Priority intervention?

StCEMT · Mar 26, 2017

Come to think of it, that shooting Saturday really highlights what I mean in regards to this. Multiple critical pt's, some with facial gsw's. If I were to be first on scene for that (very possible since I was working and it was .5 miles from one of our post), my 3 month old self would definitely have a couple second pause of "**** me, where do I start?". I think reading post from you and others here definitely helps keep me aware of the right things to focus on and I know I KNOW where to start, but jump that far outside of my comfort zone that fast and I will definitely be living by the phrase fake it til you make it for at least part of the call.

Chase said:
Barnes was on Divert for a little bit because of it. Ended up flying a few patients to the county.

I know, I called a doc to cover my *** on an OD and the nurse told me to make it quick. That call was right around the time they would have gotten word those folks were inbound. I think the doc said all of 2 words to me.

NysEms2117 · Mar 26, 2017

completely agree with @EpiEMS. In a major city getting places fast requires a few things:
first and foremost: maneuverability. not rocket science, police cars more maneuverable then ambulances
2. getting into the method of travel fast. LEO's wont fiddle around, its drag lay down in seat. slam door, drive super fast. Maybe TQ before moving.
3. clearing lights/ understanding traffic LEO's(that i know) have more training with that then EMT's do.

Sometimes people just overthink interventions IMO. Sometimes you just have to swallow your pride and say "well fk, sorry pal me as a **insert pre-hospital care provider here** can't do much for you, high flow diesel and cooking to the ER/OR is the best for you, we'll do our best to do that". I do think that is something some paramedics can't quite grasp (from what i can gather everybody on here that knows what they're doing understands that though so +1 to all you guys/gals!)

EpiEMS · Mar 26, 2017

FWIW, the 2011 Philly study showed:

We are left with the conclusion that police transport of patients with proximal penetrating injuries is not associated with lower survival when compared to EMS-transported patients.

If we cannot show that EMS is superior for penetrating trauma, there really is little reason to not encourage PD to transport urgently. Probably hard to study this with an RCT, but the evidence I've seen is pretty clear.

VentMonkey · Mar 26, 2017

NysEms2117 said:
getting into the method of travel fast. LEO's wont fiddle around, its drag lay down in seat. slam door, drive super fast. Maybe TQ before moving.

Yeah, no. I love stats, studies, and facts just as much as the next guy, but it's all fine and dandy until it's not...as in a real bad wreck because they're rushing to get the victim, or God forbid, their co-worker to the ED.

NysEms2117 said:
clearing lights/ understanding traffic LEO's(that i know) have more training with that then EMT's do.

Maybe they're excellent drivers where you're at, I'm not doubting you, but where I am they're more often than not some of thee scariest code three drivers around. I don't think I am alone in my train of thought, but maybe I am...

NysEms2117 said:
Sometimes people just overthink interventions IMO. Sometimes you just have to swallow your pride and say "well fk, sorry pal me as a **insert pre-hospital care provider here** can't do much for you, high flow diesel and cooking to the ER/OR is the best for you, we'll do our best to do that". I do think that is something some paramedics can't quite grasp (from what i can gather everybody on here that knows what they're doing understands that though so +1 to all you guys/gals!)

Again, the "diesel bolus" should be titrated to safely and effectively getting you, your partner(s), and the patient to definitive care.

Should we be flogging around on scene with IV's and the like? Clearly not, but reminding everyone to slow down while moving at a pace that translates into efficient urgency is much different than flinging "GSW Joe" in the back of the meat wagon and driving like a bat out of hell. Sorry, NYS, but that's how your post came across.

NysEms2117 · Mar 26, 2017

Not how it was meant, but I could see how it was interpreted.
Safety is implied in my posts... No offense but I'm an *******, you as the provider are more important then 2 minutes of time saved. I'm not a fan of not coming home to my fiancé :/

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Tigger · Mar 26, 2017

NysEms2117 said:
completely agree with @EpiEMS. In a major city getting places fast requires a few things:
first and foremost: maneuverability. not rocket science, police cars more maneuverable then ambulances
2. getting into the method of travel fast. LEO's wont fiddle around, its drag lay down in seat. slam door, drive super fast. Maybe TQ before moving.
3. clearing lights/ understanding traffic LEO's(that i know) have more training with that then EMT's do.

Sometimes people just overthink interventions IMO. Sometimes you just have to swallow your pride and say "well fk, sorry pal me as a **insert pre-hospital care provider here** can't do much for you, high flow diesel and cooking to the ER/OR is the best for you, we'll do our best to do that". I do think that is something some paramedics can't quite grasp (from what i can gather everybody on here that knows what they're doing understands that though so +1 to all you guys/gals!)

Efficiency, not speed matters. Having someone bleed out in a cruiser because no one wanted or knew to put a tourniquet on is a problem. So are tension pneumos. And dying in a wreck. Or showing up to a non a trauma hospital or a trauma hospital that isn't even remotely prepared or otherwise unable to accept the patient.

PD homeboy ambulance might work in the right place, but there's some luck involved.

NysEms2117 · Mar 26, 2017

Tigger said:
Efficiency, not speed matters. Having someone bleed out in a cruiser because no one wanted or knew to put a tourniquet on is a problem. So are tension pneumos. And dying in a wreck. Or showing up to a non a trauma hospital or a trauma hospital that isn't even remotely prepared or otherwise unable to accept the patient.

PD homeboy ambulance might work in the right place, but there's some luck involved.

Well I mean sometimes it's better to be lucky then good? Just kidding!!!
Again I get both sides. But a bls ambulance vs a cruiser with maneuverability... Bls can't do much for tension pneumo's either. I get where your coming from/aiming at. Where I live if you work county level down. And you get hurt, you're going to Albany med, it's just that simple. If they transfer you to a smaller hospital because they're full that's once you get there. I'd like to hope Leo's can at least say "officer shot en route to Albany med" and somebody would pick up on it.
I'd also like to hope the same level of common sense would apply to a tq. Again this may be just my thinking since I'm an emt and a Leo, sorry for any confusion. I'm still trying to figure out how to post for the general ems population since I have 0 experience outside of my first and only ems job so far.

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StCEMT · Mar 27, 2017

The maneuverability is an advantage up to point. On the main road leading to the big STL hospital, a cruiser won't have any better of a time getting around when traffic is bad due to congestion and roadwork. It has had to be done by PD too at that exact hospital. Their benefit was that transport time was immediate and the hospital was close.

Honestly, I'd say it depends on the part of the city they are in. On the main strip, near by? Go for it. More extended and further North? Or just 1600 and rush hour traffic. At least have us intercept.

VentMonkey · Mar 27, 2017

NysEms2117 said:
But a bls ambulance vs a cruiser with maneuverability... Bls can't do much for tension pneumo's either.
I'd rather have a well-oiled BLS unit cautiously take me to the proper ED than me being flung about in the back of a patrol vehicle; call me crazy.
I'm still trying to figure out how to post for the general ems population since I have 0 experience outside of my first and only ems job so far.
Perhaps herein lies the disconnect? As an EMS-only provider I can only speak from my experiences.

My experiences have seen way too many emotionally charged firefighters and police officers trying to rush through situations such as this. They often hinder care, and not help it when they attempt to get involved.

As you said, there are times when each service should do their jobs, respectively; this would more often than not be one of those times.

We don't know what we don't know, right? Also, aside from Philly, what other LE agencies are doing this, and how have their outcomes held up? I haven't seen, or heard of too many doing this, even in densely populated urban areas. I have to wonder why it hasn't picked up steam by now with the LE community.

Perhaps you know why it hasn't yet?

NysEms2117 · Mar 27, 2017

VentMonkey said:
We don't know what we don't know, right?

Understood sir

, bottom line for me, when **** hits the fan and God forbid I get shot or stabbed or insert *very bad Owwie here* I'd hope that the folks taking care of me made choices that bettered my chances. Ultimately it's getting to the hospital safely. I understand I said "run and gun" with Leo's before, I just meant they can go faster while being safe as well. If my best chances of survival are being jostled in the back of a patrol car for 10 minutes but getting to the hospital sooner (while being safe) so be it. If my chances are to have a paramedic lift me into an ambulance and drive at a slower speed, so be it. Whatever lets me see my family again, whatever lets my patient/partner/ fellow first responder see their family again, that's what i will do.

If you folks couldn't tell I'm a very results oriented guy, how it happens that's an after thought.

I am safety oriented in real life* don't want you folks thinking I'm a run and gun person, I just assume since we're all here voluntarily safety and precautions are assumed

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DrParasite · Mar 27, 2017

wait, the answer isn't scene safety?

DrParasite · Mar 27, 2017

VentMonkey said:
We don't know what we don't know, right? Also, aside from Philly, what other LE agencies are doing this, and how have their outcomes held up? I haven't seen, or heard of too many doing this, even in densely populated urban areas. I have to wonder why it hasn't picked up steam by now with the LE community.

Perhaps you know why it hasn't yet?

Homeboy taxi service has been doing it for years.

it hasn't caught on in the LEO community because they don't want to always be washing the blood out of the backseats of their patrol cars. Philly is smart; they have a van where they can just run the hose out of the back. And they have a very poorly managed, understaffed, all ALS system, and historically have extended response times, which is why PPD adopted the scoop and run in the PD van SOP for GSW victims. After all, why fix the EMS when the cops can just drive really fast to the ER?

SpecialK · Mar 27, 2017

VentMonkey said:
Ok I have to ask, @SpecialK what are the assault weapons of choice in New Zealand?

Fists, bit of wood, bottles, bat, those sorts of things; mainly blunt trauma with a very low rate of penetrating injuries but mostly from domestics or some blokes have a bit of biffo and somebody picked up a knife but they're usually short kitchen knives. Every now and then somebody gets shanked with a screwdriver.

The only people I've heard of being attended to who were shot with a handgun is when the police are the ones shooting. And that's maybe one person a year out of the whole country. Some of the overseas personnel from London and South Africa reckon it's paradise down here cos of lack of penetrating violent injuries.

EpiEMS · Mar 27, 2017

VentMonkey said:
Also, aside from Philly, what other LE agencies are doing this, and how have their outcomes held up?

I found an article published in December 2016 that used the National Trauma Databank (this is voluntarily provided data on traumatic injury, and covers over 700 facilities). The authors, in their case-control study, found that:

Patients transported by police were no more likely to die than those transported by EMS (OR=1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit).

So, that's nearly 90% of police transports in a study of nearly 90,000 patients (covering the 100 most populous trauma systems in the United States) - and only three cities.

More detail on the outcomes:

Unadjusted mortality rates were higher for police transport than ground EMS for GSWs (26.4% vs. 20.8%, p<0.001) and not significantly different for stab wounds (3.5% vs. 3.3%, p=0.89). Following risk-adjustment*, patients transported by the police department were no more likely to die than those transported by ground EMS (OR=1.01, 95% CI: 0.68-1.50). This held true for GSWs (OR=0.93, 95% CI: 0.62-1.41) and stab wounds (OR=0.32, 95% CI: 0.09-1.14).

*They adjusted for "age, gender, race, ISS, HR, SBP, GCS-Motor, and insurance status."

More conclusive results could be obtained by a RCT, but I doubt that is likely to happen anywhere. (Chicago would be a good candidate city.)

MonkeyArrow · Mar 27, 2017

EpiEMS said:
More conclusive results could be obtained by a RCT, but I doubt that is likely to happen anywhere. (Chicago would be a good candidate city.)

But is Chicago so understaffed that the EMS vs. LE response times would differ significantly? The only place I see this making sense is somewhere with extended EMS response times due to chronic understaffing like Philly as mentioned, or maybe Detroit?

EpiEMS · Mar 27, 2017

@MonkeyArrow, I think that anywhere with high rates of penetrating trauma would be a reasonable place to study it. Based on the Philly data, PD transport is strictly preferable under certain conditions, and I don't think it really matters whether there are extended EMS response times under those constraints (e.g. penetrating trauma to the torso).

kirky kirk · Mar 28, 2017

Wow, the wealth of information I got from you guys.

phideux · Mar 29, 2017

kirkyrabbit said:
During one training session, this scenario was given.

Patient arrived at the ER, gunshot wounds to the left chest, left abdomen. Patient is gasping, bleeding profusely and de-saturating fast. What is the priority intervention?

Back to this, I'm going with IV or IO, RSI, slow the bleeding and get blood going in, Maybe dart the chest while the Doc sets up the chest tube tray and puts in a tube, CT to see what's actually going on, and take it from there.

StCEMT, I was working triage at the ER one night when a car pulls up with 5 people with multi-GSWs. One was DRT, the other 4 made it. We had 2 GSWs walk in through triage last weekend. We see a bunch of that here.

CoraElizabeth · Mar 31, 2017

Trying to figure out an "exit wound" is a waste of time. Just count the holes, it makes ZERO impact on our care, and quite frankly, if someone is gasping for breaths, I just have bigger priorities. I once heard a trauma surgeon talking, apparently, they aren't even allowed to document an entrance/exit wound, because they aren't medical examiners. All the trauma surgeons document is number of holes. Apparently, if they do document entrance or exit, the could be completely
I'm also not HUGELY concerned about things like distance. Most of our GSWs are street violence, so no one around knows, or is willing to talk, so I don't even ask. The reality is, regardless of how far away the person was or was not...the wounds are still the wounds, and that's all that's needed to know in the emergency setting.

CALEMT said:
This. Maybe try to find some info on the gsw. Caliber? Entrance/exit wound? Approximate distance from shooter to victim?

VentMonkey · Mar 31, 2017

CoraElizabeth said:
Trying to figure out an "exit wound" is a waste of time. Just count the holes, it makes ZERO impact on our care, and quite frankly, if someone is gasping for breaths, I just have bigger priorities. I once heard a trauma surgeon talking, apparently, they aren't even allowed to document an entrance/exit wound, because they aren't medical examiners. All the trauma surgeons document is number of holes. Apparently, if they do document entrance or exit, the could be completely.

Eh, I don't know about all of that. The "Bullet Rule" still holds value to many-a-trauma surgeons I have encountered.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255182/#!po=70.4545

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