Moving Backwards in Trauma Care?

[usalsfyre]

http://m.jems.com/article/news/ohio-system-wants-paramedics-h

I've been under the (apparently mistaken) impression we were moving from MOI as a determiner and that the Golden Hour myth was dead. Thoughts?

 

[firecoins]

So none of the patients in the article died? Than why the need to take them to the trauma center first? $$$

 

[Melclin]

Whats with the style of writing they use? Its sounds like its written by a lay person, for a lay person.

The term golden hour was used a bit when I was at uni but I don't think anyone every took it to be literal. I certainly never thought of it that way. The first time I was exposed to the idea that somebody took it literally was when I came to this web site and even then all that anybody said was that it shouldn't be taken literally.

I always saw it (and still do) as a simple term to recognise and remind providers of the idea the some serious traumatic injuries are very time critical.

 

[Veneficus]

It doesn't look like a step back to me, it looks like it says that strict guidlines are not working and paramedics are now able to use their clinical judgement rather than follow a flowsheet.

Isn't that a good thing?

I think it is not only good, but absolutely required to provide proper care.

 

[JakeEMTP]

I think this is a good step.

Some take the protocols to literally like with the falls of >10 ft only if you are over 65 or a child as trauma.

The Golden hour does not mean the patient has to be in the OR in an hour. It means you should be in the appropriate facility in an hour to determine the correct course of treatment.

The Golden Hour also came out when CT Scanners were not in every hospital like they are today. Other diagnostic equipment wasn't that readily available either and alot of small hospitals had a Radiology Tech on call which could mean another 30 - 60 minute delay. Today, most small hospitals have the appropriate technology for diagnostics but not for treatment which again does not have to mean surgery.

When the Golden Hour came out it was also a time when Paramedics were staying on scene establishing 2 IVs, intubating and running as much fluid as they sometimes carried to get a decent BP before they moved to the ambulance.

Once taken to the hospital with limited abilities, it is unlikely you will be immediately transferred. By EMTALA, stabilization must be done and the appropriate transport team should be called. If the person is kept in the ER, it can be simpler with an ER to ER transfer. If the person is moved to an ICU for care in a little hospital, it become more difficult with an acceptance to another facility. Once a transport team arrives, they might spend another hour stabilizing the patient or even refusing transport if the patient is now too unstable. A few transfers are still done soley by driving as fast as you can between hospitals.

We also have now come to realize MIs and Strokes can have good outcomes where before it was a wait and see at a small hospital that is basically a band aid center and transport in the morning to a cath lab when the ambulances have an extra day crew. The closest facility concept is primarily for the convenience of EMS and not for the treatment of the patient. The attitude of you can not take a STEMI down the road a few more miles because a trauma call might come in and another unit might have to take it from a little further should not dictate patient care. The same for a trauma patient who might be borderline criteria for a trauma center. We have also seen some use the trauma criteria too literally just for the convenience of calling a helicopter when the patient could easily have gone by ground. At some point your professional judgement should be determine where the patient goes and those who exercise profesional judgement should be allowed to use it.

Don't just take the words literally like some do their protocols which is where the recipe mentality came from. The Golden Hour is a useful guide even now if you understand your system and health care.

 

[mycrofft]

Melclin, agree with everything you wrote. Others, yes also.

This is a layperson article written for laypeople. It is mostly from one source, plus a few side quotes , and none from field supervisors or techs.

I bet the fire official, until asked about it here, would skin and dry anyone not following those protocols to the letter. After that prologue, it would sound nonsensical not to agree, but he will probably return to the protocols, otherwise, no control mech for all this field techs.

GOLDEN HOUR originated before rapid transport from the battlefield. I have heard two versions of its origins, but in either case modern technology was not in existence then and they accepted a higher mortality rate as unavoidable.

 

[Aidey]

You know what I read in between the lines? The trauma centers wan a monopoly on all trauma patients "just in case" and they are using the ideas of MOI and the golden hour to push for it.

And JEMS? Eww.

 

[mycrofft]

and this was a big-level confab with lots of press (read political exercise).
I'm not even mentioning it was in Ohio.

 

[JakeEMTP]

You know what I read in between the lines? The trauma centers wan a monopoly on all trauma patients "just in case" and they are using the ideas of MOI and the golden hour to push for it.

And JEMS? Eww.

Accepting any and all trauma patients is not in their best interest so there probably was some thought given to allow the Paramedics make the call to determine if someone should go to a trauma center. Paramedics should be able to veer from their protocols if they feel it is the correct thing to do for the patient. Not everything is black and white like the protocols you follow. Of course there are some Paramedics who might use this reason with the big bad trauma center to deflect the real issue if they don't want to make the call themselves and only want to follow the existing protocol to the letter.

Trauma patients are usually very costly and these hospitals rely on state and Federal funding including taxes to stay afloat. Alot of hospitals who jumped to be a trauma center quickly let their accreditation go when they started hemmorhaging money. You might even find another article in a hospital business journal with administrators complaining what this could mean to overcrowding and cuts in services for rehab of the trauma patient.

This was not an article written in JEMS. This was pulled from the newswire with an EMS search engine. It ran on a few other news listings.
A simple search on a medical search site will show Ohio has done alot of trauma studies published in other journals.

 

[JakeEMTP]

and this was a big-level confab with lots of press (read political exercise).
I'm not even mentioning it was in Ohio.

The public whose tax dollars go to fund these trauma centers do have a right to know about certain changes. This could be costly. Not wanting to be informed is your right if you don't want to hear about it but then you shouldn't complain when your taxes are increased which includes sales tax.

 

[Melclin]

The public whose tax dollars go to fund these trauma centers do have a right to know about certain changes. This could be costly. Not wanting to be informed is your right if you don't want to hear about it but then you shouldn't complain when your taxes are increased which includes sales tax.

You call this information?

I'd call this a small fragment of a media strategy.

 

[Veneficus]

GOLDEN HOUR originated before rapid transport from the battlefield. I have heard two versions of its origins, but in either case modern technology was not in existence then and they accepted a higher mortality rate as unavoidable.

Strangely enough now that we have technology, people seem to not accept any mortality at all.

Ironic.

 

[Veneficus]

You know what I read in between the lines? The trauma centers wan a monopoly on all trauma patients "just in case" and they are using the ideas of MOI and the golden hour to push for it.

The reason I do not subscribe to JEMS. They write about paramedics not having to follow a protocol to the letter as if it was news.

Writing to the lowest common denominator.

Anyway, back on point.

Trauma centers trying to monopolize trauma is not new. No more than cardiac centers, stroke centers, pedatric centers, the list goes on.

But there is some level of truth to it. From my experience working in one of the finest trauma centers in the world, the stuff (quality of care) I saw transfered in from non trauma or even level III trauma centers has convinced me that the value of a trauma center to a trauma patient is far in excess of anything offered anywhere else.

As a medical professional, I don't care how "nice" the community hospital staff are. I don't care how much they "try." I don't care if it is "close to home."

If I am a trauma patient, I want to go to the ivory tower...

The academic, level I trauma center. Nothing else will do.

Even if I am not that serious, I want to here it from them, not the people who don't even know what serious is, because everything they see they think is serious or BS.

 

[Aidey]

Without more information on the actual patients it is hard to tell if what Ohio is pushing for is reasonable. I suspect a large percentage of the pts who died at non trauma centers were dead anyway. I don't disagree that patients receive better care at speciality centers I just wonder if there is truly a problem that needs fixing. Most of the injuries that were transferred that were listed in the article don't strike me as things that automatically qualify as trauma activations. I also question how many additional patients would be brought to trauma centers strictly based on MOI that don't need a trauma center.

 

[Veneficus]

Without more information on the actual patients it is hard to tell if what Ohio is pushing for is reasonable. I suspect a large percentage of the pts who died at non trauma centers were dead anyway. I don't disagree that patients receive better care at speciality centers I just wonder if there is truly a problem that needs fixing. Most of the injuries that were transferred that were listed in the article don't strike me as things that automatically qualify as trauma activations. I also question how many additional patients would be brought to trauma centers strictly based on MOI that don't need a trauma center.

Ohio is my home state and where I spent most of my career.

The problem in Ohio is they went from local control of EMS very similar to Texas now to a rigid statewide directive system. (basically over managed)

Ohio could really be 2 seperate states, an industrial north and a largely agricultural south. So what works in one area absolutely doesn't work in the other.

In my opinion, the original way worked better, but people get power and want to micromanage what doesn't need to be micromanaged. Mostly for their own ego than for public good.

I think this story has a fair amount of propaganda, but the reality is Ohio EMS became so rigid that it is not practical.

 

[mycrofft]

As long as the people not supplying care make the rules, they are unaffected and will continue to build their political empires.
I say, every time a trauma pt dies away from a trauma center, they get a poke in the eye. Each of them.