Civilian Forward Surgery

[Veneficus]

"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

I agree with Machiavelli, on more accounts than this here.

However, the reason hospitals in the US are pulling field lines and hospitals all over the world pull lines when a patient gets to a floor or ICU fall under the realm of preventable infection. (or reasonably preventable)

Field resuscitation techniques, surgical or otherwise generally fall under "acceptable risk of infection" for the preservation of life and limb.

I would also call attention to the fact that infections caused by community organisms are far easier to treat than those found in the healthcare setting, particularly in surgery and intensive care.

The organisms there are the survivors of the fittest.

 

[mycrofft]

Maybe they can introduce some non-antibiotic resistant competitors to the ensconced hospital germs? (kidding).

I think the concept of forward care has been established as fact for major trauma in Fallujah and other places, but it is the political aspect which will thwart the science and practical application.

Another potential use for this: extensive burns. Proper anesthesia, airway management, fluid resuscitation and introduction of surgical IV sites, escharotomies, and analgesia?

By the way, how large a mobile carrier do you think this will take (mobile fluoroscope, mobile lab, mobile anesthesia, mobile supply carrier, etc.). It could look like the circus is coming to visit poor Mr Smith and his severed hand or impaled abdomen. Maybe need to call a roach coach and honey wagon as well?

 

[Veneficus]

Maybe they can introduce some non-antibiotic resistant competitors to the ensconced hospital germs? (kidding).

But it is not a bad idea.

I think the concept of forward care has been established as fact for major trauma in Fallujah and other places, but it is the political aspect which will thwart the science and practical application.

That does seem like the biggest hurdle.

Second to that would be finding surgeons who would do it. Especially if is going to count against somebody's publically published stats. On the bright side, each of the 2 surgeons could blame the other.

Another potential use for this: extensive burns. Proper anesthesia, airway management, fluid resuscitation and introduction of surgical IV sites, escharotomies, and analgesia?

I could see many uses of this.

By the way, how large a mobile carrier do you think this will take (mobile fluoroscope, mobile lab, mobile anesthesia, mobile supply carrier, etc.). It could look like the circus is coming to visit poor Mr Smith and his severed hand or impaled abdomen. Maybe need to call a roach coach and honey wagon as well?

I think it comes down to wants and needs.

Most of the stuff you listed is a want.

Needs would be a handful of instruments, some tubes, and some suture. There are some surgical procedures, one I have personally done, where the patient is in so much pain that the cutting without even local anesthesia actually brings relief from the pain.

I would be of the mind that if you were going to start setting up an anesthesia machine, then that person doesn't need field surgery.

 

[mycrofft]

How about a list of potential types of insults/patients and procedures to do?

 

[platon20]

I see no reason why an advanced paramedic couldnt be trained to do amputations and thoracotomies in the field. Instead of taking the surgeon out of the OR, train the paramedic to be the field surgeon.

 

[VFlutter]

I see no reason why an advanced paramedic couldnt be trained to do amputations and thoracotomies in the field. Instead of taking the surgeon out of the OR, train the paramedic to be the field surgeon.

And how much education do you plan on adding to accomplish this goal?

I am hoping at least gross anatomy with a cadaver lab...

 

[rescue1]

I'm not a huge fan of paramedic amputations. There is a reason surgeons go to 4 years of medical school and then have a long residency.

 

[JPINFV]

I'm not a huge fan of paramedic amputations. There is a reason surgeons go to 4 years of medical school and then have a long residency.

I'd argue that a paramedic, especially a fire medic (more likely to be familiar with oscillating saws), could be easily trained to do an emergency amputation. RSI, tourniquet, cut through soft tissue, oscillating surgical saw through the bone, transport. The patient can be taken to the OR immediately for a revision or better hack job.

The real question is how often are field amputations actually needed.

 

[rescue1]

The real question is how often are field amputations actually needed.

And how rapidly the amputation needs to be performed. If you can wait for a team from the ER/Trauma room to arrive, there's no need for EMS to run around cutting off people's limbs willy-nilly.

That being said, I guess if doctors did it in the 19th century with a semi-clean saw and a shot of whiskey, I guess it could be feasible for emergent amputation to be in the scope of EMS.
I remain unsold on EMS thoracotomies though.

 

[medichopeful]

I see no reason why an advanced paramedic couldnt be trained to do amputations and thoracotomies in the field. Instead of taking the surgeon out of the OR, train the paramedic to be the field surgeon.

But skills degrade. There's discussion all over this board over failed intubations due to lack of experience/skills degradation, so what makes amputations different? A surgeon does surgery routinely (though, granted, it might not be amputations all the time), so they're experienced. Paramedics wouldn't be doing surgery every day, so their skills wouldn't stay around for too long!

In addition, there's the education factor. In my opinion, no one without an MD/DO behind their name should be taking anyone's limbs away.

 

[JPINFV]

And how rapidly the amputation needs to be performed.

I don't think it's too hard to envision a plausible scenario where waiting for someone to run down to the local trauma center and grab a surgeon for an entrapped patient puts the entrapped patient at greater risk. It's like justifying paramedics carrying blood in case of the bus full of hemophilic nuns crashes with a daycare van. Possible... but very rare.

...and rarity is more important in this case than necessity for speed.

 

[111111111111111101]

Im shadowing a trauma surgeon, hell go out sometimes its pretty epic.

 

[rescue1]

I don't think it's too hard to envision a plausible scenario where waiting for someone to run down to the local trauma center and grab a surgeon for an entrapped patient puts the entrapped patient at greater risk. It's like justifying paramedics carrying blood in case of the bus full of hemophilic nuns crashes with a daycare van. Possible... but very rare.

...and rarity is more important in this case than necessity for speed.

I suppose. I was thinking that if you could place an effective tourniquet on the limb you should buy yourself plenty of time, but there's always the patient with multisystems trauma AND entrapment or any number of situations.

Either way, I agree, the rarity makes such an education-intensive skill kinda inefficient.

 

[wanderingmedic]

I know I have said something similar to this before, but what about having PA's function prehospital? They have a very generous scope of practice in most states, and are very capable of performing surgery. There would certainly need to be some additional training for them, but that is to be expected with any specialized job in healthcare.

In terms of opportunity cost, Physicians are very expensive in terms of $ and time to train. PA's need a Bachelors (for most programs, although I have heard of some that do not require it) and ~27 months of PA school. Prehospital work is inherently dangerous, and I do not think it is worth risking a MD when they are worth a lot to society because of the time and $ spent training them.

While a PA certainly does not have the training to provide the level of surgery a MD can, they could certainly do a lot more invasively prehospital to help a patient.

Are there any procedures in particular you would like to see done prehospital? For the most part, trauma surgery (yes, I know I am oversimplifying) is about stabilizing a patient and addressing immediate life threats. Orthopedic, reconstructive, and a lot of the cleanup work to return the patient to normal function is done after the patient's initial surgery and their physiology returns to normal, since they are more stable. Is there any reason a PA couldn't clamp a bleeding artery, or address another life threat that is only solved by surgery in a prehospital setting?

 

[Carlos Danger]

In my opinion, no one without an MD/DO behind their name should be taking anyone's limbs away.

"I realize, sir, that you are definitely going to die trapped in this car if we have to send the helicopter on a 60 minute roundtrip flight to pick up a surgeon. But I don't have MD or DO after my name, so it's too risky for me to do what needs to be done to try to save your life."

Not saying I think paramedics should be trained to do amputations, just that this is where your logic leads.

I have literally been in this exact situation more than once.

 

[Veneficus]

I know I have said something similar to this before, but what about having PA's function prehospital? They have a very generous scope of practice in most states, and are very capable of performing surgery. There would certainly need to be some additional training for them, but that is to be expected with any specialized job in healthcare.

I don't think you understand the nature of the types of surgical correction that may be required.

Trauma surgery is not like a prescheduled surgery where you know what procedure you are going to follow. In many cases it will be improvised, and could be anywhere in the body.

To my knowledge, there is no "general surgey" PA who is trained and experienced operating on any part of the body.

The second big inhibition with this is that said PA training does not have the depth to manipulate different aspects of biological systems. They are trained to provide care that is already shown to work. I recently equated what these provers do as an imitation of system manipulation, which is what is being done by physicians.

Do you really want somebody with 27 weeks of training and some OTJ operating on you making it up as they go? Because if that is the case, we could just use medical students. They probably need the money so will work for far less.

In terms of opportunity cost, Physicians are very expensive in terms of $ and time to train. PA's need a Bachelors (for most programs, although I have heard of some that do not require it) and ~27 months of PA school.

From what I have come to understand, PAs bill at least 80% of what a physician does. I am not sure that is really cost ssavings.

As for time in training, you realize that PAs are basically a North American concept and the rest of the world trains an adequete number of physicians for their need?

So they are not using the "cheaper" less qualified alternative. The person showing up to help in major emergencies on the streets of Kenya to the streets of London when surgical intervention is required is a doctor. Why would anyone in one of the most advanced countries in the world want or accept less?

27 weeks and some OTJ is not going to effectively replace the knowledge or experience of a qualified surgeon. Surgery is not like learning from a book, experience counts.

As a matter of trivia, the reason medical residencies exist is because of the demands of the surgical profession.

Prehospital work is inherently dangerous, and I do not think it is worth risking a MD when they are worth a lot to society because of the time and $ spent training them..

Perhaps we should keep them under glass in the ivory tower to make sure no ills befall them?

I will again point out that many places around the world use physicians in their EMS systems to great effect. The very purpose of a physician is to help people. That is best done by being where people need help and not out of reach of mere mortals to have servants do their bidding.

While a PA certainly does not have the training to provide the level of surgery a MD can, they could certainly do a lot more invasively prehospital to help a patient.

Than a paramedic? Yes that is true, but will it be enough to make a difference? Possibly.

Are there any procedures in particular you would like to see done prehospital? For the most part, trauma surgery (yes, I know I am oversimplifying) is about stabilizing a patient and addressing immediate life threats.

That is the idea behind damage control surgery, which is not practiced in any appreciable quantity outside of the military anyplace. It would be nice if they did. But it will take major changes for that to come about.

Orthopedic, reconstructive, and a lot of the cleanup work to return the patient to normal function is done after the patient's initial surgery and their physiology returns to normal, since they are more stable.

Also part of damage control surgery.

There is more to surgery, especially trauma surgery, than just clamping and sewing. It also involves the immediate and ongoing resusctitation treatments.

When you are speaking of somebody who is going to manage this very complex event, a small amount of "training" is not going to do it.

Is there any reason a PA couldn't clamp a bleeding artery, or address another life threat that is only solved by surgery in a prehospital setting?

Clamp an artery? No, but a paramedic can do the same thing. Why don't they? Because that is not usually the best treatment. That is why it was removed from the paramedic scope back in the 1970s.

But a surgeon can decide the best best route of access to control internal hemorrhage, they can create temporary vascular shunts to maintain circulation or make use of collateral circulation.

Advanced education also permits anticipation and preventative treatments to stop things from getting worse depending on the injury.

In truama, many textbook anatomical landmarks are destroyed or unrecognizale. This same situation is found in reoperations, which are only undertaken by the best surgeons, making use of such valuable experience in a more uncontrolled environment.

Using the military model, the use of a forward surgeon has been well demosntrated as beneficial. Particularly in maintaining maximal recovery of function and not just stopping death.

 

[Rialaigh]

Since much of the effectiveness of this idea relies on cost, and a very very high one at that, I am curious what cost you guys think would be "to much" to be worth saving a life....

I just don't see Forward surgery as a good idea, period, in any context in the US at all. There will always be "1/1,000,000) situations in which it will work beautifully but as a whole I think it would save or improve pretty close to 0 lives at a really really huge cost.

 

[Veneficus]

Since much of the effectiveness of this idea relies on cost, and a very very high one at that, I am curious what cost you guys think would be "to much" to be worth saving a life....

I just don't see Forward surgery as a good idea, period, in any context in the US at all. There will always be "1/1,000,000) situations in which it will work beautifully but as a whole I think it would save or improve pretty close to 0 lives at a really really huge cost.

I am not sure that "forward" and "field" are exactly one in the same.

One of the functions of critical care transport between facilities is to add expertise and skills for taking care of critical patients in outside facilities.

There are at least 2 flight services in the US that use EM and surgeons as part of their critical care flight crews and several services that under various circumstances field physicians in response vehcles.

Throughout the thread there seems to be a focus on specific surgical procedures, or individual treatments. I don't think anyone would be able to find a specfic procedure or intervetion that would make the idea cost effective.

Emergency service of any type is generally a losing economic venture. Consider the amount spent on fire suppression, which is almost never used.

So would it be better to measure the idea in value?

As I mentioned, rather than in lives saved, we might be looking at function retained.

Just like any type of specialty service it would have to be regional to have enough volume to make it effective in any level.

Unless there is an airmed component, the value would also be greater in population centers. Particularly where penetrating trauma is more common. But I just don't see having a physician or surgeon sitting around just waiting to respond or jumping EMS calls. It would have to be a part of already existing 24 hour hospital coverage.

 

[Rialaigh]

I am not sure that "forward" and "field" are exactly one in the same.

One of the functions of critical care transport between facilities is to add expertise and skills for taking care of critical patients in outside facilities.

There are at least 2 flight services in the US that use EM and surgeons as part of their critical care flight crews and several services that under various circumstances field physicians in response vehcles.

Throughout the thread there seems to be a focus on specific surgical procedures, or individual treatments. I don't think anyone would be able to find a specfic procedure or intervetion that would make the idea cost effective.

Emergency service of any type is generally a losing economic venture. Consider the amount spent on fire suppression, which is almost never used.

So would it be better to measure the idea in value?

As I mentioned, rather than in lives saved, we might be looking at function retained.

Just like any type of specialty service it would have to be regional to have enough volume to make it effective in any level.

Unless there is an airmed component, the value would also be greater in population centers. Particularly where penetrating trauma is more common. But I just don't see having a physician or surgeon sitting around just waiting to respond or jumping EMS calls. It would have to be a part of already existing 24 hour hospital coverage.

I just don't buy that there would be any benefit (increased survivability or quality of life) in enough if any patients to make this idea viable at all. Now if you are talking about improving the cutting edge of medicine and having the best most up to date skills, practices, and protocols at your facility then I could see adding something like this as a wonderful life saving oriented PR stunt basically. It would bleed money like crazy and would likely affect the discharge outcome of patients by 0 while placing valuable hospital resources (like a trauma surgeon and critical care nurses) at risk (if we are talking about choppers) and out of service for hours or shifts at a time while they complete field surgeries that will make great newspaper stories or great photo's but will (statistically) be nothing more than a great PR move that will place a facility on the "cutting edge" of EMS and surgical response.


If we are talking about providing a surgical team to fly to a small hospital or clinic to preform a surgery (forward surgery as opposed to field) that is emergent again I just don't buy that they will make a difference. The facility doesn't have the proper capabilities to care for the patient afterwards (or during) and I would rather fly the patient before surgery and hope they live then preform a risky surgery and hope to fly them right after.


Now there will always be those special cases when this could be very beneficial. Lets say we get a massive building collapse in Chicago or something, hundreds trapped, dozens or hundreds suffering from amputations, compartment syndrome, crush injuries, massive trauma, etc. I could see setting up forward surgery for this. But outside of a big natural (or unnatural) disaster I just don't see any benefit in the US.

 

[EpiEMS]

Throughout the thread there seems to be a focus on specific surgical procedures, or individual treatments. I don't think anyone would be able to find a specfic procedure or intervetion that would make the idea cost effective.

Emergency service of any type is generally a losing economic venture. Consider the amount spent on fire suppression, which is almost never used.

So would it be better to measure the idea in value?

As I mentioned, rather than in lives saved, we might be looking at function retained.

I dunno about the losing economic venture part. There's some value that people assign to being assured that, say, if there is a fire, there's someone to help -- or, an even closer analogy would be that people assign some value (which we can quantify) to having the ED staffed by a physician 24/7 so that if they need care, there is care available.

Depends on the value of a statistical life and the value of function. If you value a life at $100,000/QALY, then a lot more things are cost-effective than valued at $50,000/QALY. You can assign a quantifiable and even monetary value to function.

Unless there is an airmed component, the value would also be greater in population centers. Particularly where penetrating trauma is more common. But I just don't see having a physician or surgeon sitting around just waiting to respond or jumping EMS calls. It would have to be a part of already existing 24 hour hospital coverage.

Probably true.

This could plausibly be tested with a bit 'o grant money.