CCT in Fly-cars

MonkeyArrow

MonkeyArrow

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I was reading literature on pre-operating room thoracotomies and there was a study of outcomes from the U.K. (http://europepmc.org/abstract/MED/21131854) and read that emergency physicians drive with fly-cars to the scene when they are needed. It seems to work very well for them and allows them to perform advanced interventions without a hospital.

I was wondering why we couldn't implement a method in the U.S. where E.M. doctors or CCT medics could intercept and perform advanced interventions (field thoracotomy, open cric, clamp and ligate, etc.) in the field where HEMS is not available or not feasible. CCT rigs could also perform this function but they do not perform in a 911 capacity in any place i have seen rather operating privately doing IFT.
 
I'd be curious if it would decrease trauma mortality. I think anywhere docs in fly cars are close enough to be of any use, the PT could be in the ambulance and en route to the OR. And most paramedics can already perform a chest decomp and surgical airway.
 
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DEmedic said:
I'd be curious if it would decrease trauma mortality. I think anywhere docs in fly card are close enough to be of any use, the PT could be in the ambulance an en route to the OR. And most paramedics can already perform a chest decomp and surgical airway.
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Sorry, I wasn't clear. By thoracotomy, I meant a surgical one done by making an incision from the sternum to the stretcher and using rib spreaders to open the chest to relieve pericardial tamponade and/or cross-clamp the aorta. Oh, and in GA, medics aren't allowed to do open crics, only percutaneous/closed ones. If the training were sufficient in, say, trauma surgery, I think trauma mortality would decrease given the appropriate equipment for the doc is on the rig. I think that civilian EMS needs to learn a thing or two from the military and how they care for their casualties. Everything is so slow to transition from saving lives on the battlefield to civilian care (Ex: tourniquets: widely used and highly effective in the mil but still see rigs without TQ or EMTs still trying to stuff massively hemorrhaging wounds with 4x4s).
 
Trauma Centers with fully functional ORs and surgeons are far closer in the American civilian world than on some remote battlefields. I don't see any utility to add something as drastic as a thoracotomy to anyone's scope other than physicians. Even physicians working full time in urban Level I trauma centers EDs aren't doing these anywhere approaching often, and they're used emergently as last ditch measures as is.
 
chaz90 said:
Trauma Centers with fully functional ORs and surgeons are far closer in the American civilian world than on some remote battlefields. I don't see any utility to add something as drastic as a thoracotomy to anyone's scope other than physicians. Even physicians working full time in urban Level I trauma centers EDs aren't doing these anywhere approaching often, and they're used emergently as last ditch measures as is.
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But is that really a good reason not to do something? Well, I could say the same thing about some paramedics and intubations. Because some medics only have X amount of intubations per year, they shouldn't be able to do them. Training and retraining is the key to any successful skill set. And yes, field surgery should only be reserved for physicians. However, that was the person originally proposed to be in the fly car doing such skills. The thoracotomies were performed with a relatively high level of success as noted in the study in the OP.
 
MonkeyArrow said:
But is that really a good reason not to do something? Well, I could say the same thing about some paramedics and intubations. Because some medics only have X amount of intubations per year, they shouldn't be able to do them. Training and retraining is the key to any successful skill set. And yes, field surgery should only be reserved for physicians. However, that was the person originally proposed to be in the fly car doing such skills. The thoracotomies were performed with a relatively high level of success as noted in the study in the OP.
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A Level 1 ED where I did a portion of my field internship did ~1 ED thoracotomy a year, and often none at all. The risk benefit ratio doesn't bear out the utility of this intervention pre hospitally. Intubations are somewhat rare pre hospitally in some systems, but nowhere near approaching the lack of use of this kind of intervention. Situations in which this would be considered prior to arrival at the hospital would make surgical crics seem routine by comparison.
 
Opals

It is an older study, but I think that it still rings true. OPALS reaffirmed the theory that critical, but possibly survivable trauma and cardiac arrest benefit from BLS. ALS and physician level crews were detriments to their patients survival. It is all a distraction from what really needs to happen, but it does keep our futility muscles well toned.

I am very proud of the range of skills that I have as a Medic, but at the end of the day, ambulances are for taking people to the doctor and taking naps in.
 
Our medical director has his own sprint car and we usually have a EM resident (required as part of EM rotation) or doc riding with our sprint medic.
 
MonkeyArrow said:
I was reading literature on pre-operating room thoracotomies and there was a study of outcomes from the U.K. (http://europepmc.org/abstract/MED/21131854) and read that emergency physicians drive with fly-cars to the scene when they are needed. It seems to work very well for them and allows them to perform advanced interventions without a hospital.

I was wondering why we couldn't implement a method in the U.S. where E.M. doctors or CCT medics could intercept and perform advanced interventions (field thoracotomy, open cric, clamp and ligate, etc.) in the field where HEMS is not available or not feasible. CCT rigs could also perform this function but they do not perform in a 911 capacity in any place i have seen rather operating privately doing IFT.
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We often have doctors on board our CCT units. But as you said, its IFT not 911.
 
MonkeyArrow said:
But is that really a good reason not to do something? Well, I could say the same thing about some paramedics and intubations. Because some medics only have X amount of intubations per year, they shouldn't be able to do them. Training and retraining is the key to any successful skill set. And yes, field surgery should only be reserved for physicians. However, that was the person originally proposed to be in the fly car doing such skills. The thoracotomies were performed with a relatively high level of success as noted in the study in the OP.
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Sorry - you really gotta look at these stats with a critical eye.

71 cases in 15 years. That's less than one every two months - barely five a year.

Only 13 survived, and two of those had poor neurological outcomes. Six of those 13 indicated the physician was already present at the time they arrested.

Although successful, these are very rare events. These statistics indicate that about one patient out of five survived each year. These are NOT "relatively high level of success" statistics to me.

Even if you're working out of Grady, AMC, or Emory Midtown in Atlanta - these are simply not procedures that you would see docs performing out on the streets. NOBODY wants that liability. And EMS is already underfunded - particularly at Grady which does the bulk of the city of Atlanta. Where on earth do you think the funding would come for having physicians driving around 24/7/365 for the incredibly rare instances where they would actually make a difference?
 
I understand the prospect of MDs being too costly but for a metro system like Grady (notwithstanding their funding issues), they have docs sitting around for OLMC. Why can't said docs actually get into fly cars and do things in the field? Just like a tiered BLS-ALS system where ALS gets activated under certain call types, why can't OLMC drive around and be able for on-site med assistance for extended extraction, etc.
 
If we really need it, read field amputation or something of the sort, we can request a trauma surgeon and we will get one.

I work in a metro system, for the most part, we've got really rural areas too and our OLMC docs are not sitting around waiting for our call they're attending physicians in the ER and we get whoever can come to the phone first.

The vast majority of the time I can be packaged, loaded, transported and to the TC before they could get on scene.

I'm not completely opposed to it but I think there needs to be more of a need than for potential thoracotomy cases. We do surgical and needle crichs on standing orders so I don't need a doctor for a surgical airway.
 
MonkeyArrow said:
I understand the prospect of MDs being too costly but for a metro system like Grady (notwithstanding their funding issues), they have docs sitting around for OLMC. Why can't said docs actually get into fly cars and do things in the field? Just like a tiered BLS-ALS system where ALS gets activated under certain call types, why can't OLMC drive around and be able for on-site med assistance for extended extraction, etc.
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Knowing the Grady system, I don't think docs are sitting around doing nothing but OLMC.
 
Robb said:
I'm not completely opposed to it but I think there needs to be more of a need than for potential thoracotomy cases. We do surgical and needle crichs on standing orders so I don't need a doctor for a surgical airway.
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I understand the current expanded scope but what do you think about prospects for this becoming the majority in the future. With the ever declining scope of basics (even though they are being phased out for AEMTs) *cough* cali *cough*, do you think that the scope of medics and basics will become restrictive enough to force the current ALS scope to become one relegated to CCT? With a bunch of providers in the field having worked a good amount of time and never worked a 911 call in their career just acting as a taxi for IFTs, do you think that one day, enough pts. will have negative outcomes due to lack of experience from said providers to force a change to the above.

BTW I completely support the requirement for medics to have an associates degree and have actually taken in depth A&P, bio, and chem courses to actually understand what pushing CaCl will do instead of matching the picture with the monitor and pushing whatever drug the book/protocls say to push.
 
My scope has been expanding over the last few years, not narrowing. So no I don't think that's the future. Our Community Health Paramedics are expanding as well. Our system has basically phased out ground critical care providers and added it all to the 911 medic scope. True CCTs will get a HEMS crew from our air service and us as a taxi.

As far as getting rid of basics, the only thing we use them for is special events staffing. No basics on ambulances here. Been that way for a long time.

Off topic but I saw your pm, read it then got busy and it got buried in there I'll get back to you a little later about that!
 
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I have personally witnessed a medical officer with our service intercept on a job and perform a clam-shell thoracotomy on a PEA arrest stabbing patient.

He died :unsure:


Some of our Intensive Care medics in fly cars now carry blood, can perform thoracostomy and RSI
 
the_negro_puppy said:
I have personally witnessed a medical officer with our service intercept on a job and perform a clam-shell thoracotomy on a PEA arrest stabbing patient.

He died :unsure:


Some of our Intensive Care medics in fly cars now carry blood, can perform thoracostomy and RSI
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Your system seems to be a lot alike to what I was describing. If you don't mind, can you describe the rest of your systems operating procedures relevant to the advanced medical care/intensive care medics/medical officer intercept. Also, do you have any statistics from QA/QI on the advanced med procedures performed by the aforementioned people.
 
Ive just completed an annual update with my service and we have been told that if a patient has blunt chest trauma cardiac arrest or peri-arrest that we are to notify HEMS immediately and if doctor on board they will come along and do a roadside clamshell thoracotomy with damage control surgery as required. Thing is it has to be in 10 minutes of the arrest or its a non starter.
The policy has been in place for 6 months now - haven't heard of any patients receiving this treatment as yet.
 
the_negro_puppy said:
I have personally witnessed a medical officer with our service intercept on a job and perform a clam-shell thoracotomy on a PEA arrest stabbing patient.

He died :unsure:


Some of our Intensive Care medics in fly cars now carry blood, can perform thoracostomy and RSI
Click to expand...

Wheres this at if you dont mind me askin ?
 
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