriorate.
I think we lost a lot of assessment skills when the industry went to mnemonic based teaching instead of actually teaching people what, how, and why to assess. People tend to focus on the rote recitation of the mnemonic without understanding the thought process that goes with it.
Amen.
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The second comment –
Russell Stine writes an interesting new blog called Hybrid Medic. This is from his comment –
I had a similar situation where I transported a patient from a rollover crash on a busy interstate. Of course I report my assessment findings to the trauma center instead of the mechanism of injury, we take her in a wheelchair as she is ambulatory and without deficit.
This is appropriate.
I go back in for signatures and the nurse asks me if I knew the crash was a rollover and that another passenger was ejected (because they were not using the vehicle’s restraint system),
Gosh! What did the nurse’s assessment show that the medic’s assessment did not?
Nothing.
I knew this, and she proceed to lecture me about the mechanism of injury. These are TRAUMA nurses, same in your case, I resisted the urge to blast her in the face with her own ignorance but decided to let it go.
In my case, it was not a trauma nurse, just an otherwise intelligent, experienced nurse I expected a lot more from.
It is sad that trauma nurses do not have a better understanding of trauma than this.
I had a student with me that day, and I properly educated her before moving on.
The education needs to be about both the proper assessment of the patient, rather than encouraging the Mechanism Of Idiocy and about dealing with the problems of the various people within your organization who incompetently discourage patient assessment.
I find it annoying that the nurses at that particular hospital complain about us bringing them non-critical traumas (which is a different matter entirely) or “non Level 1 traumas” (which all the criteria are physiologic based) and then talk about mechanism of injury like it’s a big deal. I’m tired of the doublespeak.
There are three levels of trauma criteria:
1. Physiologic – The assessment most likely to identify unstable patients.
2. Anatomic – This is a much less effective assessment for identifying unstable patients.
3. Mechanism – This is the least effective means of identifying unstable patients. This is not an assessment. This is just a crutch for the incompetent.
The outlying hospitals feed into this. I had a 16 y/o girl roll her vehicle, self extricate and be without injury only to be turned away diverted away from a trauma center and the outlying hospitals tried to send us to the hospitals that just diverted them away.
This agrees with what I wrote above in response to TOTWTYTR.
Some of the emergency physicians at the local hospitals are affected by this same incompetence.
We need to eliminate, or remediate, medics who are incapable of a competent assessment. We need to educate people about assessment, rather than MOI.
MOI is not an assessment.
I think the problem has been fixed, largely, but there is a serious lack of education and communication among hospital personnel on what actually constitutes a serious trauma. It’s like they make up their own rules, based on what day it is.
I think that you are overly optimistic.
You are describing a primitive culture, made up of many people who do not understand research.
MOI is just a primitive superstition.
Why do we allow anyone to promote MOI criteria?
Why do we allow these people to discourage competent assessment?
Our patients deserve competent patient care.
Competent patient care requires a competent assessment.
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What’s interesting about MOI being considered for trauma criteria is that the CDC’s new Field Triage Scheme plays directly into it. My county used to have the following trauma criteria:
– Physiologic
– Anatomic
– Paramedic consideration (included the MOI criteria and some others, but you could easily not activate based on your discretion and a base consult)
In order to fall in line with the CDC guidelines, the county has taken out Paramedic Consideration and replaced it with MOI. Having looked through the presentation on the CDC’s website, they state that available research guided the changes. While I certainly don’t think that MOI should trump an actual assessment, the CDC makes a compelling argument that MOI places a patient at a higher risk for injury. Now I didn’t say, “should be trauma activated” but rather “placed at higher risk”. Why can’t we go back to a system that educates responders about MOI increasing risk for injury and encourage (require!) that they perform a hands on assessment and use those findings to guide their transport decision? MOI is a great tool, but it’s being sold as the end-all, be-all of trauma care.