Calling Trauma Team Alerts

[KellyBracket]

Sometimes you just have to finish the chapter ok? h34r:

edit: the chaplain already read the bible, he knows how it ends

I might share the joke with the chaplain. Anesthesia, not so much.

By the way, there's a great on-going discussion in the EM and trauma worlds about who should be doing the "trauma activations" in the future. While there is a small bit of a turf war going on, the surgeons also realize that the rate of immediate surgical intervention has been dropping for years. Who wants to do in-house call just to write adnission orders for serial CBCs, when you could be well-rested for the 8 cholecytectomies in the morning. Plus, trauma cases tend not to be well-insured...

edit: I got a strong sense of deja-vu writing this response. This topic doesn't come up often, does it?

 

[adamjh3]

Our criteria for a "major trauma" in San Diego is very similar to Bullets' area.

We can request activation at the BLS or ALS level, but it's really the nurse or physician on the radio that makes the decision. It's very rare that a BLS rig here will get an activation because almost all 911 transports are done by ALS, though it did happen to me twice in two years on a BLS rig. Both were patients that went to an urgent care that should have gone to an ER, and one was borderline.

That said, doing ride alongs on ALS rigs I've seen it activated when it shouldn't be and vice-versa.

 

[Handsome Robb]

We have a couple different levels of activation here. It's a Level II Trauma Center for what it's worth.

There's green, yellow and red, then a "Trauma Pre-alert".

Each has different paramaters and responses, green get an ERP and a Nurse right off the bat in the trauma room, generally there's a tech or two, lab and xray/CT or soon after you arrive. Yellow and red get progressively more of a response, the charge nurse makes the decision on what to activate on and to what level. They have specific parameters that I don't know. A pre-alert is the biggest "show" with basically everyone and their mother in the trauma room. Every time I've seen it happen it usually ends with "if you aren't absolutely necessary get out". Pre-alert criteria are GSW to the torso, profound hypotension after a traumatic injury and unconscious with a unilaterally blown pupil.

State trauma criteria have three components. Mechanism, Injury and Physiologic categories. If any one of the categories are met the patient is to be transported to a trauma center.

Mechanisms are: MVC > 40 mph, fall > 20 feet, MVC resulting in 20 inches of severe damage to the vehicle, rollover > 90 degrees, death in the same passenger compartment, auto vs. ped > 6 mph or thrown/run over, intrusion > 12 inches into the passenger's side of the compartment, motorcycle accident > 20 mph or thrown at any speed, extrication > 20 minutes and ejected from a motor vehicle.

Injuries are : flail chest, acute paralysis, two or more proximal long bone fractures, combination of burns > 15 % or burns to the face or airway, penetrating trauma to the head, neck, chest, back, abdomen or groin and amputations proximal to the wrist or ankle.

Physiologic criteria are: GCS < 13, Systolic BP < 90, Revised Trauma Score < 11 or GCS < 14

 

[NomadicMedic]

We have specific trauma protocols, but a "trauma alert" is different at every facility we transport to. Obviously the paramedic can request a trauma alert, but normally the receiving facility will decide if they want to trauma alert a patient or not, based on the information given in the radio report. What it boils down to is, if the doc at the other end of the radio knows and trusts the paramedic, the clinical picture painted in the report… Or sometimes its just, "that sounds like a bad one" let's trauma alert it.

 

[Veneficus]

I might share the joke with the chaplain. Anesthesia, not so much.

Just tell them you heard it from the guy that does a 5 minute stand-up for intensivists on how to get EM to do your work for you.

Anesthesia is pretty good at laughing at themselves. My favorite is this little gem.

http://www.youtube.com/watch?v=xuZl9tRqjoQ

written and performed by one.

(just to show there are no hard feelings I also have "the EDs guide to getting surgery to do their work for them"

I guess we should talk about something serious now...

By the way, there's a great on-going discussion in the EM and trauma worlds about who should be doing the "trauma activations" in the future. While there is a small bit of a turf war going on, the surgeons also realize that the rate of immediate surgical intervention has been dropping for years. Who wants to do in-house call just to write adnission orders for serial CBCs, when you could be well-rested for the 8 cholecytectomies in the morning. Plus, trauma cases tend not to be well-insured...

I have been around the US for this particular turf war, It has been going on at least a decade.

I think the first thing that has to be understood is that probably 99% of all modern surgeons do not like to do trauma. They were trained in an era where ruling out candidates for surgery was more important than actually operating. So much so, I actually have a book detailing that only 20% of an attending surgeon's time in the hospital is in theatre. (not all that much for people who claim to love operating)

Of the remaining "old school" surgeons, many of them haven't adapted with modern techniques in surgery. So much so, they create studies that demonstrate effectiveness of what they are doing in order to keep getting paid for them. How many studies on vascular stenting have you seen where the conclusion is either:

a. This is just as good as open repair.

or

b. in select populations intravascular repair is showing to be superior in the short term, but more studies are needed.

As the perfect example I like to use pelvic fracture. The threat in pelvic fracture is bleeding from the various illiac vessles. They are large caliber vessles that are easily accessed intravascularly. So why not take these people to fluro and fix it that way?

The reason I hear most is: "because they we have to get an interventional radiologist or vascular surgeon."

Why do only a few trauma surgeons learn these techniques? Isn't a majority of life threatening trauma vascular or are patients bleeding from a location different from a blood vessel?

Modern surgery lags behind its medical counterparts in insisting that surgery is divided by location instead of pathophysiology. Surgeons are not usually big picture people so you have to give them some time to catch on. You also have to let a few Master's of the Universe die off or retire so the young guys can actually affect some change because of the hierarchal nature of surgery. Remember surgeons have only been doctors for about 150 years and there is still a lot of technical labor culture to them. (if it wasn't for them medical residencies would not exist)

Another key aspect of trauma is who it affects. It affects poor people disproportionally and is a recurring disease. That is why we see more trauma in developing nations, war zones, austere environments, and refugees. It is also why a majority of 1st world trauma patients are from lower socioeconomic status. They share the same environment.

If somebody became a trauma surgeon to save the lives of the upper middle class family guy, they picked the wrong profession. That guy is in bed by 9pm and his idea of "living on the edge" is mowing the lawn every 9 days instead of every 7 like his homeowners association demands.

The town drunks, drug abusers, roofers, treecutters, factory workers, unskilled labor, and criminals are the patient population. 99% of their injuries are preventable. Especially when highly educated people see them all suffer from the same things again and again.

This population is also the very definition of charity care. I am not sure how any fee for service provider thought they were going to take the poorest population who requires the most medicine the most often and make big dollars.

It is obvious why hospitals don't like this population.

To say the solutions are simple. Putting them in effect... an entirely different matter.

Since trauma is charity care, there needs to be a larger pool of trauma providers so that they all have less time exposure to this nonpaying population.

Either that or trauma facilities will have to salary these people at a rate that makes it lucrative not to have to hold over the next day to do paid operation. Fat chance of this though. (heavy sarcasm)

During a visit to the trauma surg department of the Royal London Hospital a few years back, I saw what was perhaps the most efficent trauma surgery dept I have ever witnessed. I particularly like their model.

A senior trauma "resident" on staff with a junior trauma "resident." (both of whom were either general or vascular surg) If things were slow, they would take a case off the morning schedule and operate on it during the night shift. If a trauma came in, one of the 2 surgeons would go and evaluate that trauma in the ED. It literally kept the OR in operation 24 hours a day. (talk about optimizing an OR)

If the trauma was bad, they could call another in hospital surgeon to perform a quick closure on what they had or even finish the OP. While attending to it.

During one night, just before shift change of course, an MVA with a partial foot amputation came into A&E. In the closest thing I have ever seen to the civilian implementation of damage control surgery, they restored vascular flow to the distal foot and then medicated and left the guy to be definitively repaired by the day shift. When we left, the pt. was still in A&E.

Another interesting component of non-US trauma surgery I have seen is keeping traumatology in ortho. (I don't really like it, but it works) There is an orthopod in the building 24/7. Since most trauma is ortho, rather than a temporary splint and an ortho follow-up, Orhto is directly given the case. The medical providers don't even see or touch the patient. If the patient is life threatening, The specif surgeon, or in multi-system cases, surgeons, and anesthesia saunter over and create a plan and take the pt away from the ED.

Unless it is life threatening by presentation, not by criteria or mechanism, these providers never know the patient exists.

In the US, ATLS, and a host of other trauma initiatives have been instituted based on mechanism and "what if" as you notice, "what if" and "holy $**T" are rare and on the decline.

As I have noticed, most of trauma care is actually intensive care. I am also starting to think the best place for the surgical trauma provider is closer to the action and farther from the ivory tower. The seriously bleeding patient in the community ED needs surgical control of bleeding. They do not need water or blood poured into an open circuit and a transfer yet.

In my not always humble opinion, the ideal trauma provider is a surgeon, and intensivist, and learns a variety of total body procedures from multiple disciplines for the sole purpose of temporizing the patient for resuscitation and later definitive repair by somebody more specialized. It is in effect the only real use for a general surgeon.

Consequently, the procedures needed are the same for any emergency surgery patient. So whether it is PCI, aneurysm repair, acute pancreatitis, appendicitis, etc, this surgeon is in effect an "emergency" surgeon, who primarily works nights, weekends, and holidays because there are ample dayshift specialsts about making nonintesivist services of this provider superfulous.

edit: I got a strong sense of deja-vu writing this response. This topic doesn't come up often, does it?

Perhaps not here, but this topic has existed as long as I can remember.

 

[Clare]

I looked it up and the trauma call at ADHB (ACH) consists of the following

- ED Registrar
- DCCM Registrar (ICU)
- Surgical Registrar (general, or if scrubbed, ortho or ortho u/a then uro or if ortho or uro u/a then paed surg)
- Airway nurse
- Circulation nurse
- ED nurse (general)
- Team leader (ED Consultant or from midnight until 0800 DCCM Reg)

Interesting there is no anaesthetist on a trauma call, and uro reg? really? uro? what is the patient doesn't have a problem with their pee pee? thats almost as bad as having the paed surg reg ... what if the patient is a big person?

 

[Veneficus]

I looked it up and the trauma call at ADHB (ACH) consists of the following

- ED Registrar
- DCCM Registrar (ICU)
- Surgical Registrar (general, or if scrubbed, ortho or ortho u/a then uro or if ortho or uro u/a then paed surg)
- Airway nurse
- Circulation nurse
- ED nurse (general)
- Team leader (ED Consultant or from midnight until 0800 DCCM Reg)

Interesting there is no anaesthetist on a trauma call, and uro reg? really? uro? what is the patient doesn't have a problem with their pee pee? thats almost as bad as having the paed surg reg ... what if the patient is a big person?

Uro and Gyn both have at least 2 years of general surgery training before specialized training in their respective fields.

They are very capable surgeons and I have never seen anyone control bleeding or find occult arteries better than a Gyn.

 

[Clare]

Uro and Gyn both have at least 2 years of general surgery training before specialized training in their respective fields.

They are very capable surgeons and I have never seen anyone control bleeding or find occult arteries better than a Gyn.

My house mate who just moved out is a general surgeon, he is moving out because he got his FRACS and bought a house as his pay rise was probably more than my total yearly salary!

He says only a small %age of patients who come from a trauma call will be admitted to surgery, most go to DCCM (ICU) and those who go to surgery tend to go to either orthopaedics or neurosurgery as high quality imaging has replaced the need to do big open laparotomies and look around peoples innards anymore.

OB/Gynae receive some surgical training but they are primarily physicians at least here. I find gynae interesting, just not the going to them part

 

[Veneficus]

My house mate who just moved out is a general surgeon, he is moving out because he got his FRACS and bought a house as his pay rise was probably more than my total yearly salary!

He says only a small %age of patients who come from a trauma call will be admitted to surgery, most go to DCCM (ICU) and those who go to surgery tend to go to either orthopaedics or neurosurgery as high quality imaging has replaced the need to do big open laparotomies and look around peoples innards anymore.

OB/Gynae receive some surgical training but they are primarily physicians at least here. I find gynae interesting, just not the going to them part

GYN is still considered a surgical discipline, it is the only medical discipline that is a combination of surgery and medicine recognized world-wide.

A handful of countries have surgical intensivists, which are surgeons that are also intensivists, These are really the only 2 "mixed" disciplines.

I would say that in addition to the imaging, nonsurgical treatments for conditions that at one time were always operated on, like low grade liver and splenic lacs, also play a major part in the reduction of emergent surgery.

I am of the opinion that acute life threatening conditions require a combination of surgical and intensive medical care in conjunction. Intravascular techniques will be a large part of the future of surgery, but like I said, surgeons are slow to catch on.

Too much trying to piss around the corners of their old kingdom than evolving to maintain value.

 

[Clare]

What's intravascular techniques?

What about optho; isnt that part medicine part surgery too?

 

[Veneficus]

What's intravascular techniques?

The same procedures and techniques used by vascular surgery, interventional cardiology, and interventional radiology.

What about optho; isnt that part medicine part surgery too?

I have never heard of optho being considered both universally. I always understood it to be primarily a surgical discipline, but I admit that I have had a very traditional medical education, so there might be some divergence.

 

[NomadicMedic]

A reminder to stay on topic please.

 

[CentralCalEMT]

In my system we have 4 steps. Step 1 is based on vital signs. Step two is based on apparent injuries such as pneumothorax, multiple long bone fx, flail chest, etc. Both of those steps are automatic activations and also are criteria for the helicopter as long as time savings is over 10 min over ground. Step 3 is MOI and step 4 is special factors such as age, existing disease processes, etc that existed prior to injury that could complicate things. Both of those are activated based on paramedic discretion or MD discretion based on the call in the paramedic does. I like this system as having discretion saves unnecessary activations and saves us bypassing other hospitals when the patient doesn't actually need the trauma center.

 

[Brandon O]

...and sometimes it's needed. I offered to run down to the blood bank on a trauma and wait while they thawed out a massive transfusion protocol set. I ended up having enough time to wander over to the cafeteria for a snack and a soda (both are on the same level) and still get back with several minutes before they were ready with the first batch.

FFP takes a good 20-30 minutes to thaw, doesn't it? To me that's a significant difference between centers with high enough acute volume to maintain a substantial stock thawed and immediately available, versus those that realistically can't.

 

[JPINFV]

FFP takes a good 20-30 minutes to thaw, doesn't it? To me that's a significant difference between centers with high enough acute volume to maintain a substantial stock thawed and immediately available, versus those that realistically can't.

I honestly don't know what's kept on hand or how long it takes to thaw. There's always a couple of rounds available, but for those that need more there's a protocol in place to get the proper amounts of FFP/platelets/pRBCs ready and up to the trauma bay.

 

[Brandon O]

I honestly don't know what's kept on hand or how long it takes to thaw. There's always a couple of rounds available, but for those that need more there's a protocol in place to get the proper amounts of FFP/platelets/pRBCs ready and up to the trauma bay.

Right, exactly. So in that crashing hemorrhagic patient needing true massive transfusion of 1:1 plasma and reds, waiting for the TV dinner to heat may take a little too long.

I believe most of the big places just circulate their on-hand supply into the elective supply when it's not used, that way you're not wasting it either way...

 

[WuLabsWuTecH]

When you have a trauma patient, and you call report and saying "I'm calling in a trauma, we're 15 minutes out with blah blah blah," does your local trauma center ever *not* alert the patient?

Is there proven benefit for patients in having the trauma team waiting for them when they arrive?

What are your local criteria? Links?

I recently took a 22 yo male who was pulled out of a house fire unconscious after falling down the stairs inside. He had an altered mental status with neck pain and severe headache after he started to wake up some. No singed facial hair, no burns, no soot in his airway. Initial sats were 100%, HR 132, BP 150/98.

After a few minutes on high flow O2, he woke up some, remained anxious, confused, oriented to person and place, and complaining of headache, still satting 100%, HR down to 92, BP 138/70.

He was complaining of neck pain, no visible trauma, no neuro deficits.

Would this guy have met the criteria for a TTA at your local trauma center?

Ohio has a set of trauma standards defined statewide: http://ems.ohio.gov/ems_trauma.stm

A the bottom of every criteria "cheat sheet" is some variation of the following:
-Physician Discretion
-Paramedic/EMS Discretion

If I call for a "Trauma Alert" with that exact phraseology, there better be a trauma team waiting for me or a damn good reason why they can't have the trauma team assembled and waiting for me. One of the hospitals in the area got in trouble for this a few years back because they kept coming back with the 20 questions and the medics didn't have the time to deal with the questions. Admittedly the patient was borderline trauma criteria, but when the called for the "Trauma Alert" the hospital did not activate the trauma based on their questions and had to scramble a team 5 minutes after arrival when the ER attending decided it was a trauma.

That's not to say they can't ask any questions--I was bagging a patient and doing CPR on a pedestrian struck and called in a Trauma Alert just because I ran out of hands for the radio and needed to do something else. The nurse called back to ask if there was any penetrating trauma and it was later explained to me that blunt force trauma and penetrating trauma have slightly different activations in the hospital.