Is trauma easier than medical?

[Akulahawk]

Anyone who thinks trauma is easy doesn't know the first thing about it.

But since EMS plays such a small role in trauma, I can see where they think it may be easy or easier.

It is just a question of not knowing what you (collective) do not know.

In a way, trauma is easier in that it's usually very initially straightforward as to time of onset and what broke or got damaged. You're right though, in that the medical side of trauma can be a nightmare to manage. Injury physiology is (to me) quite fascinating! It's also why I want to get to an injured patient quickly. If I can limit further injury, I can decrease the amount of time it takes someone to make a functional return to activity. Now then, most of my experience in this matter is in sports injury. However, I know that the things I do early in the post-injury period can shave weeks off an athlete's return to full functional activity.

We don't consider the possibility of compartment syndromes, and since we don't consider it, we don't attempt to minimize the damage from it. We don't consider that injured tissues can become acidotic, to the point of extending tissue damage. We just don't consider that stuff unless we're specifically told or taught about it.

Those are just some examples.

 

[mycrofft]

Examples of things in the field that affect care in the ED-OR: over the counter salves and oints and gels that need to be removed; wounds full of clotting agents needing to be removed; dry dressings over abrasions full of foreign objects (road rash) necessitating more-prolonged debridement under sedation; using up the good veins (ante cubes) for simple peripheral uses which the anesthesiologist wanted; not watching distal circulation when any (primarily circumferential) restriction was applied such as bandage, splint, spine board, which can cause ischemic related damage; failure to cover both eyes when you have foreign object or other damage to one which needs the eye to hold still, which can cause exacerbation of the primary injury; lacerating the oropharynx with a OP airway or use of ad hoc or antique airway adjuncts (bite sticks, J tubes, "Choke-Saver" forceps, improper finger sweeps) causing trauma, inhalation, or just failing to work and making it harder to place an advanced airway later (not to mention possible death enroute); hyperinflation of stomach by CPR inflations leading to ineffective subsequent CPR, need to decompress, and potential for aspirational event.
These are all reasonable measures but either under the EMT level, or errors in the course of reasonable measures with potential for misadventure. All affect hospital care.

BTW, besides recording and watching out for circumferential constrictions (iatrogenic or otherwise), what can you do in the field for compartmentalization?

 

[Veneficus]

BTW, besides recording and watching out for circumferential constrictions (iatrogenic or otherwise), what can you do in the field for compartmentalization?

Not make it any worse

 

[Craig Alan Evans]

One aspect about trauma we have not discussed that may make it a little harder for EMS is recognition. This may seem silly as who could have any issues recognizing trauma. One upon a time a read about a case where a pedestrian was struck on his left side by a slow moving vehicle. Less than 5 mph. The patient did not hit their head or lose consciousness and barely fell down. The only complaint on scene was some minor leg pain. The patient could walk and talk and reported no injuries. The patient refused treatment and subsequently died four days later from a lac to the spleen. We need to be very circumspect about mechanism of injury. A 2000 lb car hitting a 150 lb human may leave a mark at any speed.

 

[mycrofft]

Job number 2, right behind Don't start any harm, is don't make it worse.

 

[Veneficus]

One aspect about trauma we have not discussed that may make it a little harder for EMS is recognition. This may seem silly as who could have any issues recognizing trauma. One upon a time a read about a case where a pedestrian was struck on his left side by a slow moving vehicle. Less than 5 mph. The patient did not hit their head or lose consciousness and barely fell down. The only complaint on scene was some minor leg pain. The patient could walk and talk and reported no injuries. The patient refused treatment and subsequently died four days later from a lac to the spleen. We need to be very circumspect about mechanism of injury. A 2000 lb car hitting a 150 lb human may leave a mark at any speed.

F=ma ???

I saw a guy who was rear-ended in a low speed MVA waiting at a light (less than 10 mph) with a ruptured diapragm.

Mechanism is extremely unreliable. To the point I wish they would stop trying to teach it.

 

[Craig Alan Evans]

I would disagree. Mechanism is not unreliable. Like I said. A 2000 lb vehicle hitting a human is serious and should be treated as such.

 

[Veneficus]

I would disagree. Mechanism is not unreliable. Like I said. A 2000 lb vehicle hitting a human is serious and should be treated as such.

My point is that mechanism is totally unreliable and nonprognostic.

You can have what would be considered a substantial mechanism and no serious injury.

At the same time you can have a very minor mechanism and a serious injury.

You must either overtriage everyone or you are no better off flipping a coin.

(come to think of it you might be better off flipping a coin)

 

[Craig Alan Evans]

Can you give me an example of a case with substantial MOI and no injury?

 

[jjesusfreak01]

Anyone who thinks trauma is easy doesn't know the first thing about it.

Plug holes, permissive hypotension, splint, drive fast, and do a detailed assessment on the way so the ER knows what they're getting ahead of time.

Seems easy enough.

 

[STXmedic]

Can you give me an example of a case with substantial MOI and no injury?

Few weeks ago, guy in his mid 50s hit by SUV, knocked through his glass storefront, drug under the SUV until finally coming to rest when the SUV came to the back of the store wall. Guys only injury (as observed by hospital as well) was superficial lacerations on his head from broken glass. Released same day. Just one example I've personally had. I've got several more instances in my short, 3yr career as well.

 

[jjesusfreak01]

Can you give me an example of a case with substantial MOI and no injury?

Vehicle rollover with ejection/death of other occupants. A restrained passenger could walk away with bruises or nothing.

 

[Craig Alan Evans]

Few weeks ago, guy in his mid 50s hit by SUV, knocked through his glass storefront, drug under the SUV until finally coming to rest when the SUV came to the back of the store wall. Guys only injury (as observed by hospital as well) was superficial lacerations on his head from broken glass. Released same day. Just one example I've personally had. I've got several more instances in my short, 3yr career as well.

The case I spoke of with the pedestrian struck was actually seen in the ER and released as well. I'm trying to keep it vague because it was recent. Have you done follow up on this case? The patient may have been more injured than initially thought. Sometimes we see so many patients in so little time that we get it wrong. I'm just saying that if something significant happens to an individual you need to give them a once over. Take nothing for granted and assess everyone thoroughly. I saw a case on TV where someone died because a stapler was thrown and hit them in the head causing a temporal artery bleed. Sounds silly but if a patient is hit in the head where the temporal artery is the most superficial then think the worst case scenario. I guess what I'm getting at is over triage and have a high index of suspicion at all times.

 

[mycrofft]

Paging Natasha Richardson...

Had a neighbor with MS in a car accident, struck her head. Sent home after four hours obs. Overnight, developed battle signs and died in bed.

 

[Maine iac]

Mechanism of injury.

[YOUTUBE]http://www.youtube.com/watch?v=YzYxz_uvtSI[/YOUTUBE]

http://youtu.be/YzYxz_uvtSI

 

[STXmedic]

Have you done follow up on this case?

Guys only injury (as observed by hospital as well) was superficial lacerations on his head from broken glass. Released same day.

Yes, followed up. His flower shop was across the street from our station also; he came by to thank us a couple shifts later. And you asked for a example, so I figured you weren't trying to keep it vague.

 

[Smash]

Can you give me an example of a case with substantial MOI and no injury?

Just about any road traffic collision these days. The idea of MOI as being predictive arose in the 60s and 70s, when the white paper on trauma was put together. I guess it may have been considered predictive at that stage because you would have repeatable patterns of injuries seen in motor vehicle collisions as heads hit windscreens, chests hit steering wheels, knees hit dashboards and so on.

With advances in design and engineering in vehicles now those same rules do not apply. They don't even apply to pedestrian impacts as vehicle manufacturers work on minimizing injuries to pedestrians as well.
MOI is not prognostic in any way, the only thing it is good for is to alert you to the potential for there to be injuries.

Plug holes, permissive hypotension, splint, drive fast, and do a detailed assessment on the way so the ER knows what they're getting ahead of time.

Seems easy enough.

I suspect Vene's point is that we see and understand so little of the process of managing trauma in the ambulance. The actual management of trauma, as opposed to just delivering trauma to the hospital, is enormously complex and difficult.

 

[Craig Alan Evans]

MOI is not prognostic in any way, the only thing it is good for is to alert you to the potential for there to be injuries.

Alerting you to the potential is where I see it best used. On a lighter side. How about this video.

http://www.youtube.com/watch?v=YzYxz_uvtSI&feature=youtube_gdata_player

 

[Smash]

Alerting you to the potential is where I see it best used.

That's not what was implied in your earlier posts:

I would disagree. Mechanism is not unreliable. Like I said. A 2000 lb vehicle hitting a human is serious and should be treated as such.

On a lighter side. How about this video.

http://www.youtube.com/watch?v=YzYxz_uvtSI&feature=youtube_gdata_player

Yes, it's a lot like this one:

[YOUTUBE]http://www.youtube.com/watch?v=YzYxz_uvtSI[/YOUTUBE]

http://youtu.be/YzYxz_uvtSI

 

[Akulahawk]

F=ma ???

I saw a guy who was rear-ended in a low speed MVA waiting at a light (less than 10 mph) with a ruptured diapragm.

Mechanism is extremely unreliable. To the point I wish they would stop trying to teach it.

How they teach "mechanism" is what makes it unreliable. I look to the mechanism to see where injury is most likely to occur in the setting of trauma. The ruptured diaphragm guy, was he restrained? How close was he to the steering wheel, if he was the driver?

You really can't get a good "feel" for kinematics of trauma a course that lasts but 16 hours total.

From my Sports Med days: Your athlete falls down to the floor after shooting a basketball. He was facing the bench when he caught the ball that was passed to him, turned, and tossed the ball through the hoop. He fell right after he threw the ball.

He is conscious, breathing, moving his extremities... where are you going to start looking for injury?