Civilian Forward Surgery

[Veneficus]

After the recent threads regarding ER bypass as well as instructional shooting I have been giving this matter some thought.

It is well known that some regions have both flight and ground response teams which include surgical capability.

We know that life threatening trauma, particularly that amiable to surgical correction is both declining and one of the few time sensitive emergencies.

Recently in London, and in years past, Israel has been able to have a positive effect on life threatening traumatic injury by having surgical capability respond to the scene.

In the US, it seems more and more, there is a push for actual medical care into the field setting. Mostly by Emergency Physicians, but in this case I do not think it matters who is doing it.

Since there is an abundance as well as new focus of prehospital emergency physician fellowships, compounded with the success of forward surgical capability in just about every war since the Napoleonic wars, should implementation of this idea be advanced?

While cost is certainly a concern, is there a way it could be made to be cost effective?

Should various high acuity calls have an automatic surgical capable physician dispatch with such things as hypothermia equipment and blood?

Given the success of other nations and the military, coupled with the knowledge of advanced and time sensitive, should this warrent at least a trial?

 

[VFlutter]

Do you think this would have an impact anywhere in the US or more so in urban or rural areas? A local FD here was a jump car that the medical director occasionally uses to respond to scenes. He also regularly rides on the ambulances. Not sure if this adds any advanced medical care or more so just for public relations.

The idea in concept sounds like a good idea but is it practical? How many emergencies would actually benefit from on scene MD/surg care? Enough to justify the costs? Would they only respond for trauma or every call (Possibly to treat and release).

 

[Veneficus]

I think I would limit it to the most high acuity calls to see if there was effectiveness in concept.

I suspect it would be most valuable in an urban setting, but I also see positive implications for both suburban and rural systems.

I think the greatest inhibiting factor would be cost. The other factors seem to be logistical, which wouldn't be difficult to overocome.

Without advanced capability though, simply putting a docotor on an ALS ambulance doesn't seem like there would be any benefit.

 

[mycrofft]

Cmdr Richard Jadick did this in the Battle of Falujah with good results.

http://www.thedailyshow.com/watch/tue-march-6-2007/richard-jadick

How about devolving medical care to a more decentralized state so hospitals are closer, then work on the transport and initial contact system?

Also, the Urban/Rural Paradox applies; the areas with sharter response times and lots of indigenous talent and money (urban) actually have a lesser need for forward/decentralized high caliber care than frontier or rural areas, which lack the talent/money or potential market to attract private firms.

One note by Dr Jadick from the book; once you get surgical (in his case, "cracking a chest"), you have pretty much tied the pt to the spot. Thoracotomies after trauma are touch and go, and a ride to another location doe not do them any good.

 

[mycrofft]

1.I think I would limit it to the most high acuity calls to see if there was effectiveness in concept.

2.I suspect it would be most valuable in an urban setting, but I also see positive implications for both suburban and rural systems.

3. I think the greatest inhibiting factor would be cost. The other factors seem to be logistical, which wouldn't be difficult to overocome.

4. Without advanced capability though, simply putting a docotor on an ALS ambulance doesn't seem like there would be any benefit.

1. Sure, but ruling out is also valuable. Go to a chest pain, cure it with simethicone/CaCO3 and reassurance versus starting an IV and trache for every case?
2. See my comment above. When Billy Bob rolls his tractor or gets his sleeve in the corn auger, he needs care as fast or faster than the MVA with a sore neck in Canton or Milwaukie.
3. Yes. Also talent; not everyone can be effective in PEMS, not even the ones who all want to be at some point.
4. Ruling-out? Or making those medical connections techs can't (such as deducing a tumor or chronic disease when presentation suggests cardiac or neuro)?

I'm given to understand I'm a "contrarian".

 

[Veneficus]

1. Sure, but ruling out is also valuable. Go to a chest pain, cure it with simethicone/CaCO3 and reassurance versus starting an IV and trache for every case?
2. See my comment above. When Billy Bob rolls his tractor or gets his sleeve in the corn auger, he needs care as fast or faster than the MVA with a sore neck in Canton or Milwaukie.
3. Yes. Also talent; not everyone can be effective in PEMS, not even the ones who all want to be at some point.
4. Ruling-out? Or making those medical connections techs can't (such as deducing a tumor or chronic disease when presentation suggests cardiac or neuro)?

I'm given to understand I'm a "contrarian".

I don't disagree with you.

But, I think asking for general EMS physicians in the US is not realistic. I think it is more realistic to have the ability to focus afew on specific types of calls. It is just my opinion and seems to work else where.

1. I agree. I just don't see it happening.

2. Again I agree. The question here becomes how soon can you get this physician there and by what means? Certainly nobody is going to pay a physician to sit around in podunk "just in case?"

3. Preaching to the choir my friend

4. Same as #1.

 

[mycrofft]

I don't disagree with you.

But, I think asking for general EMS physicians in the US is not realistic. I think it is more realistic to have the ability to focus afew on specific types of calls. It is just my opinion and seems to work else where.

1. I agree. I just don't see it happening.

2. Again I agree. The question here becomes how soon can you get this physician there and by what means? Certainly nobody is going to pay a physician to sit around in podunk "just in case?"

3. Preaching to the choir my friend

4. Same as #1.

You are absolutely right.

Haven't we been around this block before? Nice orange letters, btw.

 

[Carlos Danger]

After the recent threads regarding ER bypass as well as instructional shooting I have been giving this matter some thought.

It is well known that some regions have both flight and ground response teams which include surgical capability.

We know that life threatening trauma, particularly that amiable to surgical correction is both declining and one of the few time sensitive emergencies.

Recently in London, and in years past, Israel has been able to have a positive effect on life threatening traumatic injury by having surgical capability respond to the scene.

In the US, it seems more and more, there is a push for actual medical care into the field setting. Mostly by Emergency Physicians, but in this case I do not think it matters who is doing it.

Since there is an abundance as well as new focus of prehospital emergency physician fellowships, compounded with the success of forward surgical capability in just about every war since the Napoleonic wars, should implementation of this idea be advanced?

While cost is certainly a concern, is there a way it could be made to be cost effective?

Should various high acuity calls have an automatic surgical capable physician dispatch with such things as hypothermia equipment and blood?

Given the success of other nations and the military, coupled with the knowledge of advanced and time sensitive, should this warrent at least a trial?

Interesting.

Twice in my career as a flight paramedic and flight nurse, I've sent the helicopter to the trauma center to pick up a surgeon to come to the scene and perform an amputation on a severely entrapped patient who was in extremis. Both times the patient arrested before the helicopter landed at the hospital. There were a few others which weren't quite so dramatic, but where I think someone with surgical skills *may* have been able to make a difference. Granted, these are only a handful of situations in more than 10 years and more than a thousand transports.

I believe there is literature that shows no improvement in outcomes of patients treated by HEMS crews consisting of RN/EMTP vs RN/MD. But like usual, I can't remember details or where or how long ago I saw that.

I wonder....if HEMS were utilized much more appropriately in the US (i.e. a lot fewer helicopters in and around urban areas, and dispatched only for very high acuity patients with long prehospital times), basically making the average acuity much higher, would a study then find differences in outcomes with a surgeon on the crew?

 

[systemet]

Our local rotary wing flies with a EM physician on some calls. They have done a few field amputations. Most of the people I've talked to have said that the value of the physician tends to be more apparent on complex medical patients coming out of rural ERs.

As with anywhere there's a lot of overtriage. What skills do you see a surgeon performing prehospitally? Is it primarily thoracotomy in penetrating trauma?

 

[mycrofft]

Could advanced help be experiencing delayed dispatch because the pt has to be virtually dead to pull the trigger on a helo?
Like waiting for asystole to address coronary artery disease...a favorite pass-time in America and really really ineffective.

But if the helo pt is already dying, then when the pt dies anyway it doesn't reflect badly on anyone because it didn't work; if they went sooner and it didn't work, or it resulted in an amputation and a save, there is no end of trouble and fault-finding to undergo.

 

[EpiEMS]

Who's gonna pay for it?

And does the number of QALYs justify it?

And does it help?

Dr. Bledsoe has a useful presentation with some literature review here, entitled "Medical Helicopters in EMS"

 

[Veneficus]

Measuring effectiveness

I don't think tha out of hospital surgical support needs to be tied to an aircraft.

Certainly the value of aircraft would be dictated by many factors, not least of which is distance.

As for who pays for it, I would answer that with: "Who pays for it now?" There are physician airmedical services around the country and the world, clearly it is being paid for.

Initially I would expect effectiveness to be quite low. Like any procedure or treatment, once instituted, it would have to go through a refinement period. I am just not deluded enough to think we are going to put a new modality into play and expect outstandng results off the line.

BUt to answer this question and another regarding "what procedures" I don't really think of it like that. Procedure based operations are largely justified by easy to quantify metrics (even if they are not representative of reality) and not least of which OR and post op resources.

From the perspective of damage control surgery, we would have to look at overall disability and quality of life. Which are very subjective. Basically preserving the ability to productively function, not promising a patient with the desire to.

Let me explain.

I don't see surgery as a collection of procedures. That is rapidly becomming an outdated concept with the advances in intravascular techniques. I see it as goal directed. So for example, many people like to cite open chests and amputations as the likely procedures to be done.

Field amputation is so rare I don't even think it is worth using as a metric. Thoracotomies in the urban areas might present more of an opportunity. But that is really just a technique of access, and even of it, there are multiple ways to open a chest. Considering these would likely be traumatic injuries, different surgical approaches as well as intervention could be used.

For example, a "clamshell" is not optimal for subclavian arteries, there is a more specific approach that is better.

But I think that more simple procedures will make or break the idea. The ability to evaluate and stop thoracic or abdominal bleeding. Earlier trending and detection of compartment syndrome, temporary vascular shunts (both artificial and biologicial) Far more options to control bleeding. Everything from simple sutures, to flaps, plugging holes with tubes, and even redirecting circulation. The goal not definitive therapy, but temporizing so that better resuscitation and definitive therapy outcomes limit the most loss and preserve the most function.

Afterall, using the amputation example, rare as it is, there is a difference in morbidity, mortality, and quality of life in where a limb is amputated.

I offer, earlier surgical intervention before having to calculate costs starting with OR utilization time, might not only save money from the medical expense standpoint, through multiple complex mechanisms, but also offer the best result for the patient, so they can choose whether they want to sit on disability at home or despite catastrophic injury, get a job on the lecture circuit.

Will the cost be worth it? I don't know. But if we don't try we will never know.

 

[EpiEMS]

It makes sense to me to try it. Maybe in a more broadly distributed urban area with a major research Level I center. Philly, say? I'm the last one to object to quick access to the OR

The cost issue is where I have questions. If it's going to cost a lot per QALY, then it's not worth going on with -- at least, depending on your cost-effectiveness threshold.

 

[systemet]

BUt to answer this question and another regarding "what procedures" I don't really think of it like that. Procedure based operations are largely justified by easy to quantify metrics (even if they are not representative of reality) and not least of which OR and post op resources.

I guess that this leads to two further questions, really:

(1) Who's doing this already? It's an interesting idea. I know the Germans involve physicians in the field with some regularity, I met a neonatologist from Koln (I think), who used to get called out routinely for all variety of neonatal patients -- on scene calls, not just transfers. I remember some furor when Princess Dianna died about them performing on scene surgery. I've seen the papers on HEMS in London doing thoracotomies - those were really exciting. But presumably somewhere, probably in Europe, there's someone flying a surgeon out to calls with some regularity.

(2) How busy does your flight program have to be, and what sort of acuity do they have to see to justify dedicating as precious and rare a resource as a surgeon?

Understand that I'm not trashing the idea. On the contrary, I'm very interested. I just know that a current issue in HEMS is an overutilisation of flight for less acute patients, and that, as you've identified previously, a lot of blunt trauma is no longer managed surgically.

My local guys cover around 1.5 million people with a single helicopter, which is a different situation from most of the US, I think. But they still do a lot of medical (probably mostly non-surgical, or at least not requiring emergent surgery), and a lot of blunt head trauma where they're primarily transporting a patient intubated in the field (granted, some of these patients might benefit from ICP management or decompression).

 

[Veneficus]

I guess that this leads to two further questions, really:

(1) Who's doing this already? It's an interesting idea. I know the Germans involve physicians in the field with some regularity, I met a neonatologist from Koln (I think), who used to get called out routinely for all variety of neonatal patients -- on scene calls, not just transfers. I remember some furor when Princess Dianna died about them performing on scene surgery. I've seen the papers on HEMS in London doing thoracotomies - those were really exciting. But presumably somewhere, probably in Europe, there's someone flying a surgeon out to calls with some regularity.

(2) How busy does your flight program have to be, and what sort of acuity do they have to see to justify dedicating as precious and rare a resource as a surgeon?

Understand that I'm not trashing the idea. On the contrary, I'm very interested. I just know that a current issue in HEMS is an overutilisation of flight for less acute patients, and that, as you've identified previously, a lot of blunt trauma is no longer managed surgically.

My local guys cover around 1.5 million people with a single helicopter, which is a different situation from most of the US, I think. But they still do a lot of medical (probably mostly non-surgical, or at least not requiring emergent surgery), and a lot of blunt head trauma where they're primarily transporting a patient intubated in the field (granted, some of these patients might benefit from ICP management or decompression).

I don't see this idea as being restricted to flight. As you have probably seen, many nations in Europe either have or have the ability to put docs on everything from motorcycles to fixed wing aircraft.

The mode of transportation is really unimportant.

As for the "on scene surgery" in a specific instance, I was spending time with a major trauma service in London when some non-trauma cretin published a book on how she could have been saved and how he would have done it. It caused a lot of stir.

Many European ambulances operate on the Franco-German system of bringing advanced care to the patient. In is the diametrically opposed type of system than the US transport to care.

The military in multiple wars, various European and Australasian systems have proven this concept works.

Whether it is better is a matter of endless debate that we will never reach consensus on here.

Having been a part of both systems, and based on what I know, I think that the Franco-German system is superior for a number of reasons, including cost. In the current US system, I do not see an opportunity to make a switch, so I would suggest a more piecemeal approach like this.

I agree that because of the relative rarity of these calls, there would be a rather small group covering a large area. I don't think it is possible to saturate areas with surgeons. Not least of which is because of their lack of interest. (Trauma is a small community and surgeons interested in it are rare and becomming more so)

I would say if you have an interested surgeon, the region probably does have the volume and potentially the need. I would even go as far to say that many regions, especially rural, have a need but not a surgeon.

I am even familiar with multiple rural hospitals in the US that use surgeons to staff their EDs, but do not provide them with the resources needed to perform even the most basic of emergency surgery. When I asked these surgeons (in 2 different non-adjacent states) if they thought it would be helpful, I was met with answers that were recurrant.

1. "It would shut down the whole ED while I did that"

2. "What do I do with the patient after I am done without post op care?"

Both are very valid concerns. BUt unfortunately, it has created a surgical culture where doing nothing is preferable to attempting something. (not that it is the only problem facing surgeons that push such culture)

 

[Carlos Danger]

I don't see this idea as being restricted to flight. As you have probably seen, many nations in Europe either have or have the ability to put docs on everything from motorcycles to fixed wing aircraft.

The mode of transportation is really unimportant.

Certainly wouldn't need to be restricted to flight, except that a helicopter is the best way to cover as large a geographic region as possible, thereby capturing as many transports as possible. And in many regions, the EMS agencies are used to requesting HEMS response anyway, for sicker-than normal patients. It would take a handful of physician-staffed ground units to cover the same area as a single physician-staffed helicopter. So it seems like a good place to start.

A fly car would be the next best thing.

University of Cincinnati Air Care staffs with docs (R2 EM residents, according to their website). And Cleveland Metro Life Flight also staffs with physicians, surgical residents I believe. There are a few other HEMS programs that fly with physicians, too. Years ago when I worked as a new paramedic in Buffalo NY, Erie County Medical Center had a program where physicians were sometimes available to respond pre-hospitally in a fly car. Don't know the status of that program now.

So the model already exists in the US, to some limited extent, at least. For anyone seriously interested in this topic, a good place to start would probably be looking into these programs in depth.

 

[Veneficus]

I am very familiar with Metro Lifeflight.

 

[mycrofft]

Ramifications of nosocomial or iatrogenic infections? Or just postsurgical infection rates for these cases , presumptively iatogenic?

 

[Veneficus]

Ramifications of nosocomial or iatrogenic infections? Or just postsurgical infection rates for these cases , presumptively iatogenic?

I would think that the infection rates would be higher. With prophylactic ab use, probably within an acceptable range if there was an increase of saving life or limb.


Edit: I would also point out that closure is not a goal of such therapy. It is by definition, damage control, definitive cleaning and repair to be done later, post resuscitation.

 

[mycrofft]

By ramifications I was thinking about backlash against the practice since it is very hard to prove something risky you did worked, versus something everybody does all the time working (when sometimes it's futile).

Like the places that remove field IV starts and then start their own, I think a hospital would not support ANY infections they think are related to this, and practitioners who don't subscribe to it would start a hooraw against it on that ground.

"It ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them." Niccolo Machiavelli