Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Trauma Criteria – preventative medicine – Part II

Continuing from Part I of an episode of the First Few Moments podcast where Kyle David Bates, Steve Murphy, Patrick Lickiss, and I discuss Patrick’s article about trauma triage criteria – Are Prehospital Trauma Triage Criteria Effective?

Table 3 only reinforces the uselessness of using just MOI (Mechanism Of Injury) to identify critical trauma patients.

This may actually demonstrate where we should focus our attention in trauma triage –


Click on the image to make it larger.[1]

This table documents part of the continuing attempt to find some sort of magic bullet of trauma assessment.

What is the goal?

A combination of high sensitivity and high specificity.

High sensitivity means that we do not miss patients who die, or are disabled, due to transport to a hospital that is not a trauma center

High specificity means that we are close to the STEMI (ST segment Elevation Myocardial Infarction) triage rate of over 95% accurate identification, rather than the current trauma triage rate of around 5% accurate identification.

If the local hospital does not see any trauma patients, the doctors and nurses may forget how to treat the occasional trauma patient who stubbed his toe and is taking clopidogrel (Plavix – the once you start bleeding, you don’t stop bleeding until it is out of your system a week later drug). The patient drove to the hospital, thus depriving EMS of the opportunity to set up a landing zone, because we can always find some relevant mechanism – and if we can’t the QA/QI/CYA department will on review of the chart.

What can we do to improve our specificity, without missing more legitimate critical trauma patients?

Table 3 does give us a bit of a hint.

Rather than use individual excuses criteria we can combine them.

This is a very scary concept that could get out of control very quickly, because this involves more complex thought than see the mechanism, call the helicopter.

What would we call this magic?

If we added a lot more to it, including judgment, we could call it an assessment.

A true assessment is much more than just combining a few measurements. A true assessment also requires that the receiving facility does not violate HIPAA by refusing to provide information about the continuing treatment of the patient at their facility.

If we do not track the results of what we do, we are only engaging in witchcraft.

Footnotes:

[1] Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.
Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.
Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.
PMID: 20430387 [PubMed – indexed for MEDLINE]

Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage.
Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW; National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC).
MMWR Recomm Rep. 2009 Jan 23;58(RR-1):1-35. Erratum in: MMWR Recomm Rep. 2009 Feb 27;58(7):172.
PMID: 19165138 [PubMed – indexed for MEDLINE]

Free Full Text from MMWR with link to PDF Download

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Trauma Criteria – preventative medicine – Part I

ResearchBlogging.org

On this episode of the First Few Moments podcast Kyle David Bates, Steve Murphy, Patrick Lickiss, and I discuss Patrick’s article about trauma triage criteria – Are Prehospital Trauma Triage Criteria Effective?

There are a lot of interesting things about this study, but Table 3 shows that there is some ability to improve the accuracy of triage criteria by combining criteria. This should be a no brainer, but here are some data to support this. 2.8% + 4.7% + 8.0% = 50%. That is a tremendous improvement over the 15.5% that they add up to individually.

This only reinforces the uselessness of just MOI (Mechanism Of Injury) to identify critical trauma patients.


Click on images to make them larger.

48.5% (N = 50) of these patients had inadequate pre-hospital data. – This refers to the patients missed by the triage criteria. However, it is difficult to make any claim about how the criteria would apply to these patients. Without the information, we do not know.

Is missing data a good predictor of failure to follow criteria, failure to assess patients, or a global failure on the part of EMS.

Table 4 shows that a lot of criteria are difficult to assess, because there are more missing data than there are positive data for any of the individual criteria. The pulse oximetry data are missing almost everything, so it is impossible to draw any valid conclusions from that. 54.5% would seem like a great predictive criterion, but we only have data for 3.9% of the patients. This is not a representative sample. The law of small numbers applies.

In small sample sizes, strong, but purely coincidental associations are expected.

The number of oxygen saturation observations was limited due to the fact that currently only MICA paramedics have the equipment required to perform this recording. Out of 17,645 patients, only 1109 (6.3%) patients had a recording for oxygen saturation. In time this equipment will become available to more of the ambulance service’s fleet.[1]

To be continued in Part II.

Go listen to the podcast.

Also see these other sources of information.

2011 Guidelines for Field Triage of Injured Patients Poster from CDC

It’s the damage stupid

Footnotes:

[1] Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.
Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.
Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.
PMID: 20430387 [PubMed – indexed for MEDLINE]

Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage.
Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW; National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC).
MMWR Recomm Rep. 2009 Jan 23;58(RR-1):1-35. Erratum in: MMWR Recomm Rep. 2009 Feb 27;58(7):172.
PMID: 19165138 [PubMed – indexed for MEDLINE]

Free Full Text from MMWR with link to PDF Download

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW, & National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC) (2009). Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control, 58 (RR-1), 1-35 PMID: 19165138

Cox, S., Smith, K., Currell, A., Harriss, L., Barger, B., & Cameron, P. (2011). Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria Injury, 42 (9), 889-895 DOI: 10.1016/j.injury.2010.03.035

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A Change of the Dogma – If spinal immobilization helps only one . . .

How dangerous is spinal immobilization? We discuss that on First Few Moments. On this Spinal Immobilization podcast, Kyle David Bates, Russell Stine, Bob Lutz, Dr. Laurie Romig, Kelly Grayson and I discuss the lack of evidence of any benefit from spinal immobilization and the evidence of harm.

A Change of the Dogma: If it helps only one? Episode 36

What is it going to take to get the medical directors, PHTLS (PreHospital Life Support), BTLS (Basic Trauma Life Support), and ATLS (Advanced Trauma Life Support) to eliminate this dogma?

What is it going to take to get someone to do a large enough study of this dogma to find out just how good/bad spinal immobilization really is?

The Cochrane Reviews looked at spinal immobilization and were not impressed –

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed – indexed for MEDLINE]

There is only one large scale study comparing spinal immobilization with no spinal immobilization –

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.

PMID: 9523928 [PubMed – indexed for MEDLINE]

Kyle starts out with a great comment for all of those who say that we should not discuss, or criticize, our current protocols, for whatever reason they give.

**This podcast is not meant to change YOUR current practice, only your medical director can do that! …but nothing says you can’t try to convince them 😉 – KDB**

 


Picture credit.

 

Plus

 


Picture credit from Voodoo Medicine Man.

 

Equals

 


Picture credit.

 

Not a formula for success.

 

What do you think?

Go listen to the podcast.

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Who is TIMA – First Few Moments Episode 28

The most recent First Few Moments podcast is about roadway safety – and it has learning objectives! Kyle David Bates, Brad Buck, Scott Kier, and I discuss what TIMA is.

Who is TIMA? Episode 28

Does this equal safety?

Or does this blind oncoming traffic?

LEARNING OBJECTIVES

1. The listener will be able to argue the need for roadway safety.

We should already be aware of the need for roadway safety, but this will give you a lot more information about the reasons.

From the beginning of the response, we make decisions about safety.

Do we wear seat belts?

Do we only proceed safely, rather than trust our lights and sirens to protect us.

Lights and Sirens do not protect us.

We use warning devices, such as lights and sirens, to make it more likely that people notice us. This is only the beginning of safety.

2. The listener will be able to identify when to employ roadway safety techniques.

Which roadway safety techniques will depend on what is available.

3. The listener will be able to discuss and employ engineering controls to make operations on the roadway safer.

Several of these are described.

4. The listener will be able to define and discuss the importance of situational awareness while operating on the roadway.

What is situational awareness?

Why are so many of us not very good at situational awareness?

No amount of flashing lights or reflective stripes makes up for a lack of situational awareness.

Is a flashing light going to stop a car?

Is reflective striping going to stop a truck?

This show is about improving the way we think about scene safety.

Thinking about what we are doing is essential to our scene safety.

Go listen to the whole podcast.

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Why We Do What We Do: a view from the ROUGE Medic at First Few Moments

At EMS Today, I participated in the First Few Moments LIVE podcast. Why We Do What We Do: a view from the ROUGE Medic Episode 20

Dr. Jeff Myers, Kyle David Bates, Scott Kier, Robert Raheb, and I discussed not why we work in EMS, but why we provide certain treatments and why we do not provide other treatments.

For example –

Spinal immobilization.

How do we justify not immobilizing?

How do we justify immobilizing?

Intubation.

How do we justify not intubating?

How do we justify intubating?

Isn’t the Gold Standard having the patient protect the patient’s airway?

The endotracheal tube is really only one of many alternative airways.

On line medical command versus on line medical consultation.

During this discussion, the following article was referred to.

Adios, Rampart: give medical control the boot.
Bledsoe BE.
JEMS. 2002 May;27(5):168. No abstract available.
PMID: 12004554 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from BryanBledsoe.com

About half way through I switched with Robert Raheb, who discussed improving driver training, especially with simulators.

Go listen to the whole podcast.

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First Few Moments – Mechanism Of Injury or Idiocy


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.

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.

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.

If we are calling for helicopters, we are making medical decisions, so we need to be able to justify those medical decisions.

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