OR resus/ed bypass

[Av8or007]

For the purposes of academic discussion, do you think there would ever be a possibility of a ED bypass for trauma, going directly to an OR sort of like a STEMI ed bypass.

What you could do is set up an OR as a resus room, therefore being able to provide the entire continuity of care to a trauma PT, from initial resus to surgical intervention. On arrival to the hospital, the patient could be taken straight up to OR, which would be set up to provide initial resus and definitive surgical intervention.

Any thoughts?

 

[Veneficus]

The OR is already set up that way.

there are a couple of problems.

The problem in the civilian world is that operative trauma is not only uncommon on the decrease. There are both less serious injuries and non/less invasive techniques to handle the same problems.

For example, in the 70s and 80s exploratory laporotomy was common in trauma. Diagnostic procedures were surgical in nature.

I was actually taught how to do a DPL. I cannot even imagine when I would use that.

Even working in an austere environment, if I got a positive result, I couldn't operate on it. Even if it was negative it opens up a big problem for the pt

Between CT and Ultrasound in the civilized world, there is absolutely no reason to do that procedure anymore.

Paying to staff and maintain an OR 24/7 is not really cost effective most places. The places that can do it already are.

There are political issues, like ED docs getting paid. the EM specialty in the US is probably one of, if not the most, politically active specialties.

Only a handful of the total population of surgeons are comfortable emergently operating. Even with docs returning from Iraq and Afg. this population is shrinking world wide.

Undoubtably for a patient who needs an OR, going right to OR is ideal. I just can't imagine it will happen in the US in my lifetime.

 

[KellyBracket]

Adding on Veneficus's comments:

Not only are more injuries treated non-operatively, but also many are no longer handled by the general/surgeon. For example, interventional radiology handles many of the heaptic/splenic injuries.

So, rather than moving towards the "ED bypass" model for STEMI care (which requires a significant investment in resources to maintain), trauma is, overall, moving towards emergency physician management being the standard model, with surgery available for consult.

There's a healthy "dialogue" in the literature about who is best trained to deal with the quotidian trauma that comes to the ED, but it is clear that there are no strong indications that surgeons will have a greater role. The economics, the medicine, and the resources, are pointing away from that, in general.

 

[Av8or007]

Thanks.

Just learned something.
As a side note, any idea why some ems systems, including the MOH system in ontario, seem to put a large emphasis on "load-n-go"?

Some issues are load and go, but for some things, mainly various kinds of med calls, why not take the hospital to the pt.

That is start treatment, then once treatment has been started then go vs. rapid transport.

For what kinds of medical calls do scene times really make a huge difference (obviously traumatic injuries are different).

 

[Handsome Robb]

Thanks.

Just learned something.
As a side note, any idea why some ems systems, including the MOH system in ontario, seem to put a large emphasis on "load-n-go"?

Some issues are load and go, but for some things, mainly various kinds of med calls, why not take the hospital to the pt.

That is start treatment, then once treatment has been started then go vs. rapid transport.

For what kinds of medical calls do scene times really make a huge difference (obviously traumatic injuries are different).

Places like Australia and NZ have moved towards treat and release models. Hopefully the US will move that way but like Vene said about ER bypass for trauma, it probably wont happen anytime soon.

A very small minority of our patients benefit from the snatch and grab model of prehospital care.

Another thing I think that influences the scoop and run mentality is system demand. We are busy, it's not uncommon for us to have pending 911 calls at least once during the day. "You call, we haul, then do it again".

 

[Veneficus]

Places like Australia and NZ have moved towards treat and release models. Hopefully the US will move that way but like Vene said about ER bypass for trauma, it probably wont happen anytime soon.

A very small minority of our patients benefit from the snatch and grab model of prehospital care.

Another thing I think that influences the scoop and run mentality is system demand. We are busy, it's not uncommon for us to have pending 911 calls at least once during the day. "You call, we haul, then do it again".

I think there is a lot of history behind this.

Until the late 90s, in medicine it was believed that many life threatening illnesses were acute. Today we know that is not the case. For example, you MI took decades to happen. Infact, if you are from a modern country like the US, the initial aortic fatty streaks likely started when you were still a fetus. (no McDonalds for mom from now on)

Today we know there are only a handful of acute life threatening emergencies. Trauma and Poison are the big ones, probably followed by environments unsupportive of human life. (like drowning)

Until the 2005 changes, even CPR was based on physiology originaly described by William Harvey in the 1600's. When I was researching my dissertation on shock, I found that all of EMS, and most of the emergency treatment of shock today is still based largely on this. The most modern knowledge of shock has not trickled down to common practice yet.

As many nations have discovered and moved away from "load and go" is simply leeches and hot poker. Not only is it not effective to transport every patient to an ED, because they likely need some other form of care, it is economically unustainable.

US EMS is slow to catch on. In fact many systems, and a handful of really reputable ones, still base their EMS effectiveness on medicine as it was understood in the 70s and 80s.

That may sound long ago, but considering that it was practice to give vasopressors in cardiac arrest back in the 1600s, after a review of current knowledge then, and we are still doing it today, 30-50 years behind may not be such a bad thing.

 

[Dwindlin]

The system I am currently in we can request a direct to OR for certain situations.

 

[VFlutter]

The system I am currently in we can request a direct to OR for certain situations.

What type of situations? The big one I can think of is a dissecting aneurysm.

 

[DrParasite]

For example, you MI took decades to happen. Infact, if you are from a modern country like the US, the initial aortic fatty streaks likely started when you were still a fetus. (no McDonalds for mom from now on)

well, yeah, the MI was cause by all the crap that built up, but the actually MI (the actual infarction), was an acute thing, correct?

Today we know there are only a handful of acute life threatening emergencies. Trauma and Poison are the big ones, probably followed by environments unsupportive of human life. (like drowning)

add choking or any airway obstruction, and uncontrolled bleeding (which is trauma, I know, but it's one of the few ways BLS interventions can really save a life). even a bad anaphylactic reaction. Most of the medical complaints aren't immediate life threats when they start, but if left untreated, get worse.

 

[Brandon O]

Even in pretty aggressive and modern facilities with truly emergent trauma, there's usually a reason to tag the ED briefly, at least. Patient has to be prepped to some extent, some degree of resuscitation will probably need to take place, and hopefully a plan established, unless you're at "eviscerate him in the hallway, there's no time!" status. And really, that's not very often. (As Jeff Guy says, take two minutes, roll upstairs where there's good light and people know the names of all the clamps.)

Even at Shock Trauma I believe they're usually tossing people through the CT first so they can operate with a map. Of course, CT is adjacent to the ED, and the OR is adjacent to that, so...

 

[Akulahawk]

I think even in high-performance systems, the impetus on load and go for the prehospital provider is simply that you want to decrease the amount of time patients wait to get to OR. While time is of the essence, I would much rather spend the time in the emergency department where there are bright lights, imaging, the availability of surgeons, and the like to develop a plan for the patient's care. As discussed above, it is very likely that the injury sustained will probably be managed medically. Some injuries, certainly, will have to be managed surgically, or at least with someone who has some surgical expertise in dealing with that particular problem.

Furthermore, as a prehospital provider I Would want to go to the emergency department anyway because I cannot do surgical prep in the ambulance. The patient is going to need some kind of preparation, further evaluation, imaging studies done and read, and the OR spun up and ready to go for receiving the patient. In particular getting the oh are ready to go takes time and I would much rather spend less time on the front end and get the patient to the emergency department where some things can be done then to sit on scene and try to do the best evaluation I can possibly do and then try to find a way to get the patient to be taken directly to OR.

In the several years that I worked the streets, I can honestly say that I went to OR exactly once. That particular patient was a direct transfer from one emergency department to OR that had the capability that the patient needed. Of course, that OR was at a different facility that had the right resources that the originating facility did not have. Most of the time, even when I took patients from the helipad around the block to the emergency department (at one particular facility) the patient had to be evaluated in the emergency department before being taken to an adjacent OR. This particular facility had extremely fast door to OR times when necessary-I've seen less than 8 minutes from door to OR. Like I said, however, this particular facility had OR literally visible from the emergency department. The times that they have had to do it that fast were relatively rare, however. More typically was probably 30 – 60 minutes from door to OR, if that was necessary at that time.

In the United States, I think it will be a very long time before we get the necessary prehospital education to determine whether or not someone must be taken directly to the OR. personally, I see direct OB admits being more commonplace even with patients that have not had prenatal care before we see direct to OR admits for trauma patients. I think the trend that is going to continue will be picking up patients, transporting them directly with minimal delay, minimal use of lights and siren, to an emergency department that has a trauma service that is ready to go and capable of handling management of those patients medically and surgically if necessary.

While I am not a direct proponent of the "golden hour" I do appreciate the concept behind it and that is simply that you want to minimize delays from the time of injury to time a definitive care. I do not care if that definitive care is bright lights and cold steel or if it is a warm bed and blankets with an excellent team to take care of the patient.

 

[Brandon O]

Around here we fairly regularly bypass the ED to OB and psych wings, by direction during radio notification -- but those have their own "ED," in the sense that people can walk into there too.

 

[Veneficus]

sorry, somehow lost track of this thread.

well, yeah, the MI was cause by all the crap that built up, but the actually MI (the actual infarction), was an acute thing, correct?

Not exactly. It is an acute exacerbation of a chronic pathology. The actual inciting event is vascular wall rupture, that is a chronic process. The wall didn't suddenly become pathologic.

Consider, the most predictive factor for a second MI is a first one. Not because the person is procoagulative, it is because if one part of a vessel wall was weak enough to rupture, somewhere else in the vascular, another one likely is as well.

The purpose of anticoagulation isn't to prevent a wall rupture, it is to make clot formation from subsequent rupture less likely. (ideally not at all)

What I think really makes it interesting is it is the same pathophysiological process as a thoracic aortic aneurysm, but not of that of a abdominal aortic, cerebral, or peripheral aneurysm.

Treating the acute symptom (in this case,MI) means it was not identified and effectively managed. (without fault on healthcare providers, patients are not always the most compliant people)


I would liken it to be the equivalent of calling for gun control after a massacre.

It is simply a symptom of the underlying disease.

add choking or any airway obstruction, and uncontrolled bleeding (which is trauma, I know, but it's one of the few ways BLS interventions can really save a life). even a bad anaphylactic reaction. Most of the medical complaints aren't immediate life threats when they start, but if left untreated, get worse.

I'll concede airway obstruction as an acute emergency, but not as one of the most common, the same with anaphylactic shock.

Who cares if BLS intervention can stop hemorrhage? Anyone can stop hemorrhage and never seek or even decline medical treatment for it. That is redundant.

Similar to choking. I can't even guess how many unreported choking cases there are in one state in a year.

 

[Veneficus]

Even in pretty aggressive and modern facilities with truly emergent trauma, there's usually a reason to tag the ED briefly, at least. Patient has to be prepped to some extent, some degree of resuscitation will probably need to take place.

That has been thoroughly debunked by the knowledge gained from Iraq and Afghanistan. There really is no reason to stop.

One of the most respected ED docs I know served in the military for both. He likes to say "The only purpose an EM physician has in serious trauma is to wave good-bye to the patient on their way to surgery."

The idea of "stabilizing" before surgery doesn't work. Anyone who has seen blood run out like cool-aid, called for multpile units of blood in an ED and watched the patient die, autotransfused in the ED, or had a patient code with normal vitals after "stabilization" in the ED can tell you that. (Been there, done all of that)

Some might argue the need of an airway, but anesthesia does that pretty well without help, and if they can't, surgery will quickly remedy the problem.

 

[NYMedic828]

Not exactly. It is an acute exacerbation of a chronic pathology. The actual inciting event is vascular wall rupture, that is a chronic process. The wall didn't suddenly become pathologic.

Consider, the most predictive factor for a second MI is a first one. Not because the person is procoagulative, it is because if one part of a vessel wall was weak enough to rupture, somewhere else in the vascular, another one likely is as well.

The purpose of anticoagulation isn't to prevent a wall rupture, it is to make clot formation from subsequent rupture less likely. (ideally not at all)

What I think really makes it interesting is it is the same pathophysiological process as a thoracic aortic aneurysm, but not of that of a abdominal aortic, cerebral, or peripheral aneurysm.

Treating the acute symptom (in this case,MI) means it was not identified and effectively managed. (without fault on healthcare providers, patients are not always the most compliant people)


I would liken it to be the equivalent of calling for gun control after a massacre.

It is simply a symptom of the underlying disease.



I'll concede airway obstruction as an acute emergency, but not as one of the most common, the same with anaphylactic shock.

Who cares if BLS intervention can stop hemorrhage? Anyone can stop hemorrhage and never seek or even decline medical treatment for it. That is redundant.

Similar to choking. I can't even guess how many unreported choking cases there are in one state in a year.

Now I am confused.

You are saying that an MI is not actually ever caused by a physical blockage of the vessel by a clot, but rather physical damage to the endothelium causing obstruction?

I assume we are considering plaque buildup to be chronic wall damage? Or are you implying that aneurysm in some form is always the cause of blockage?

 

[Veneficus]

Now I am confused.

You are saying that an MI is not actually ever caused by a physical blockage of the vessel by a clot, but rather physical damage to the endothelium causing obstruction??

As the plaque expands, tears in the "cap" of it expose vWF beneath it. This sets off the clotting cascade. Without exposure of vWF there is nothing to initiate the formation of the clot.

The clot and subsequent ischemia is the symptom of a tear in the enlarged plaque.

I assume we are considering plaque buildup to be chronic wall damage? Or are you implying that aneurysm in some form is always the cause of blockage?

Yes, Plaque buildup causes chronic wall damage. The relationship to aneurysms is just personal musings that thoracic aneurysm has the same pathological process only instead of plaque weakening into the lumen, it weakens instead exteriorly.

This pathophys is not shared by other aneurysms. Considering that the sections of the aorta and venacava in close proximity share the same embryological make-up as the heart and plaque formation is thought to be from deficency in human evolution, I consider this more than simple coincidence.

 

[NYMedic828]

As the plaque expands, tears in the "cap" of it expose vWF beneath it. This sets off the clotting cascade. Without exposure of vWF there is nothing to initiate the formation of the clot.

The clot and subsequent ischemia is the symptom of a tear in the enlarged plaque.

So without physical damage, a clot cannot actually adhere itself to anything and should keep moving on by?

What about when a clot enters a coronary vessel ultimately smaller than itself, and simply lodges in the lumen?

 

[Veneficus]

So without physical damage, a clot cannot actually adhere itself to anything and should keep moving on by?

Without physical damage a clot never forms. Once the vWF is exposed, a clot forms at that location. (Which can be anywhere, but most common in arteries, especially tortuous ones) If the clot remains adhered to that location it is a thrombus. If it moves from that location it is an embolis.

What about when a clot enters a coronary vessel ultimately smaller than itself, and simply lodges in the lumen?

It is an embolis, but it had to originate somewhere. Platelets also have vWF which can activate, but that is usually found in the venous system and are your precusors of DVT and PE. Of course there is the stasis in the L atrium in afib which then usually becomes a stroke.

I often say that all trauma is medical all medical is trauma. But I think A.T.Still summed it up best, abnormal structure causes abnormal function. (Of course now we have the benefit of molecular biology and biochemistry which proves that at a level much smaller than anything he probably imagined.

 

[Brandon O]

That has been thoroughly debunked by the knowledge gained from Iraq and Afghanistan. There really is no reason to stop.

One of the most respected ED docs I know served in the military for both. He likes to say "The only purpose an EM physician has in serious trauma is to wave good-bye to the patient on their way to surgery."

How many civilian surgeons do you know that would be willing to work this way, especially on anything but the most clear-cut and catastrophic cases? Even if we manage to bypass things like CT and don't need much sedation, anything necessary that's not done in the field or ED will presumably still need to be done in the OR, either before surgery (in which case why not do it in the ED), or during... so are you really suggesting that the routine approach should be to have people running about cutting off clothing and placing lines while the surgeon cuts around them?

I obviously agree with you in principle here, but I do think that in most cases stopping for at least a few minutes of prep is both appropriate and reasonable, particularly since in the US civilian environment the vast majority of cases aren't so obvious and do need risk stratification (and also because EMS is often not a perfect extension of this process, especially if a patient doesn't come by ambulance).

The exception is perhaps the few patients who are pretty much going to die in the elevator, and the system shouldn't be designed around them.

 

[Dwindlin]

How many civilian surgeons do you know that would be willing to work this way, especially on anything but the most clear-cut and catastrophic cases? Even if we manage to bypass things like CT and don't need much sedation, anything necessary that's not done in the field or ED will presumably still need to be done in the OR, either before surgery (in which case why not do it in the ED), or during... so are you really suggesting that the routine approach should be to have people running about cutting off clothing and placing lines while the surgeon cuts around them?

Yes, we do that frequently here. Patients come directly to the OR with nothing, soon as an airway is secured, surgeons start and anesthesia works on grabbing lines, activating massive transfusion, etc.

It's not as problematic as you would think.