How much effort do spend on trauma?

[Veneficus]

Because there has been this idea going around for some years that trauma is simple so prehospital providers don't need to spend a lot of time with it, despite the fact EMS was formed for trauma, I figured I'd see where everyone stands on this.

 

[lightsandsirens5]

Well, if you boil it way down it comes out as: trauma care=keep them breathing and stop their bleeding. Oh, and dont paralyze them. I guess if you are ALS you can add IV to keep up blood volume. So that part is pretty simple.

I think that it is the carring out of trauma care that isn't simple. In my opinion, they should not cut any more trauma time out of class. It may not be the #1 thig EMS responds to, but it is a big part of it.

 

[artman17847]

Alot of medics do cookbook trauma pt's, i.e. ABC's and rapid transport. I have always been of the thinking that we must have top notch assesment skills when it comes to treating these pt's. We must be able to recognize subtle signs and symptoms that may be masking cricital injuries.

 

[daedalus]

Cookbook trauma? What is there even to do? Package and transport.

Lets do a quick review of ALS interventions for trauma:
IV Fluid resusitation- Myth
C-Spine- Myth
Traumatic arrest- Dead
Splinting and bleeding control- Any boy scout could accomplish
Airway control- Paramedics cannot even effectively intubate (says recent study)
RSI- Controversial and its not in my protocols.



Am I wrong and just cynical that all this paramedic education amounts to jack ****? Or does what I do for trauma patients make a difference?

 

[daedalus]

I am starting to think that a taxi ride would produce better evidence based outcomes.

Common sense seems to be always wrong when we preform studies to examine our traditional intervention and treatments.

 

[Epi-do]

I am starting to think that a taxi ride would produce better evidence based outcomes.

There are studies out there that look at this, however, I don't have the time at the moment to look them up.

As for my opinions about trauma, I think our options for treating trauma in the field are pretty simple, and limited. However, our ability to assess our patients determines how successful we are at properly managing the trauma patient.

You could teach my 5 year old son how to needle decompress a chest, but there is no way I would trust him to be able to assess and properly decide when it is appropriate to do so. We aren't failing with trauma patients because we don't know how to "do trauma". We are failing with these patients because we aren't properly assessing the patient and identifying what does or, sometimes more importantly, does not need to be done. Continually working to improve our assessment skills can only benefit all who are involved, be it trauma or medicine patients. Without a proper assessment, how can you properly determine what does or doesn't need to be done?

 

[mycrofft]

i can't answer those categories because they mix premises

...but I hear your point.
BLS/trauma was founded as much to teach what not to do as what to do. In the short-response sub/urban setting when not overwhelmed with casualties, trauma is pretty well addressed unless the pt is going to die anyway. It seems low priority because in America as a whole (apart from inner city ED's where combat wounds and MVA's are plenty, most emergency pt's are sick, not shot, as we used to say. Also, trauma has it's own periodic experimental lab, warfare, where liability gets a back seat sometimes to innovation. Illness and saving us old crocks is a legal arena and best addressed where the big diagnostic guns and OR's are.
Now, long-haul trauma, industrial/rural/agricultural trauma, and ultiple systems trauma are a different story. Compare a snowboarding tib-fib at a snowpark versus a kid with an arm in a corn auger in Cherry County, Nebraska.

 

[Veneficus]

Cookbook trauma? What is there even to do? Package and transport.

Lets do a quick review of ALS interventions for trauma:
IV Fluid resusitation- Myth
C-Spine- Myth
Traumatic arrest- Dead
Splinting and bleeding control- Any boy scout could accomplish
Airway control- Paramedics cannot even effectively intubate (says recent study)
RSI- Controversial and its not in my protocols.



Am I wrong and just cynical that all this paramedic education amounts to jack ****? Or does what I do for trauma patients make a difference?

Unfortunately this is the cookbook, which probably means there are substantial amounts of providers doing more harm than good.

I agree the education is flawed. But we also have to be fair and look at what trauma is. Most trauma is orthopedic in nature, which means most patients do not need a level 1 or even level 2 trauma center. But it also means that it is well within the ability of a paramedic to make a difference in the care of most trauma patients with boy scout treatments like splinting and bleeding control. I would toss pain control into that group too.

I agree that assessment is important. But look at the failure there. NREMT seems to think that trauma assessment is somehow different from medical assessment. It is taught separately.

How many EMS providers even know trauma is a disease? How many know the pathological basics behind it? For that matter even the physiological norms? Anyone who understands clotting cascades should understand fluid is not the answer.

I noticed there are a lot of poll results about people that live, eat and breath trauma, but somehow I doubt it is representative of EMS as a whole or maybe people do not understand what trauma really is. (not their fault, just poor initial education)

One of the top trauma centers in the US (arguably one of the best) sees ~4500 surgical trauma cases a year. At that rate how many “serious” traumatic injuries are there? Would a provider know a serious trauma if they even saw it?

I agree with Epi, the most valuable Prehospital treatment is assessment. But that is seriously lacking in many training programs. If I have said it once I have said it 1000 times. Proficiency builds speed, speed does not build proficiency. Why do we limit our “on scene time” which inhibits the ability to properly assess? Golden hour is a myth too. We are judging the seriousness of trauma on first impression and mechanism, both of which are not reliable. Add to this we are struggling to accomplish a few useless skills in the same time frame.

Does it strike anyone else that ironically a whole profession (white paper) set up to aid with trauma care spends less time learning about trauma than every other part of class except operations? In your medic class what percentage of the hours is spent on cardiology? Yet the leading cause of death of productive adults and children is trauma. Basics are worried about giving "life saving drugs" and IV skills, where is the focus on physical exam and history taking? Something has gone horribly wrong somewhere.

Perhaps it is time to get back to basics. Not basic skills, basic science, maybe even basic assessment.

 

[woodymt205466]

as I see it. . . .

I guess all I can add is this, The medics I get to work with have the skills and knowledge to differentiate true trauma needs vs. your common EMS call. Even though we are a billing agency we do not follow the "stick 'em for all you can" theory that some agencies use.
As far as trauma in the field, we are sometimes delaying the inevitable but I rest easier at noght knowing that every once in a while, I was able to assist a medic in an actual life saving action. ie : Narcan on the heroin OD, D50 on the diabetic, and a few other things that I have seen first hand.
The basic and most fundamental rule of ALL EMS is simple, DO NO HARM. We all know who that pertains to. Witht that said, we got into this profession or hobby to help possibly prolong life for people that experience emergency situaation, trauma or medical, whichever the case may be. I like knowing that some of the things I have been trained for may actually make a difference.

 

[mikie]

One of the top trauma centers in the US (arguably one of the best) sees ~4500 surgical trauma cases a year.

Not to steer the thread away, but may I ask which hospital you speak of? Thanks

 

[triemal04]

I'm not quite sure how to answer this one. The effort that we spend on trauma...really not much. As far as actual treatements go; pn management, fluids, surgical crichs, chest decompression, splinting, etc etc...probably not a lot because we don't do a lot. Most of the effort and education should go into how to properly assess a pt and figure out what is/isn't wrong with them and was does/doesn't need to be done. As well as what's going to happen in the next 60 minutes. Which may or may not happen.

As far as trauma being made so simple...while I don't agree, I can understand it. Look at the list above; there's really not a whole hell of a lot that we will be doing in the field, aside from recognizing what is going on. So getting taught to load and go since we won't be doing much...understandable, if not really the best route to take.

Even something as simple as a laceration will take a doctor to stich up. A broken bone will almost always get a consult with an orthopod. Serious trauma will need surgical intervention. What we do will not fix the problem; it'll sustain the pt (hopefully) but beyond that, they will need more help. The amount of time that goes into how to properly assess and recognize traumatic injuries may be lacking, but I'm curious Veneficus, beyond recognition and an understanding of what's happening/what will happen, how in depth do you think it should go?

And daedalus...wow! That's got to be the fastest paramedic program out there. What, 2 months and you're allready a medic? Impressive.

 

[downunderwunda]

There are studies out there that look at this, however, I don't have the time at the moment to look them up.

As for my opinions about trauma, I think our options for treating trauma in the field are pretty simple, and limited. However, our ability to assess our patients determines how successful we are at properly managing the trauma patient.

You could teach my 5 year old son how to needle decompress a chest, but there is no way I would trust him to be able to assess and properly decide when it is appropriate to do so. We aren't failing with trauma patients because we don't know how to "do trauma". We are failing with these patients because we aren't properly assessing the patient and identifying what does or, sometimes more importantly, does not need to be done. Continually working to improve our assessment skills can only benefit all who are involved, be it trauma or medicine patients. Without a proper assessment, how can you properly determine what does or doesn't need to be done?

Or is it simply too many in EMS decide that they are better than everyone else & take too long on scene, under the guise of perfoming an assessment
only to take to long?

The cookbook is talked about, we know the Golden Hour is a load of crap, so where does that leave us?

It leaves us with the one thing you cannot teach - common sense. To try to compartmentalise as is being done here, is rediculous, put the scenarios up. The one positive that came from the Golden Hour fantasy is that in put pressure on EMS to get patients to hospital fast. While I do not always agree with that principay, we need to avoid delayed scene times like the plague. Most assessments (tertiary & subsequent) can & should be performed er route, primary & secondayry prior to departure. However, if you had a pt with a GCS of 3, with decorticate posturing, why the hell would you bother? get the poor :censored::censored::censored::censored::censored::censored::censored: to hospital.

The eternal question - is the person better in an ambulance or in a hospital?

 

[daedalus]

I'm not quite sure how to answer this one. The effort that we spend on trauma...really not much. As far as actual treatements go; pn management, fluids, surgical crichs, chest decompression, splinting, etc etc...probably not a lot because we don't do a lot. Most of the effort and education should go into how to properly assess a pt and figure out what is/isn't wrong with them and was does/doesn't need to be done. As well as what's going to happen in the next 60 minutes. Which may or may not happen.

As far as trauma being made so simple...while I don't agree, I can understand it. Look at the list above; there's really not a whole hell of a lot that we will be doing in the field, aside from recognizing what is going on. So getting taught to load and go since we won't be doing much...understandable, if not really the best route to take.

Even something as simple as a laceration will take a doctor to stich up. A broken bone will almost always get a consult with an orthopod. Serious trauma will need surgical intervention. What we do will not fix the problem; it'll sustain the pt (hopefully) but beyond that, they will need more help. The amount of time that goes into how to properly assess and recognize traumatic injuries may be lacking, but I'm curious Veneficus, beyond recognition and an understanding of what's happening/what will happen, how in depth do you think it should go?

And daedalus...wow! That's got to be the fastest paramedic program out there. What, 2 months and you're allready a medic? Impressive.

Not even close to done. I was just rambling about the fact that I worry that EMS will never embrace evidence based practices.

 

[Veneficus]

The amount of time that goes into how to properly assess and recognize traumatic injuries may be lacking, but I'm curious Veneficus, beyond recognition and an understanding of what's happening/what will happen, how in depth do you think it should go?

Recognition is the key I think. It has to go farther than that DCAPBTLS bull****. I agree you shouldn’t waste time on scene with multisystem or otherwise severe trauma, but in the rush to put patients on a board that doesn’t do anything; a large part of assessment often gets overlooked in the hurry to get rolling. In my experience, once moving, assessment basically stops while IVs are started, phone calls made etc. I think if you can transmit a 12 lead to the hospital to get a PCI lab moving, so should you be able to get a surgical theatre ready. (or stand one down) The other problem is overtriage. We have got to stop the thinking that all injuries are serious until proven otherwise. Not only does it cost an outrageous amount of money, it is a tremendous waste of resources. Recent headlines aside, I cannot tell you the amount of “critical” patients flown to hospitals I have worked at to see them discharged in a few hours. (<3) That practice also puts lives at risk.

How in depth? Well if there is time to spend on acid base balance and Na and K pumps there is time for basic cellular metabolism and shock physiology. Even down to the biochemical level. Of course this has the bonus of not only helping with trauma, but with other pathologies as well.

Many times a trauma surgeon assesses a patient and decides his skills are not needed. This is a great example on how sometimes it is not what you do, but what you know. You could also add disease progression and the physical exam techniques to look for occult injury if you wanted to “do” something. It is worth far more to know what is going on than to start an IV or board somebody. It is important to know what all stages of traumatic injury are, which might make a difference in patient care. (as an example knowing that a pneumo develops over time so just because you heard clear lung sounds 5-10 minutes ago doesn’t mean it’s time to start writing your report) For early shock stages fluid might help, for later ones it can be harmful. Knowing where you are at and if anything has changed is a big deal.

Understanding cellular metabolism allows you to predict decompensation as well as determine how well your interventions are working. (particularly useful in peds and geriatrics, as well as different)

Without reopening the education debate, what EMS can “do” has gotten it nowhere in the last 30 years, maybe it is time to switch to what EMS providers know? It seems to be working for every other healthcare field.

It is also part of my mission in life to make people realize that a physical exam and history taking are no different in trauma than in any other medical cases. No matter what the fools over at NREMT think.

 

[BLSBoy]

Do I agree that there is a HUGE over triage of trauma patients?

Hell yes.

The theory goes that they would rather see us over triage 100 pts, then miss that one.
It had even been said in this thread, practice builds speed, speed does not always build practice.

Now, does every Drama Alert need to be flown?

Hell no.

It needlessly puts lives in danger, and the inexperienced provider that does that needs to seriously reevaluate their skills or ther job choice/hobby choice.

Trauma is a SURGICAL DISEASE.
From the kid with the broken leg, to the multi system, critical MVC pt, it is surgical in nature.
Its quite simple kiddies.

Asses and correct ABCs.
Determine severity of pt.
Make a transport decision. (Where and how)
C-Spine.
Put in mode.
Make mode go.
Detailed exam.
Large bore IV x2 (This is done more for the hospital, who can push blood products, not us to turn blood to Kool-Aid)
I personally would not want to push much NSS, to prevent from turning their blood into Kool-Aid.

I forget who said that C-Spine was a myth, but you are wrong.
Studies can, and are, flawed.
My first trauma as a medic had a fx C-2. The slightest movement coulda jacked this boy up like a soup sandwich.

We managed to C-Spine around 2 hoodies, his jacket, the wet ground, then put him in a Stokes basket, and have a USCG Helo "dust off",pick him up, reel him in, and go.

 

[triemal04]

Veneficus...what in the hell are you doing in Europe? Get your *** back here where it belongs, roll up your sleeves and go to work! And if you find anyone else with similar ideas, bring them with you.

How in depth? Well if there is time to spend on acid base balance and Na and K pumps there is time for basic cellular metabolism and shock physiology. Even down to the biochemical level. Of course this has the bonus of not only helping with trauma, but with other pathologies as well.

Works for me. Only arguement I'd have is that this isn't neccasarily something that should be in the paramedic class, but taught before you ever enter it. Understanding how the body works should be done before you start learning how to fix it. Proper physical assessment skills still need to be a huge part of it though; understanding what is happening doesn't matter if you can't determine what the problem is.

I agree you shouldn’t waste time on scene with multisystem or otherwise severe trauma, but in the rush to put patients on a board that doesn’t do anything; a large part of assessment often gets overlooked in the hurry to get rolling. In my experience, once moving, assessment basically stops while IVs are started, phone calls made etc. I think if you can transmit a 12 lead to the hospital to get a PCI lab moving, so should you be able to get a surgical theatre ready. (or stand one down) The other problem is overtriage. We have got to stop the thinking that all injuries are serious until proven otherwise. Not only does it cost an outrageous amount of money, it is a tremendous waste of resources. Recent headlines aside, I cannot tell you the amount of “critical” patients flown to hospitals I have worked at to see them discharged in a few hours. (<3) That practice also puts lives at risk.

I think more areas have that ability (to get a surgical suite prepped) than you give credit for. While it's not national (unfortunately) the trauma system in my part of the country is pretty well established, and once a trauma alert is called, based on the level of alert, that very well may be happening. Far as the lack of assessments...gonna vary. My experience is the exact opposite; much of the assessment is done after leaving...though not all. Which is as it should be; while some needs to be done immedietly, once it's been determined that a pt with potentially severe traumatic injuries will need transport, there is no need to **** around on scene. (yes, there are exceptions to this) Head for the hospital and assess enroute. Course, this may or may not be possible based on transport times, which is part of where the problems come up.

I do agree though that helicopters are way over utilized. Hopefully, with the recent crashes, standards for their use will be enforced and that may change. Honestly, I can't understand it. If you are going to call a helicopter, when the actual time for them to arrive is factored in, there is plenty of time to do a proper assessment.

So...when are you going to be back to start fighting for this kind of thing?

 

[downunderwunda]

Trauma is a SURGICAL DISEASE.

WHAT????????????

Are you kidding?

Trauma is a Disease??????????????????????????????????????????

Now i have heard everything. That is a joke right.

NOT ALL TRAUMA NEEDS SURGICAL INTERVENTION

Since when do all trauma cases need surgery. I think you need to look more closley at modern practices. Gone are the days of opening someone up just for exploritory surgery.

Today we have womderful machines like CAT scanners, Portable Ultrasound. Abdo clearances don in the ER, amazing, reduces the need for surgery. In many cases a 'Wait & See' attitude prevails, surgery is a last option.

You need to learn what happens after you off load your patient & understand that many doctors now, through evidence based paractice, will not rush patients in for an operation, but see if they will stabilise without putting them at extra risk of MORE TRAUMA. Surgury is an insult to the body, therfore a trauma also.

 

[Veneficus]

Trauma is classified in medicine as a disease. The same as cancer and other conditions requiring surgery. It is such because of the nature of the pathological condition.

Apparently from this last post BLSboy is the "defender of the true faith" of EMS mantra in the US. All of us educated people apparently will never share such wisdom.

Not all truama requires surgery, but when it does, nothing else will do. We can now non operatively manage minor spleen and liver lacs as well as many other "wait and see" injuries. There is also damage control surgery, meant to inhibit any more damage not to return to normal function. (which is done at a later time if at all). Many places do not routinely see injuries like that.

The problem is in my experience, most providers don't know when they are/are not looking at something serious. They see blood or an angulation, and think it is terrible. When they don't see blood they think it must be ok.

Overtriage is not going to be maintainable forever. Not to mention it still doesn't stop patients from slipping through the cracks. Somebody has to pay for all of this. Any idiot can run every medical test known to man. It doesn't take a healthcare provider to do that. It does take one to use knowledge and experience to come up with the best treatment plan.

Studies can be flawed. But anecdotes do not make for best practice. There is significant evidence longboarding doesn't work. Some even shows it is harmful. Just because a provider doesn't like what the study says doesn't mean it is worthless. In your example is there any evidence that careful manipulation of the patient would have been any less detrimental than "c-spine" precautions? Do you think we keep people with fractured spines on boards in the hospital?

Do people post this kind of crap just to start an arguement? Apparently a bit more effort needs to be spent on trauma.

 

[daedalus]

Studies may be flawed but anecdotal evidence and passionate argument are most certainly flawed proof for a practice.

 

[daedalus]

WHAT????????????

Are you kidding?

Trauma is a Disease??????????????????????????????????????????

Now i have heard everything. That is a joke right.

NOT ALL TRAUMA NEEDS SURGICAL INTERVENTION

Since when do all trauma cases need surgery. I think you need to look more closley at modern practices. Gone are the days of opening someone up just for exploritory surgery.

Today we have womderful machines like CAT scanners, Portable Ultrasound. Abdo clearances don in the ER, amazing, reduces the need for surgery. In many cases a 'Wait & See' attitude prevails, surgery is a last option.

You need to learn what happens after you off load your patient & understand that many doctors now, through evidence based paractice, will not rush patients in for an operation, but see if they will stabilise without putting them at extra risk of MORE TRAUMA. Surgury is an insult to the body, therfore a trauma also.

Actually, trauma is a surgical disease.