On the First Few Moments podcast we had an interesting discussion about the usefulness of mechanism in making treatment and transport decisions.
Mechanism of Injury or Idiocy?
Dr. Jeff Myers, Kyle David Bates, Rick Russotti, and Scott Kier.
Should anyone view mechanism as anything more than an indication of where to pay closer attention during assessment of trauma patients? In this case, a trauma patient does not mean a patient going to a trauma center, but a patient who has had any kind of injury.
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One of the points mentioned is that the main controversies that have been discussed recently by several of us on other podcasts (such as Dr. Bill Toon mentioned on Doctor Doctor Doctor: EMS Garage Episode 101) is that too often we use treatments in the absence of a specific indication.
Oxygen – not to treat any signs of hypoxia, but because we figure it can’t hurt and What if . . . ?
The alternative is to have EMS competently assess the patient.
Spinal immobilization – not to treat any signs of spinal cord injury, but because we figure it can’t hurt and What if . . . ?
The alternative is to have EMS competently transport the patient.
Naloxone – not to treat any signs of opioid overdose, but because we figure it can’t hurt and What if . . . ?
The alternative is to have EMS competently assess the patient and manage the airway.
50% Dextrose – not to treat any signs of hypoglycemia, but because we figure it can’t hurt and What if . . . ?
The alternative is to have EMS appropriately assess and treat decreased levels of consciousness with the appropriate treatment – for symptomatic hypoglycemia, titrate 10% dextrose to an appropriate response.
Epinephrine – not to improve survival from cardiac arrest, but because of the short term buzz of getting a pulse back and we figure it can’t hurt and What if . . . ?
The alternative is to limit EMS to effective treatments.
Mechanism Of Injury (MOI) – to replace assessment – not to improve assessment, and because we figure it can’t hurt and What if . . . ?
The alternative is to have EMS competently assess the patient.
It is important to train/educate EMS well enough to be able to provide this competent assessment.
It is idiocy to have EMS use an irrelevant damage report on the motor vehicle, which we will not be treating.
Endotracheal intubation – not because it provides a better airway, but because somebody called it a Gold Standard and we figure it can’t hurt and What if . . . ?
The alternative is to have EMS competently assess and manage the patient’s airway.
Helicopters – not to improve treatment or make a significant difference in transport time, but because we figure it can’t hurt and What if . . . ?
The alternative is to have competent EMS.
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The answer seems to be that we need to improve EMS and EMS education – a lot.
Maybe we need to create a No Fly Zone around each trauma center. For example, if the patient is closer than an hour drive time from the trauma center any flight should be treated as a sentinel event and investigated thoroughly.
Maybe we need to have the fire companies and ambulance companies pay for any flights that are determined to have been unnecessary. If we really want to limit unnecessary flights, what will work better than forcing those of us who call for the helicopter to have to have the ability to justify the flight medically.
If a helicopter is called, just because it is easier to send a patient by helicopter than by ambulance, a $10,000 to $20,000 convenience charge may be a great way to fund helicopters and to discourage abuse of helicopters.
If we do not understand what is going on medically with the patient, we should not be making patient care decisions.
Calling for a helicopter because I am too stupid to assess my patient is bad medicine.
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RM – Your posts make my head hurt – in a good way. So many thoughts that MAKE SENSE!
The aeromedical industry has built themselves into the 600# Gorrilla that they are, and accidents be damned. I’m not sure 1 hour is quite right – I’d say 30 minutes NO Fly, and 45 minutes goes before a review board.
As of the end of the month, the local Level II Trauma Center goes live as a state-appoved Trauma Center. I see my flights going from limited to non-exisisant. I further see myself getting sent there by OLMC with stuff that this week, the local hosptial would take, because the trauma center is only 15 minutes farther, and it seemingly reduces the liability on the local hospital.
Jon B.,
Thank you.
The specific times should be set by the local organization, but treating a flight for a less than one hour drive time distance as a sentinel event should not be extreme. We need to get in the habit of justifying our aggressive treatment.
This is something that should happen with all aggressive treatment immediately, or as close as practical, after the treatment (and a flight is a treatment with a significant risk). Whether I am sticking a needle in someone’s chest, intubating (all intubations), giving aggressive doses of fentanyl, midazolam, NTG, . . . or any aggressive treatment – there should be a mandatory review with a page to the medical director (or surrogate) at the time of transfer of the patient.
We need to be aggressive about demonstrating competence.
We should not tolerate that juvenile behavior from doctors in the emergency department. Contact the director of the trauma center and see if you can call them for destination decisions. Pennsylvania changed to that method of destination decision several years ago. I am sure some of the medical directors violate the protocol and insist that their people call the local ED, but that appears to be because they do not care about patients. Sending everyone to a trauma center against their wishes is not good patient care.