# Maryland Trauma Decision Tree



## emtvirus (Jan 13, 2011)

Anyone work in Maryland that can explain the Trauma Decision Tree and its purpose/implementation to me? I am, hopefully, taking my reciprocity exam next week and am from the midwest where we seem to do things a bit different. Just hoping for a little clarification. Thanks!


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## FireResuce48 (Jan 13, 2011)

Straight from the MD protocol

WHILE TIME, DISTANCE, AND PROXIMITY ARE ALL FACTORS TO BE CONSIDERED IN
THE TRIAGE DECISION, THE TRAUMA DECISION TREE SHOULD BE USED TO
DETERMINE WHO SHOULD BE TRANSPORTED TO THE NEAREST APPROPRIATE
TRAUMA CENTER AND WHEN THE TRANSPORT SHOULD OCCUR.

Really, its main focus seems to be the utilization of the helo. For a cat a or b trauma you do not need to consult with the receiving trauma center while a cat c or d trauma requires a consult in order to get the helo on the way. 
Maryland really has been trying to stop the over use of helo transports since the trooper 2 crash. I agree with it too. A lot of the transports done around my area can make it to the major trauma centers in less than 30 minutes unless the roads are just jammed to all heck.

http://www.miemss.org/home/EMSProviders/EMSproviderProtocols/tabid/106/Default.aspx

This link has the full protocols in pdf form.


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## emtvirus (Jan 13, 2011)

Thanks for the reply, that info really cleared that up. I actually have the full copy I'm studying to, hopefully take my test soon.

If you don't mind me asking, what all did the miemss protocol exam cover? I'm trying to figure out what to study but the manual is huge... Just wondering if there is some areas they tend to focus on. Thanks!


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## frdude1000 (Jan 13, 2011)

Here is the chart.
http://www.miemss.org/home/LinkClick.aspx?fileticket=pw9w-1JsO24=&tabid=106&mid=534

The best thing to remember is "when in doubt take patient to appropriate trauma center"


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## JJR512 (Jan 13, 2011)

Category A are the life-threatening injuries.

Category B are serious injuries not immediately threatening to life but not likely to be fixed at the local hospital.

Category C are the "mechanisms", when something about the MOI says the patient should go, even if they don't necessarily seem that bad. For example, death in the same passenger compartment, ejection from vehicle, etc.

Category D are the co-morbid factors, such as age <5 or >55, pregnancy, etc.

(Explanation from my instructor.)


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## usafmedic45 (Jan 13, 2011)

> Really, its main focus seems to be the utilization of the helo.



"It puts the patient in the helicopter or else it gets the hose again."


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## CANMAN (Jan 13, 2011)

Trauma decision tree stemmed from the over utilization of MSP helicopters for trauma flights and too my knowledge is now a National Model. Just got a trauma tree in this months copy of JEMS which is exactly what the MD tree is. 

As far as the protocol test it has been about 8 years for me but I will tell you EVERYTHING in that huge book is fair game. When I took it for EMT-P there were ALOT of legal questions such as: You have a exceptional call how long do you have to notify the state medical examiner. 

Also alot of peds dosage questions, and study the CPAP and NTG protocol's. Those have recently changed in the past two years and my guess is with the escalating NTG dosages and Captopril/NTG paste there will be a few questions on that as well. 

You can skip the jurisdictional extras, wilderness medicine, tactical medicine, and specialty care protocols. None of that stuff will be on there.

Where are you coming from and where are you looking to get a job. If you need ne help or have questions PM me. I currently work F.T. in a MD 911 system and do Critical Care for a very large local hospital.


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## emtvirus (Jan 13, 2011)

Thanks that really helps a lot. I was actually only glanced at the high dose NTG stuff. Guess that's one more notecard I'll have to make


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## FireResuce48 (Jan 13, 2011)

I took the I protocol test early last year and canman is correct. Everything in the book is fair game including how long you have till the medical director for situations.

I will be taking the p protocol test hopefully next month.


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## EMS49393 (Jan 13, 2011)

I just took my reciprocity paramedic exam last month.  There aren't many jobs in PA, so I was hoping I'd have better luck in my home state.  So far it's been a bust (I'm not a fire fighter), so it looks like private ambulance might be my future.  My exam was heavy on peds, both dosages and electrical therapy.  I had two questions on crush syndrome/hyperkalemia and all I can say to that is high-dose albuterol 20 mg for adults, know your ped doses for crush as well.  I had questions on the first couple of pages of the book where they go through the "exceptional call, failure to carry out a physician order, protocol variation" stuff.  

I actually have such a memory that I could immediately recall nearly 30 questions and answers from the 50 question test I received (oh, yes, I wrote them all down).

I warn you, Maryland has some peculiar protocols and they are a tiny bit behind a lot of other states.  What you know to be true through evidenced-based medicine may not be the correct answer on this exam.

Which exam are you sitting for?


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## emtvirus (Jan 13, 2011)

I'm sitting in for the ALS exam hopefully here in a few weeks if I can get everything ironed out with my affiliation paperwork with a service here.


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## EMS49393 (Jan 13, 2011)

emtvirus said:


> I'm sitting in for the ALS exam hopefully here in a few weeks if I can get everything ironed out with my affiliation paperwork with a service here.



There are two ALS categories in Maryland, intermediate and paramedic.  Which of those tests are you sitting for?


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## emtvirus (Jan 13, 2011)

Paramedic


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## EMS49393 (Jan 13, 2011)

emtvirus said:


> Paramedic



It's late for me, but I'll try to PM you some test goodies tomorrow.  Hopefully you'll get some of the same questions and be able to use the notes.


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## emtvirus (Jan 13, 2011)

Thanks a lot, I'd really appreciate that!


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## usafmedic45 (Jan 14, 2011)

> Trauma decision tree stemmed from the over utilization of MSP helicopters for trauma flights



Actually it came from the overutilization of MSP helicopters for effectively uninjured patients and the resulting deaths of several people including a friend of mine.  It was a piece of fluff put out by MSP Aviation Division and MIEMSS to allow themselves to have something to point at when the legislators in the state started asking questions about why bodies were scattered around a park on a flight dispatched to avoid inconveniencing the volunteers in Charles County and why so many other flights were being operated needlessly at state expensive with practically no publicly demonstrated benefit.  



> and too my knowledge _is now a National Model_.



Only in the minds of the gurus at MIEMSS.  The rest of the nation pretty much continues to just point at their faith in HEMS in what amounts to urban and suburban settings and laugh.  There is no widely accepted national model because there is so little data to support their use.  There's a couple of widely publicized profit-driven models put forth by the various services and a couple of the industry lobbies, but they are based on superstition, tradition and scare tactics more than anything else.  Then again....so is the MIEMSS HEMS protocol.


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## rescue1 (Jan 14, 2011)

Well, in response to usafmedic45, I can say that while I have no idea why you'd fly out of an urban area (where you probably have at least a level 2 center within 30 minutes), it's certainly nice to have HEMS on the Eastern Shore, where the local 12 bed ED is probably not going to be able to handle (and in fact, will refuse to handle) trauma that is more then a broken bone or two.

That being said, I have seen lots of people flown on mechanism who were back in town in two days with one arm in a cast and otherwise completely recovered.


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## usafmedic45 (Jan 14, 2011)

> it's certainly nice to have HEMS on the Eastern Shore, where the local 12 bed ED is probably not going to be able to handle (and in fact, will refuse to handle) trauma that is more then a broken bone or two.



It really is arguable whether a non-trauma center can manage some "moderate" trauma.  Honestly, I think a lot of the Eastern Shore's refusal has to do with the fact that they don't have to because the Shock/Trauma gurus have been so overbearing for so long.  Besides, most of the Eastern Shore is close enough to PRMC (or Baltimore or Wilmington, DE or Dover or Ocean City; especially when you take into account the distribution of the geography of trauma) that you could almost get the patient to these sites by ground before you could get a helicopter on the scene unless you are "pre-launching" the helicopter which increases the risks so  much that it's a reprehensible practice.   

Also, remember that Shock/Trauma is not a nationally accredited trauma center by the most commonly used standard.  It's more or less a "trauma center" because they say they so.  This is not to say they are not a good facility (personally, I don't think they are all that great, but there are far worse choices).


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## rescue1 (Jan 14, 2011)

Easton, Kent Island, and Cecil County might be fairly close to a trauma center, but in the bustling metropolis of Kent County it's a good 2 hrs to Baltimore, and even longer back. And in a county where volunteer participation (and therefore staffing/response times) is, to put it lightly, :censored::censored::censored::censored:ty, taking a staffed ambulance that far out isn't something I'd do lightly.


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## EMS49393 (Jan 14, 2011)

rescue1 said:


> Easton, Kent Island, and Cecil County might be fairly close to a trauma center, but in the bustling metropolis of Kent County it's a good 2 hrs to Baltimore, and even longer back. And in a county where volunteer participation (and therefore staffing/response times) is, to put it lightly, :censored::censored::censored::censored:ty, taking a staffed ambulance that far out isn't something I'd do lightly.



Christiana?  It's 70 minutes from Chestertown.  <_<

I do not understand why people in Maryland think STC is the only place they can go for trauma.  If I get a trauma north of my volunteer station, I sure as hell am not going to STC, I'm not calling for a medevac, I'm hauling them 20 minutes up the interstate to York Hospital, a level 1 trauma center.  Know your resources, especially in you work in a boarder county.


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## rescue1 (Jan 14, 2011)

Touche. Though for some strange reason (really, I have no idea why), none of the ALS providers ever try to go there by ground, except the folks in Galena. My argument about staffing still stands though, since we're not talking about a huge change in travel times (It's actually 90 mins to ST, I just checked).


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## usafmedic45 (Jan 14, 2011)

> Christiana? It's 70 minutes from Chestertown.



I was thinking more like Elkton for Christiana.  Honestly, I think Chestertown and its area is one of the few in the state (outside of Cumberland) that is really "remote". 



> I do not understand why people in Maryland think STC is the only place they can go for trauma



Propaganda. 



> 'm not calling for a medevac, I'm hauling them 20 minutes up the interstate to York Hospital, a level 1 trauma center.



Even if I would get hurt in suburban Baltimore, I'd rather go to York Hospital.


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