# Is trauma easier than medical?



## Chris07 (Mar 13, 2012)

I had the opportunity to take a PHTLS course recently and found it to be very enlightening...and fun! Since I work mostly BLS IFTs, major trauma situations were not really a strong suit for me and I found the course more challenging than initially expected. Several seasoned medics said they found the course a little more challenging than they expected! 
During the course introduction, the principal instructor asked the class which was harder, trauma or medical? There seemed to be an almost immediate consensus among the class that medical was much harder most of the time. Then the instructor said something interesting: "Although trauma calls are thought to be easier, EMS sucks at trauma." 

I can defend that medicals are more taxing in that they require more detective work. Even experienced EM Physicians dread acute abdominal pain cases due to their difficulty in diagnosing. At the same time, I can say that trauma is much more difficult. Trauma typically involves less detective work and more mechanical work, but does that make it easier? Is full blown chest pain harder than extracting a 240lb male with a broken hip from his '86 Yugo?

What are your thought? In general, is trauma easier than medical? If it is, then why is EMS (as a whole) not good at it?


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## firecoins (Mar 13, 2012)

It would be hard work for an 86 Yugo to be moving a 250lb male.

Trauma is easier.  Yes, there is more mechanical work but you know what to do quickly.


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## EFDUnit823 (Mar 13, 2012)

Trauma is pretty straight to the point, thus in my opinion easier.


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## downunderwunda (Mar 13, 2012)

Trauma is in your face in most cases. For example you know where to look for deceleration internal injuries & I'm many cases predict injuries. Mechanism of injuries gives you those predictors. 

In the same way we can predict a medical call in some cases, loin pain & renal colic for example but the majority requires a good grasp of a&p as well as being able to get a good history.


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## mycrofft (Mar 13, 2012)

How much "medical" does a basic EMT do?

My experience was that our knowledge beyond Basic EMT-ery was good to keep us from inadvertently doing something wrong, and gathering info beyond name-address-insurance number that could help in later diagnosis.

Also, ask any dedicated MD or super-Medic, everything becomes medical, given time. 

Maybe the instructor meant American (and other) EMS is poor at trauma, not that it is more difficult than non-traumatic cases. What were his arguments in favor of that throwaway statement?


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## Veneficus (Mar 13, 2012)

*Trauma easier?*

Anyone who thinks trauma is easy doesn't know the first thing about it. 

But since EMS plays such a small role in trauma, I can see where they think it may be easy or easier.

It is just a question of not knowing what you (collective) do not know.


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## Remeber343 (Mar 13, 2012)

mycrofft said:


> How much "medical" does a basic EMT do?



An emt can actually do quite a bit "medical" wise.


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## firecoins (Mar 13, 2012)

Veneficus said:


> Anyone who thinks trauma is easy doesn't know the first thing about it.
> 
> But since EMS plays such a small role in trauma, I can see where they think it may be easy or easier.
> 
> It is just a question of not knowing what you (collective) do not know.



we don't do trauma surgery in the ambulance, so yes, for EMS, it's easy.  If I was a trauma surgeon, I might have the responsibility of actually treating it. Than what would I be doing in an ambulance.


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## Veneficus (Mar 13, 2012)

firecoins said:


> we don't do trauma surgery in the ambulance, so yes, for EMS, it's easy.  If I was a trauma surgeon, I might have the responsibility of actually treating it. Than what would I be doing in an ambulance.



it is not about surgery, it is really the medical part of it that is complex


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## firecoins (Mar 13, 2012)

Veneficus said:


> it is not about surgery, it is really the medical part of it that is complex



Most of that again comes after we have handled the patient, at the trauma center.  Of course not every hospital can handle trauma patients which bolster your point that trauma is complicated but also bolster my point that EMS does not handle the complicated aspects of trauma.

For EMS its pretty straight foward. Medically speaking, your right, its complicated.


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## Veneficus (Mar 13, 2012)

firecoins said:


> Most of that again comes after we have handled at the trauma center.  Of course not every hospital can handle trauma patients which bolster your point that trauma is complicated but also bolster my point that EMS does not handle the complicated aspects of trauma.



that was my point


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## abckidsmom (Mar 13, 2012)

firecoins said:


> Most of that again comes after we have handled at the trauma center.  Of course not every hospital can handle trauma patients which bolster your point that trauma is complicated but also bolster my point that EMS does not handle the complicated aspects of trauma.



I agree. For EMS, trauma is supportive care and packaging for delivery. The most complex issues we fight    that we can do something about are tension pneumo and cold stress.


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## mycrofft (Mar 13, 2012)

Did the instructor in question limit his definition of EMS to prehospital care (PEMS) or include ED and etc? I'm curous about this persons's take on stuff.

 And as to how much medicine (versus "trauma") a basic EMT does, most interventions are not far beyond first aid other than oxygen, maybe Actidose (charcoal), oral sugar, maybe ASA for chest pain with supporting vitals and history of cardiac, and the pusilanimous (on the part of the authorites) "helping" people self-administer nitro, epinephrine, glucagon, etc. All potentially very important, but not in the league with using/choosing from dozens of oral or parenteral meds, IV volume supplementation, etc.

Oh, yeah. CHILDBIRTH! Almost forgot.


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## Handsome Robb (Mar 13, 2012)

Like someone said, from an EMS standpoint trauma is relatively simple. We fix immediate life threats, package and deliver. It's a linear process, you take note of things and fix them as you find them through a systematic approach to your assessment. 

Even at the ED level they receive the patient into a trauma room where the patient stays for a short period of time and then is whisked off to CT and surgery then to the ICU, assuming it is a serious multi-system trauma that requires surgical intervention. 

I'd be willing to say that definitive care for serious traumas is just as difficult if not more difficult than medical cases. 



mycrofft said:


> Oh, yeah. CHILDBIRTH! Almost forgot.



Meh honestly, after my OB rotations I'm not nearly as intimidated by childbirth as I was. With that said I've been fortunate enough to never had to deal with a breach delivery, complications or a serious OB problem. 

Neonatal resuscitation is a totally different story. I know what needs to happen but I can only imagine how stressful that situation actually is.


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## MSDeltaFlt (Mar 13, 2012)

Since we are not allowed to treat (read: fix) trauma, our protocols are pretty straightforward thus interpreted as easy.  However trauma is not all that easy.  It's even more complicated when you add any medical component to it because it also increases their mortality and morbidity.


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## Veneficus (Mar 13, 2012)

mycrofft said:


> Oh, yeah. CHILDBIRTH! Almost forgot.



pssst.

Childbirth is surgical not medical


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## mycrofft (Mar 15, 2012)

(I interpreted the instructor's "medical" to mean anything not involving blunt, sharp or tortuous force. At least none of those occurring less than nine months in the past).


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## Veneficus (Mar 15, 2012)

NVRob said:


> I'd be willing to say that definitive care for serious traumas is just as difficult if not more difficult than medical cases.



The real kicker to it is that interventions performed or not performed by EMS providers make treatment rendered in the hospital more difficult or even futile.



NVRob said:


> Neonatal resuscitation is a totally different story. I know what needs to happen but I can only imagine how stressful that situation actually is.



It's like anything else, if you do it regularly, it is just a part of your day.


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## rescue1 (Mar 15, 2012)

Veneficus said:


> The real kicker to it is that interventions performed or not performed by EMS providers make treatment rendered in the hospital more difficult or even futile.



Just out of curiosity, what interventions did you specifically have in mind, and what might the effect be in the ER/OR?


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## Veneficus (Mar 15, 2012)

rescue1 said:


> Just out of curiosity, what interventions did you specifically have in mind, and what might the effect be in the ER/OR?



to name a couple off hand,
spinal immobilization, fluid over-resuscitation, and intubation can all have effects that cause long term complications. Some as early as the ER some in the ICU.

I also suspect that with the pathophysiology of hyperoxygenation that there may be harmful implications that have not been properly explored mostly due to lack of interest.


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## Akulahawk (Mar 15, 2012)

Veneficus said:


> Anyone who thinks trauma is easy doesn't know the first thing about it.
> 
> But since EMS plays such a small role in trauma, I can see where they think it may be easy or easier.
> 
> It is just a question of not knowing what you (collective) do not know.


In a way, trauma _is_ easier in that it's usually very initially straightforward as to time of onset and what broke or got damaged. You're right though, in that the medical side of trauma can be a nightmare to manage. Injury physiology is (to me) quite fascinating! It's also why I want to get to an injured patient quickly. If I can limit further injury, I can decrease the amount of time it takes someone to make a functional return to activity. Now then, most of my experience in this matter is in sports injury. However, I know that the things I do early in the post-injury period can shave weeks off an athlete's return to full functional activity. 

We don't consider the possibility of compartment syndromes, and since we don't consider it, we don't attempt to minimize the damage from it. We don't consider that injured tissues can become acidotic, to the point of extending tissue damage. We just don't consider that stuff unless we're specifically told or taught about it. 

Those are just some examples.


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## mycrofft (Mar 17, 2012)

Examples of things in the field that affect care in the ED-OR: over the counter salves and oints and gels that need to be removed; wounds full of clotting agents needing to be removed; dry dressings over abrasions full of foreign objects (road rash) necessitating more-prolonged debridement under sedation; using up the good veins (ante cubes) for simple peripheral uses which the anesthesiologist wanted; not watching distal circulation when any (primarily circumferential) restriction was applied such as bandage, splint, spine board, which can cause ischemic related damage; failure to cover both eyes when you have foreign object or other damage to one which needs the eye to hold still, which can cause exacerbation of the primary injury; lacerating the oropharynx with a OP airway or use of ad hoc or antique airway adjuncts (bite sticks, J tubes, "Choke-Saver" forceps, improper finger sweeps) causing trauma, inhalation, or just failing to work and making it harder to place an advanced airway later (not to mention possible death enroute); hyperinflation of stomach by CPR inflations leading to ineffective subsequent CPR, need to decompress, and potential for aspirational event.
These are all reasonable measures but either under the EMT level, or errors in the course of reasonable measures with potential for misadventure. All affect hospital care.

BTW, besides recording and watching out for circumferential constrictions (iatrogenic or otherwise), what can you do in the field for compartmentalization?


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## Veneficus (Mar 17, 2012)

mycrofft said:


> BTW, besides recording and watching out for circumferential constrictions (iatrogenic or otherwise), what can you do in the field for compartmentalization?



Not make it any worse


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## Craig Alan Evans (Mar 17, 2012)

One aspect about trauma we have not discussed that may make it a little harder for EMS is recognition. This may seem silly as who could have any issues recognizing trauma.  One upon a time a read about a case where a pedestrian was struck on his left side by a slow moving vehicle. Less than 5 mph.  The patient did not hit their head or lose consciousness and barely fell down.  The only complaint on scene was some minor leg pain.  The patient could walk and talk and reported no injuries.  The patient refused treatment and subsequently died four days later from a lac to the spleen.   We need to be very circumspect about mechanism of injury.  A 2000 lb car hitting a 150 lb human may leave a mark at any speed.


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## mycrofft (Mar 17, 2012)

Job number 2, right behind Don't start any harm, is don't make it worse.


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## Veneficus (Mar 17, 2012)

Craig Alan Evans said:


> One aspect about trauma we have not discussed that may make it a little harder for EMS is recognition. This may seem silly as who could have any issues recognizing trauma.  One upon a time a read about a case where a pedestrian was struck on his left side by a slow moving vehicle. Less than 5 mph.  The patient did not hit their head or lose consciousness and barely fell down.  The only complaint on scene was some minor leg pain.  The patient could walk and talk and reported no injuries.  The patient refused treatment and subsequently died four days later from a lac to the spleen.   We need to be very circumspect about mechanism of injury.  A 2000 lb car hitting a 150 lb human may leave a mark at any speed.



F=ma   ???

I saw a guy who was rear-ended in a low speed MVA waiting at a light (less than 10 mph) with a ruptured diapragm. 

Mechanism is extremely unreliable. To the point I wish they would stop trying to teach it.


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## Craig Alan Evans (Mar 17, 2012)

I would disagree. Mechanism is not unreliable.  Like I said.  A 2000 lb vehicle hitting a human is serious and should be treated as such.


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## Veneficus (Mar 17, 2012)

Craig Alan Evans said:


> I would disagree. Mechanism is not unreliable.  Like I said.  A 2000 lb vehicle hitting a human is serious and should be treated as such.



My point is that mechanism is totally unreliable and nonprognostic. 

You can have what would be considered a substantial mechanism and no serious injury. 

At the same time you can have a very minor mechanism and a serious injury. 

You must either overtriage everyone or you are no better off flipping a coin. 

(come to think of it you might be better off flipping a coin)


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## Craig Alan Evans (Mar 17, 2012)

Can you give me an example of a case with substantial MOI and no injury?


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## jjesusfreak01 (Mar 17, 2012)

Veneficus said:


> Anyone who thinks trauma is easy doesn't know the first thing about it.



Plug holes, permissive hypotension, splint, drive fast, and do a detailed assessment on the way so the ER knows what they're getting ahead of time. 

Seems easy enough.


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## STXmedic (Mar 17, 2012)

Craig Alan Evans said:


> Can you give me an example of a case with substantial MOI and no injury?



Few weeks ago, guy in his mid 50s hit by SUV, knocked through his glass storefront, drug under the SUV until finally coming to rest when the SUV came to the back of the store wall. Guys only injury (as observed by hospital as well) was superficial lacerations on his head from broken glass. Released same day. Just one example I've personally had. I've got several more instances in my short, 3yr career as well.


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## jjesusfreak01 (Mar 17, 2012)

Craig Alan Evans said:


> Can you give me an example of a case with substantial MOI and no injury?



Vehicle rollover with ejection/death of other occupants. A restrained passenger could walk away with bruises or nothing.


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## Craig Alan Evans (Mar 17, 2012)

PoeticInjustice said:


> Few weeks ago, guy in his mid 50s hit by SUV, knocked through his glass storefront, drug under the SUV until finally coming to rest when the SUV came to the back of the store wall. Guys only injury (as observed by hospital as well) was superficial lacerations on his head from broken glass. Released same day. Just one example I've personally had. I've got several more instances in my short, 3yr career as well.



The case I spoke of with the pedestrian struck was actually seen in the ER and released as well. I'm trying to keep it vague because it was recent.  Have you done follow up on this case? The patient may have been more injured than initially thought.  Sometimes we see so many patients in so little time that we get it wrong.  I'm just saying that if something significant happens to an individual you need to give them a once over.  Take nothing for granted and assess everyone thoroughly.  I saw a case on TV where someone died because a stapler was thrown and hit them in the head causing a temporal artery bleed.  Sounds silly but if a patient is hit in the head where the temporal artery is the most superficial then think the worst case scenario.  I guess what I'm getting at is over triage and have a high index of suspicion at all times.


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## mycrofft (Mar 17, 2012)

Paging Natasha Richardson...

Had a neighbor with MS in a car accident, struck her head. Sent home after four hours obs. Overnight, developed battle signs and died in bed.


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## Maine iac (Mar 17, 2012)

> Mechanism of injury.



[YOUTUBE]http://www.youtube.com/watch?v=YzYxz_uvtSI[/YOUTUBE]

http://youtu.be/YzYxz_uvtSI


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## STXmedic (Mar 17, 2012)

Craig Alan Evans said:


> Have you done follow up on this case?






PoeticInjustice said:


> Guys only injury (as observed by hospital as well) was superficial lacerations on his head from broken glass. Released same day.



Yes, followed up. His flower shop was across the street from our station also; he came by to thank us a couple shifts later. And you asked for a example, so I figured you weren't trying to keep it vague.


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## Smash (Mar 17, 2012)

Craig Alan Evans said:


> Can you give me an example of a case with substantial MOI and no injury?



Just about any road traffic collision these days.  The idea of MOI as being predictive arose in the 60s and 70s, when the white paper on trauma was put together.  I guess it may have been considered predictive at that stage because you would have repeatable patterns of injuries seen in motor vehicle collisions as heads hit windscreens, chests hit steering wheels, knees hit dashboards and so on.

With advances in design and engineering in vehicles now those same rules do not apply.  They don't even apply to pedestrian impacts as vehicle manufacturers work on minimizing injuries to pedestrians as well.
MOI is not prognostic in any way, the only thing it is good for is to alert you to the _potential_ for there to be injuries.



> Plug holes, permissive hypotension, splint, drive fast, and do a detailed assessment on the way so the ER knows what they're getting ahead of time.
> 
> Seems easy enough.



I suspect Vene's point is that we see and understand so little of the process of managing trauma in the ambulance.  The actual management of trauma, as opposed to just delivering trauma to the hospital, is enormously complex and difficult.


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## Craig Alan Evans (Mar 17, 2012)

Smash said:


> MOI is not prognostic in any way, the only thing it is good for is to alert you to the _potential_ for there to be injuries.



Alerting you to the potential is where I see it best used.  On a lighter side.  How about this video.  

http://www.youtube.com/watch?v=YzYxz_uvtSI&feature=youtube_gdata_player


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## Smash (Mar 17, 2012)

Craig Alan Evans said:


> Alerting you to the potential is where I see it best used.



That's not what was implied in your earlier posts:



Craig Alan Evans said:


> I would disagree. Mechanism is not unreliable.  Like I said.  A 2000 lb vehicle hitting a human is serious and should be treated as such.





> On a lighter side.  How about this video.
> 
> http://www.youtube.com/watch?v=YzYxz_uvtSI&feature=youtube_gdata_player



Yes, it's a lot like this one:



Maine iac said:


> [YOUTUBE]http://www.youtube.com/watch?v=YzYxz_uvtSI[/YOUTUBE]
> 
> http://youtu.be/YzYxz_uvtSI


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## Akulahawk (Mar 18, 2012)

Veneficus said:


> F=ma   ???
> 
> I saw a guy who was rear-ended in a low speed MVA waiting at a light (less than 10 mph) with a ruptured diapragm.
> 
> Mechanism is extremely unreliable. To the point I wish they would stop trying to teach it.


How they teach "mechanism" is what makes it unreliable. I look to the mechanism to see where injury is most likely to occur in the setting of trauma. The ruptured diaphragm guy, was he restrained? How close was he to the steering wheel, if he was the driver? 

You really can't get a good "feel" for kinematics of trauma a course that lasts but 16 hours total. 

From my Sports Med days: Your athlete falls down to the floor after shooting a basketball. He was facing the bench when he caught the ball that was passed to him, turned, and tossed the ball through the hoop. He fell right after he threw the ball. 

He is conscious, breathing, moving his extremities... where are you going to start looking for injury?


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## Akulahawk (Mar 18, 2012)

Smash said:


> Just about any road traffic collision these days.  The idea of MOI as being predictive arose in the 60s and 70s, when the white paper on trauma was put together.  I guess it may have been considered predictive at that stage because you would have repeatable patterns of injuries seen in motor vehicle collisions as heads hit windscreens, chests hit steering wheels, knees hit dashboards and so on.
> 
> With advances in design and engineering in vehicles now *those same rules do not apply*.  They don't even apply to pedestrian impacts as vehicle manufacturers work on minimizing injuries to pedestrians as well.
> *MOI is not prognostic in any way, the only thing it is good for is to alert you to the potential for there to be injuries.*
> ...


Yes, the old rules of injury patterns and vehicles don't apply... because people are wearing seatbelts more often and interiors of vehicles are much better designed to reduce injury by absorbing energy when impacted. This has the effect of reducing the forces that are applied to the body during a MVC. The same rules of knowing injury patterns still does apply though. If you do not know where and how energy is transferred between objects, the best you can do is guess that the body sustained a significant impact...

Mechanism is very, very poor at predicting presence of _actual _injury, but it is very good at "showing" where injury is likely to occur. If you get struck in the head by a rock, I'm not going to look at your feet to see if your toes were broken or dislocated by the impact your head sustained. In that regard, I'm probably not going to look any further "south" than C7-T1.

You really don't, and can't, get a good understanding of this kind of stuff in a short merit-badge trauma course. 

The human body is a remarkably tough and fragile thing. Apply stress in just the wrong place in the wrong direction, and things can break spectacularly easily... yet apply the same amount of force to the body in a different direction and you'll see no evidence of injury because there is none to be found.


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## Veneficus (Mar 18, 2012)

Akulahawk said:


> How they teach "mechanism" is what makes it unreliable. I look to the mechanism to see where injury is most likely to occur



So you are really using index of suspicion?



Akulahawk said:


> The ruptured diaphragm guy, was he restrained? How close was he to the steering wheel, if he was the driver?



No idea, my first contact with him was after the x-ray tech called me and asked me why the cxr didn't look right. He went to surgery moments later.



Akulahawk said:


> You really can't get a good "feel" for kinematics of trauma a course that lasts but 16 hours total.



Knowing the kinematics and identifying the injury are different things. I can calculate the force transfer of a bullet hitting somebody's body, but it doesn't mean I know what that bullet injured. (they have a tendency to not do logical things once they hit the body) 

It is similar for many other injuries as well, body composition, relative health, age, car safety features, etc, all make mechanism a very poor identifier in the general population.

It is also dependant on perception or a second (possibly 3rd) hand account. 



Akulahawk said:


> From my Sports Med days: Your athlete falls down to the floor after shooting a basketball. He was facing the bench when he caught the ball that was passed to him, turned, and tossed the ball through the hoop. He fell right after he threw the ball.



Ask him what hurts?


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## Akulahawk (Mar 18, 2012)

My responses in red, for some clarity:


Veneficus said:


> So you are really using index of suspicion?
> 
> If you want to call it that. A bit more involved than a "gut" feeling about what might have happened. I'm not going to make my trauma decisions based on what I suspect alone. MOI just tells me where to look. Once you learn how to read it, it's not difficult to know where to focus your exam. GSW's tend to be more difficult because the wound track can take some interesting turns if the bullet strikes hard objects... thus if the bullet hasn't exited the body or the exit wound isn't in line with the entry wound, I don't even bother to hazard a guess as to what got damaged.
> 
> ...


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## Akulahawk (Mar 18, 2012)

mycrofft said:


> Examples of things in the field that affect care in the ED-OR: over the counter salves and oints and gels that need to be removed; wounds full of clotting agents needing to be removed; dry dressings over abrasions full of foreign objects (road rash) necessitating more-prolonged debridement under sedation; using up the good veins (ante cubes) for simple peripheral uses which the anesthesiologist wanted; not watching distal circulation when any (primarily circumferential) restriction was applied such as bandage, splint, spine board, which can cause ischemic related damage; failure to cover both eyes when you have foreign object or other damage to one which needs the eye to hold still, which can cause exacerbation of the primary injury; lacerating the oropharynx with a OP airway or use of ad hoc or antique airway adjuncts (bite sticks, J tubes, "Choke-Saver" forceps, improper finger sweeps) causing trauma, inhalation, or just failing to work and making it harder to place an advanced airway later (not to mention possible death enroute); hyperinflation of stomach by CPR inflations leading to ineffective subsequent CPR, need to decompress, and potential for aspirational event.
> These are all reasonable measures but either under the EMT level, or errors in the course of reasonable measures with potential for misadventure. All affect hospital care.
> 
> BTW, besides recording and watching out for circumferential constrictions (iatrogenic or otherwise), what can you do in the field for compartmentalization?


The first thing about compartment syndromes is recognizing it... after that, don't make it worse. You want to limit any edema and reduce the metabolic needs of the affected tissues. That will buy time for more definitive management later. If you recognize it early, it's possible to greatly limit the cell damage. Compartment syndrome of the anterior tibialis might be overlooked and can very easily result in a LOT of tissue necrosis... and the precipitating event can be less than what might otherwise considered a minor trauma to the anterior tibia.


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## Veneficus (Mar 18, 2012)

Akulahawk said:


> My responses in red, for some clarity:



The reply in the reply really makes it hard to reply 

It is not what I want to call something, it is a predefined term, if you use them interchangably, you create confusion. 

Mechanism is supposed to alert you to the possibility of an occult injury. That is why they came up with qualifiers like "death in the same compartment, intrusion into the compartment, fall from height X, etc.)

Index of suspicion is what you think could be injured based on what happened. All providers use index for both medical and traumatic pathology.

As for the patient with the rupture, his only complaint was "finding it hard to take a deep breath" he went to surgery where the only thing that required attention was the herniation. I am thinking he was just suseptable for this injury and the MVA triggered the event. 

I am willing to bet the ED physician got a report from the medic that brought him in. I doubt it included any urgency based on the story I heard from the patient in my 3 or 4 minute contact with him. 

Given the pt was alone in xray for standard trauma films, I would wager there was not a whole lot found on physical exam either. 

Just my opinion, but any injury requiring surgery is not lucky.

A list of what might be wrong (index of suspicion) is based on an actual report of injury.  

Everytime somebody pivots you don't start taking precautions for occult injury. (which is what mechanism of injury is)


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## Akulahawk (Mar 18, 2012)

Sorry about that.  


Veneficus said:


> The reply in the reply really makes it hard to reply
> 
> It is not what I want to call something, it is a predefined term, if you use them interchangably, you create confusion.
> 
> ...


Based on the definition of "index of suspicion" you give, then yes, that's precisely what I do. The diaphragm guy's c/o and mechanism would really have piqued my ear. I'd likely have opted for taking him to a trauma center rather than a local ED. Reviewing our trauma triage protocols, he would likely have been not triaged to a TC outside Paramedic Discretion. Like I indicated earlier, I'd almost be willing to bet that he was the driver, probably unrestrained, sitting really close to the wheel, or both. 

As to the pivot mechanism, lots of people do it w/o injury all the time - except when they plant their feet in one direction and forget to pivot on the ball of the foot when the pivot around to another direction and then extend the knee forcibly. That torques the MCL, ACL, and pinches the medial meniscus into an injury. The ACL gets a 3rd degree sprain, MCL gets a high-degree (2+ or 3) sprain, and the meniscus gets a (usually) significant tear. One of the key descriptors I gave was that the athlete collapses/falls to the floor immediately after plant, turn, shoot... I might even catch seeing the feet facing the "wrong" direction. 

That's a problem with high jumpers too, using the back-flip technique (Fosbury Flop) they use to jump over the bar. Before that was invented, knee injuries that torqued the ACL out of existence didn't happen because the athletes jumped pretty much straight over or did a kind of "hurdle" to jump over. 

Discus throwers can also do that, but they usually have their feet moving along with them, so they rarely plant and twist.

My favorite tests when I see that are Lachman's and Pivot-Shift.


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## Shishkabob (Mar 18, 2012)

Is it easier?  Yes.

Is it any less complicated?  No way.




Let that sink in for a bit.


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## Veneficus (Mar 18, 2012)

Akulahawk said:


> The diaphragm guy's c/o and mechanism would really have piqued my ear. I'd likely have opted for taking him to a trauma center rather than a local ED. Reviewing our trauma triage protocols, he would likely have been not triaged to a TC outside Paramedic Discretion. Like I indicated earlier, I'd almost be willing to bet that he was the driver, probably unrestrained, sitting really close to the wheel, or both. .



Don't know much more than I told you.

The patient was at the trauma center, I would guess simply because it was the closest hospital at the time.

My part in the story was simply answering the xray tech's question that the xray was not normal, asking the guy a few questions, and then summoning the surgeon who ordered the xrays.

I was a bit surprised by the description myself and hung around for the CT scan, waved good-bye on his way to surgery, and asked about the operation later.


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## mycrofft (Mar 19, 2012)

"Mechanism is supposed to alert you to the possibility of an occult injury."

I was going to put it as "Hmm, THIS happened, why don't we see THAT in the pt?". 

Akula, thanks for the compartment syndrome comeback. That whole scene deserves its own advanced thread.
But the baseline (for the masses) is avoid circumferential constrictions/injuries, watch distal circs, listen to complaints, and get them in with a good HX and exam as done during a prudently long on-scene period, right?
A diagram of potential compartments would be a good one, like dermatomes, because some compartments don't need a circumferential insult, just a well-aimed one, right? (Never saw a well-aimed myself, yet).


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## Akulahawk (Mar 19, 2012)

mycrofft said:


> "Mechanism is supposed to alert you to the possibility of an occult injury."
> 
> I was going to put it as "Hmm, THIS happened, why don't we see THAT in the pt?".
> 
> ...


Somewhat correct. An insult to the right area can precipitate compartment syndrome. That insult can be circumferential or specifically at the compartment. For example, the anterior tibialis is really at risk because medially, it has the tibia, laterally, it has the fibula, deep is the fascia between tib and fib, all preventing tissue expansion. Superficially, you have skin and that can only stretch so much.

The anterior tibialis, the muscle bundles just deep to the soleus and right next to the tib-fib on the posterior side, and the deeper muscles in the forearm are probably the most vulnerable to developing compartment syndrome quickly. The brain is probably the most sensitive to compartment syndrome... we just don't call it that. Any place where tissue has a limited ability to expand to accommodate swelling, there's a risk of compartment there, and it's worse if it limits innervation or perfusion to that same area and/or areas distal to that compartment. 

Fasciotomy is the emergent tx of compartment syndrome when the anterior tibialis is involved. That "releases" the compartment and allows the muscle to expand deep while keeping intracompartment pressures low enough to prevent further tissue damage. They may even keep the incision open to further allow "anterior" expansion too.


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## firetender (Mar 19, 2012)

Craig Alan Evans said:


> Can you give me an example of a case with substantial MOI and no injury?


 
In 1978 I hit a VW bug with my motorcycle at about 60 MPH. He ran a stop sign coming on to a mountain road. On impact, me and the bike went airborne, separated, flew parallel paths for 75 feet, hit the tarmac, bounced, flew another 25 feet, the bike landed and stopped, I bounced on my (helmeted) head and skid another 16 feet before stopping. P.D. details and narrative by a Jehovah's Witness, so probably accurate. Ambulance ride to the hospital, head-to-toe X-Rays, discharged to home then, about  2 hours later my left foot swole up with a sprain!

Does that count?


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## Akulahawk (Mar 19, 2012)

firetender said:


> In 1978 I hit a VW bug with my motorcycle at about 60 MPH. He ran a stop sign coming on to a mountain road. On impact, me and the bike went airborne, separated, flew parallel paths for 75 feet, hit the tarmac, bounced, flew another 25 feet, the bike landed and stopped, I bounced on my (helmeted) head and skid another 16 feet before stopping. P.D. details and narrative by a Jehovah's Witness, so probably accurate. Ambulance ride to the hospital, head-to-toe X-Rays, discharged to home then, about  2 hours later my left foot swole up with a sprain!
> 
> Does that count?


This would pique my interest, have me searching for signs of actual injury, and if I'm not finding anything substantial, I'll just give you a nice, slow, ride... yes, you'd be going to a TC, but I'm not going to fly you there. I would hazard a guess that you didn't have much of a vertical component to your "flight" and thus didn't hit the ground all that hard. Motorcycle racers frequently get that same kind of mechanism... and rarely get badly injured. I'd expect that you likely didn't encounter any curbs or big bumps while skipping along the ground.


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## mycrofft (Mar 19, 2012)

Anterior leg, got it. Like what hits the underside of the dashboard on a frontal collision MVA.

I remember long ago the forum had a go at closed head injury as a compartmentalization. I think the term ought to be called "fascial compartmentalization syndrome" as it is currently used.

I've tended quite a few post-fasciotomy patients during healing by secondary intention or mesh grafts.


Tender, lateral impact (rolling and sliding) beats slamming anytime. Ask Jackie Chan. And I noticed decades ago that patients in rollover accents, if they were lucky, seemed to do better than patients with similar speeds and forces but their car slid and hit a curb or a tree to stop. Lucky you did as well as you did. I don't think there is a compartment for an ankle sprain to occupy, but I could definitely be wrong.


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## zmedic (Mar 20, 2012)

mycrofft said:


> Anterior leg, got it. Like what hits the underside of the dashboard on a frontal collision MVA.
> .



There are multiple compartments of the leg, you can get compartment syndrome in any of them from an increase in pressure. Not just the anterior compartment.


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## mycrofft (Mar 20, 2012)

*Going further afield...*

Lots of lateral cross sections available for compartments, but I meant a colored-in zone indicator. Sort of like this:





Since they are sometimes laterally overlaid maybe the color scheme would be prohibitive? (Then show them in 3D, right? I'm so 2-D).


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## Veneficus (Mar 20, 2012)

mycrofft said:


> Since they are sometimes laterally overlaid maybe the color scheme would be prohibitive? (Then show them in 3D, right? I'm so 2-D).



Just spend a few hours in a cadaver lab or a couple of years with your 7 favorite anatomy texts and you'll get the idea.


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## mycrofft (Mar 20, 2012)

I have the idea, just thinking off-thread about how to more-efficiently teach it quickly.
Sometimes it takes a while I guess.
Anyway, on thread, trauma is medical is surgical.


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## Veneficus (Mar 20, 2012)

mycrofft said:


> I have the idea, just thinking off-thread about how to more-efficiently teach it quickly.
> Sometimes it takes a while I guess.
> Anyway, on thread, trauma is medical is surgical.



It is like fine drinks.

Sure you could make some spirits in a few hours,  but the really good stuff takes a few years. (Usually at least 10)


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## paramagician (Mar 20, 2012)

Trauma is way easier for me.. very cut and dry.


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## Veneficus (Mar 20, 2012)

paramagician said:


> Trauma is way easier for me.. very cut and dry.



Awesome.

Could you tell me the cut and dry solution for managing cerebral perfusion pressures while not causing the patient to bleed to death from an actively hemorrhaging internal wound, mitigate ICP to prevent herniation, but not over ventilate, and prevent the damage to the GI tract while balancing the treatment of systemic BP and kidneys?

It has been a thorn in my side for some time.

Edit: and while we are at it, prevent the ill effects of systemic immune response while still maintaining immunocompetency to prevent sepsis from infiltration of bacteria from the GI to the abd cavity?

Strict glycemic control while balancing the needs of anabolic metabolism?

Osmotic fluid balance without over hydration?


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## Pavehawk (Mar 20, 2012)

Veneficus said:


> Awesome.
> 
> Could you tell me the cut and dry solution for managing cerebral perfusion pressures while not causing the patient to bleed to death from an actively hemorrhaging internal wound, mitigate ICP to prevent herniation, but not over ventilate, and prevent the damage to the GI tract while balancing the treatment of systemic BP and kidneys?
> 
> ...




Trauma rattles, trauma rattles, chanting and dancing around the fire... (grass skirt and headress optional except for DIC)

I think he means from a rudimentery on the street back of the ambulance EMS kinda way not in an insulting trauma is "da easy" kinda way


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## Veneficus (Mar 20, 2012)

Pavehawk said:


> Trauma rattles, trauma rattles, chanting and dancing around the fire... (grass skirt and headress optional except for DIC)
> 
> I think he means from a rudimentery on the street back of the ambulance EMS kinda way not in an insulting trauma is "da easy" kinda way



That is what I figured, but I stand by my earlier statement, what is done in the field influences the outcome no matter what the effort in the hospital.

It is important for field providers to think and make informed and purposeful decisions on what they are doing with these patients, not simply to see how proficently they can perform a set of skills.


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## abckidsmom (Mar 20, 2012)

Veneficus said:


> That is what I figured, but I stand by my earlier statement, what is done in the field influences the outcome no matter what the effort in the hospital.
> 
> It is important for field providers to think and make informed and purposeful decisions on what they are doing with these patients, not simply to see how proficently they can perform a set of skills.



So for the people who don't speak in such multisyllabic complex sentences (ie typical medics, technicians not clinicians) pain us a scenario of this complex patient and walk us down both pathways, briefly, and if you have time. 

Like you said above, it takes time and experience, and experience without education is useless for learning, or not very useful anyway.


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## mycrofft (Mar 20, 2012)

*Mycrofft's Theorem of Medical Cut-ness and Dried-ness*

Anything is cut and dried in direct proportion to your degree of willingness to let things take their own course.

(The humbling and seductive part is that so often they do anyway).


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## Akulahawk (Mar 20, 2012)

zmedic said:


> There are multiple compartments of the leg, you can get compartment syndrome in any of them from an increase in pressure. Not just the anterior compartment.


note that the deep posterior compartment has 2 bones and fascia between those bones that limit where it can expand. While it's possible to get compartment syndrome in any of those compartments, it's the deep posterior and anterior compartments that will experience the compartment syndrome much more readily than the others. Now, here's a twist... encapsulate the whole lower leg in a cast before swelling really sets in and you can cause the whole lower leg to experience compartment syndrome...


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## Akulahawk (Mar 20, 2012)

Veneficus said:


> Awesome.
> 
> Could you tell me the cut and dry solution for managing cerebral perfusion pressures while not causing the patient to bleed to death from an actively hemorrhaging internal wound, mitigate ICP to prevent herniation, but not over ventilate, and prevent the damage to the GI tract while balancing the treatment of systemic BP and kidneys?
> 
> ...


Just the fun kind of balancing act that needs a bit of a metabolic tightrope... right under the ICU big-top!


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## Akulahawk (Mar 20, 2012)

Veneficus said:


> That is what I figured, but I stand by my earlier statement, *what is done in the field influences the outcome no matter what the effort in the hospital.*
> 
> It is important for field providers to think and make informed and purposeful decisions on what they are doing with these patients, not simply to see how proficently they can perform a set of skills.


Sounds about exactly like what I was saying in some earlier posts (not sure if I'd said so in this thread) about the things that I do in the minutes after athletic injury that makes a huge difference down the road in recovery. Damage control starts from the moment the injury happens and some of the cascade of events may be too far along by the time EMS gets there to prevent further damage, regardless of what's done in the field OR in the hospital. 

Gotta love this stuff!


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## mycrofft (Mar 21, 2012)

Cast causing compartmentalization..why pts get a bivalved splint the first 24 to 48 hrs with a f/u.
So we shouldn't encase the entire leg tightly in Ace wrap (especially with those nifty little finger slashers, I mean clips)? Or do it tightly enough to discourage arterial perfusion into the compartment?
(yeah right)


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## Veneficus (Mar 21, 2012)

abckidsmom said:


> So for the people who don't speak in such multisyllabic complex sentences (ie typical medics, technicians not clinicians) pain us a scenario of this complex patient and walk us down both pathways, briefly, and if you have time.
> 
> Like you said above, it takes time and experience, and experience without education is useless for learning, or not very useful anyway.



This scenario could be any multisystem trauma patient with TBI. I wasn't joking, this is an old and difficult question with more complexity than I listed.

I once posed it to a trauma surgeon when I was struggling with reconciling treatments that benefit one organ at the expense of another.

He laughed at me, said there was no easy cut and dry answer and if I found one to let him know. (that was nearly 10 years ago)

It is all a balancing act, and it starts with the first person who tries to help. Hyperventilation or not? fluid boluses or not? How much? Of what? Local trauma center or ivory tower? 

While surgery and the ICU have a few toys and tehniques to play this balancing act, it really is made diffiuclt by things like 2 large bore IVs running wide open, over oxygenation/ventilation, intubation attempts, poor/no hemorrhage control, etc.

The deeper I get involved with it, the better "don't do anything and just drive to the hospital" looks.  It takes a clinician and not a technician. More so when you add a pediatric who requires more than normal saline boluses.


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## Akulahawk (Mar 21, 2012)

mycrofft said:


> Cast causing compartmentalization..why pts get a bivalved splint the first 24 to 48 hrs with a f/u.
> So we shouldn't encase the entire leg tightly in Ace wrap (especially with those nifty little finger slashers, I mean clips)? Or do it tightly enough to discourage arterial perfusion into the compartment?
> (yeah right)


Oooohhhh, I just _love_ those little finger slashers...:wub:

Done right, an ACE wrap, a little tape, and a little cardboard can do wonders... Done wrong, those same things can cause much damage. When it comes to soft tissue injury, I also like to employ gravity, when appropriate, in my damage control quest.


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