OR resus/ed bypass

[Farmer2DO]

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.

Any thoughts?

Our level I trauma center has the ability to do this. They even have a name for it. It's truly very rare, though. (So much that I don't even know the name they use for it.)

One of the few times it's ever been done (I've been full time in this system for over 10 years) was one of my friends had a patient that was home after some major abdominal surgery. He tripped, and caught his fresh wound on the corner of the table, ripping it wide open. My friend arrived, and was level headed. When he arrived at the trauma center, straddling the gurney, with his hands in the guy's open belly, after requesting a trauma alert, the conversation went something like this:

Surgeon: Hey paramedic, whatcha got a hold of there?

Paramedic: Doc, I think it's his mesenteric artery.

Surgeon: That's good. Don't change a thing. Keep the gurney going, we'll go right to the OR.

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

Even here, you have to find out for sure first if it's a dissection, which means a trip to the CT scanner. And some dissections are managed medically.

 

[Veneficus]

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?

My experience here does not make this a reasonable question.

This is my chosen field of medicine, sme of my earliest mentors as well as the people I look up to are all these type of surgeons. I am surrounded by these people.

In fairness it is not that common in surgery as a whole. But when you meet one, there will be no doubt in your mind not only of their desire, but of their ability to do it.

Emergency surgery is rather a dying breed of surgeons, because of several factors. Generally it doesn't pay as well as elective procedures. The hours are 24/7 nights, weekends, holidays. It does take a lot of effort and knowledge to manage complicated cases, particularly in extremes of age.

Open surgery also is not all these providers do. Most have a myriad of trauma specific credentials like ultrasound, numerous vascular procedures, intensivist training, etc. (In all fairness ortho also does a lot of short notice procedures that are not easily elected out of)

In the words of one of my surgery profs, "trying to medically treat somebody who needs surgery simply delays them from the care they need."

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?

If you have never seen it, some similar things are done. Like cutting off cloths and starting lines. But also preping the area and a myriad of other surgery and anesthesia specific tasks. These are done as part of a team and near simultaneously. These tasks must also be done when the patient stops at the ED first, so it is really an unneeded delay to stop there.

As well, an escalation of care can happen during the surgery as it becomes more advantageous. A 14g peripheral can be used initially instead of a central line. You can switch from TIVA to an inhaled formula if it is more beneficial. Temporary vascular shunts can be used. Crossclamp times minimized. There is a whole list of things.

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).?

If a patient needs risk stratification, they do not need an emergent life saving surgery.

By its very nature emergency surgery is life or death. If you build a system by which you cannot do it, you have decided on a system where this patient population is written off for dead.

From trauma to vessles ruptured from medical pathologies, cardio bypass, and GI surgical emergencies, all be it small, this population still exists and a small but rather dedicated group of people do try to save them. Even in the US.

It is one of the reasons I have no faith in community hospitals. The people that have the knowledge, skills, and experience are found in the ivory towers. If you are going to be saved, it is going to be by these people.

Take for example one of my focuses, ruptured aneurysm. If you have a rupture a community hospital may simply decide it is terminal in the ED and not even wake up a surgeon. God forbid they have to call one in. But in all 3 academic centers I have been involed with, it is game on. Saves are extremely rare. They take a lot of resources, and there is usually some type of deficit. But people do go home and to good lives from time to time.

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.

From things like stab wounds and gun shot wounds and multi system wounds. But they don't die in the elevator. They die in the ED while everyone fools around with BS stabilization measures there or in CT while trying to determine if the person "needs" surgery.

I have seen it countless times and even managed to help recover from more than a handful of them.

 

[Veneficus]

Even here, you have to find out for sure first if it's a dissection, which means a trip to the CT scanner. And some dissections are managed medically.

Never use the phrase dissecting aneurysm or any of its forms in my presence

It is a pseudoaneurysm.

Sorry, pet peeve.

 

[VFlutter]

Never use the phrase dissecting aneurysm or ay of its forms in my presence

It is a pseudoaneurysm.

Sorry, pet peeve.

Out of curiosity, care to explain?

From what I understand Ectasia is arterial dilation less then 50%, Aneurysm is dilation over 50% and then dissection is an intimal tear separating the layers of vessel wall. A pseudoaneurysm is a hematoma outside the arterial wall but still communicates with the artery? Is the difference that a true aneurysm involves dilation of all the layers where as in a pseudoaneurysm involves separation of the layers? I am confused

 

[Veneficus]

Is the difference that a true aneurysm involves dilation of all the layers where as in a pseudoaneurysm involves separation of the layers? I am confused

This

 

[Farmer2DO]

In the words of one of my surgery profs, "trying to medically treat somebody who needs surgery simply delays them from the care they need."

He's a wise man.

It is one of the reasons I have no faith in community hospitals. The people that have the knowledge, skills, and experience are found in the ivory towers. If you are going to be saved, it is going to be by these people.

Much of my work involves saving people from the "care" at community hospitals and getting them to the ivory towers.

Never use the phrase dissecting aneurysm or any of its forms in my presence

It is a pseudoaneurysm.

Sorry, pet peeve.

I'm right there with you. But it wasn't ME who used the term "dissecting aneurysm". I referred to a dissection. I find that many of my colleagues don't understand the difference between aneurysm and dissection, and use the terms interchangeably. It irritates me greatly.

 

[Brandon O]

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.

I think this is splendid. Everybody is on board with it? EM, anaesthesia, trauma, etc?

I assume this is a Level I?

 

[Brandon O]

In fairness it is not that common in surgery as a whole. But when you meet one, there will be no doubt in your mind not only of their desire, but of their ability to do it.

Again, I certainly agree that this is a worthwhile and at times a lifesaving approach. But it does require widespread buy-in from almost everybody involved, as well as a meaningful commitment of time and training. For instance, it won't work if your EMS isn't good enough to accurately triage these types of patients and appropriately notify; it won't work if the ED flinches and decides to sit on someone for a bit; it won't work if anybody on the surgical team isn't comfortable doing the "pit crew" dance; and these aren't things to cross your fingers and hope for on that day, they're things to discuss beforehand, establish protocols for, and ideally practice ahead of time.

And the fact is that the patients who truly need this are very few, unless you're in South Africa or something. Only the really big academic centers will maintain enough volume for it to be at all reasonable, never mind to be good at it. So at some point I think we do have to accept that sufficiently rare cases should not dictate the overall system.

With that said, I would like every ED I walk into to work as you described. But the deficiencies that prohibit that are far wider and deeper than just emergent trauma care, and if we could rub the lamp and make a wish to fix something, we'd probably be better off starting with the frequent rather than the very rare.

 

[Veneficus]

Again, I certainly agree that this is a worthwhile and at times a lifesaving approach. But it does require widespread buy-in from almost everybody involved, as well as a meaningful commitment of time and training. For instance, it won't work if your EMS isn't good enough to accurately triage these types of patients and appropriately notify; it won't work if the ED flinches and decides to sit on someone for a bit; it won't work if anybody on the surgical team isn't comfortable doing the "pit crew" dance; and these aren't things to cross your fingers and hope for on that day, they're things to discuss beforehand, establish protocols for, and ideally practice ahead of time.

It has been my observation that where it exists, it is a culture of excellence as measured by perfection, not by "better than yesterday."

I would say the providers have more than buy in, they are all in. From the janitor to the heads of ED, surgery, anesthesia, and intensive care.

There is a self perpetuating pride and desire to be the best. People who do not share the desire often leave in short time.

EMS does not have to be a component. This is necessitated by cookbook providers still hell bent on getting a tube on scene at all costs. But with the reinforcement of "just go to the hospital protocols" it can work.

And the fact is that the patients who truly need this are very few, unless you're in South Africa or something. Only the really big academic centers will maintain enough volume for it to be at all reasonable, never mind to be good at it. So at some point I think we do have to accept that sufficiently rare cases should not dictate the overall system.

I agree that this population is decreasing worldwide, even in developing countries, but I wouldn't say it is very few. At the last US hospital I worked at a handful of these patients would show up every shift or two.

As for the overall system, as long as the patient gets transported or transferred to the larger facilities that have this level of care, there is no reason to try and replicate it at every hospital.

What I see as the 2 biggest problems in order:

1. Community facilities that try to manage because they underestimate the severity of the pt or try to run 10,000 diagnostic tests to figure out how severe they are.

2. EMS transporting to the closest hospital out of fear because they do not see these types of patients very often and either overestimate the capabilties of the local ED or simply don't care in their effort to punt.

With that said, I would like every ED I walk into to work as you described. But the deficiencies that prohibit that are far wider and deeper than just emergent trauma care, and if we could rub the lamp and make a wish to fix something, we'd probably be better off starting with the frequent rather than the very rare.

I would like to see that too, but it is simply fantasy. In order to be good at this patient population like all others, you need experience. Lots and lots of it. If we bought all the equipment, it would be a waste, there simply aren't enough providers of all the required disciplines interested. Even if there were, you would so dilute the experience and procedures that everyone would suck at it.

While it may seem counter intuitive, when it comes to severely injured and ill, or even the possibility somebody might be, outside facilities need to punt early and often.

I think efforts are better focused on speeding the ability of hopital to hospital transfer than trying to make all hospitals major trauma and acute care centers.

I think it would help if EMS providers took it upon themselves to become familiar with exactly what the capabilities of recieving hospitals were. For example, knowing a hospital has a a service like PCI doesn't mean they are prepared or comfortable to do emergent cases. Just becase a hospital has a surgeon in house doesn't mean that surgeon is able to handle every type of surgical emergency. Technically they should have learned to in residency, but we must be realistic. Most spend the most minimum amount of time with that as humany possible and do their best to avoid it after residency at all costs.

We have a trauma system (which is basically acute care surgery) because the system can work. I detailed the breakdowns above already.

 

[Dwindlin]

I think this is splendid. Everybody is on board with it? EM, anaesthesia, trauma, etc?

I assume this is a Level I?

Yeah, I'm at a level I. We have three levels of trauma activation. Cat I, II, and Direct to OR.

Cat II is "stable" trauma. Gets our trauma team, sans attending, and the EM attending will poke their head in to make sure they aren't needed.

Cat I is unstable blunt trauma without clear signs of bleeding (so could be unstable because of unsecured airway) or "stable" penetrating trauma to the core. These get trauma team, with trauma attending, and anesthesia. EM is hands off.

Direct to OR is unstable penetrating trauma and blunt trauma with clear signs of hemorrhage (expanding abd. is really the only thing they'll call). Also, any case of arrest after transport goes direct to OR for thoracotomy.

System works with us calling in, giving them what we see, and the receiving facility decides which level they want to call it.

Again, works well. They do 8-12 direct to ORs a month, with about 2800 total trauma activations a year.

 

[Farmer2DO]

Even if there were, you would so dilute the experience and procedures that everyone would suck at it.

This is a concept I think many people don't grasp.

I think efforts are better focused on speeding the ability of hospital to hospital transfer than trying to make all hospitals major trauma and acute care centers.

Or stroke centers? It's kind of a pet peeve of mine. In New York State, everyone and their brother is declaring themselves a stroke center. But there's no tiering of them, to classify them as far as capabilities. So, the 800 bed University Medical Center that does neurosurgery and interventional radiology, clips and coils, open craniotomies, and has arguably the most cutting edge neurosurgeon MD/PhD in upstate NY is classified the same as the 62 bed community hospital who got their stroke center designation because they have a book they pull out with a checklist every time a stroke comes in, someone willing to push tPA, and an agreement with a SNF.

I think it would help if EMS providers took it upon themselves to become familiar with exactly what the capabilities of recieving hospitals were. For example, knowing a hospital has a a service like PCI doesn't mean they are prepared or comfortable to do emergent cases. Just becase a hospital has a surgeon in house doesn't mean that surgeon is able to handle every type of surgical emergency.

Couldn't agree with you more. Field providers should know their hospitals well, and know what they're capable of and comfortable with.

Direct to OR is unstable penetrating trauma and blunt trauma with clear signs of hemorrhage (expanding abd. is really the only thing they'll call). Also, any case of arrest after transport goes direct to OR for thoracotomy.

That's fantastic. But as is being pointed out, the whole system needs to be on board for it to work. Our chief of trauma surgery used to be a paramedic, and is fantastic. People live when he's doing the surgery, and he's an excellent teacher, to boot. But if he's not on, watching traumas can be painful. I've seen them kill people, and want to just scream "Go to the effing OR! Hanging blood, starting a central line and an art line, and hanging pressors on a pedestrian struck with an expanding belly will do NOTHING!" (This patient presented with plenty of warning, bilateral 16s running great, and intubated. The trauma attending couldn't be bothered to come down, and the ED attending wouldn't stand up to the surgery resident.)

Or when I called the trauma center (a nurse answers) and told her explicitly "Traumatic cardiac arrest", "pulseless", "intubated", and "CPR in progress". When I rolled in, the trauma team said "They're doing CPR! Would have been nice to know that."

Maybe you could teach our trauma center a few things.....

 

[medicdan]

For those physicians around, do you see value in ED bypass for the (few) services that carry prehospital ultrasound? For Blunt Abdominal Trauma, with unstable vs, and a FAST exam indicating blood in Morrison's pouch or the splenorenal shunt? At the ED, they aren't going to do a CT, and blood products can be started in the ED before the ex lap...

 

[Veneficus]

For those physicians around, do you see value in ED bypass for the (few) services that carry prehospital ultrasound? For Blunt Abdominal Trauma, with unstable vs, and a FAST exam indicating blood in Morrison's pouch or the splenorenal shunt? At the ED, they aren't going to do a CT, and blood products can be started in the ED before the ex lap...

I would say it would be dependant on how the OR is set up. If it is set up with an ultrasound and intravascular capability as well as open surg, it might.

Generally the people who need emergent laps in this day and age are so profound they don't really need an ultrasound either.

 

[DrParasite]

Or when I called the trauma center (a nurse answers) and told her explicitly "Traumatic cardiac arrest", "pulseless", "intubated", and "CPR in progress". When I rolled in, the trauma team said "They're doing CPR! Would have been nice to know that."

I can top that one. many years ago, we took a a traumatic arrest to the closest hospital. BLS and ALS crews. had dispatch tell the ER we were bringing in a traumatic arrest. ER wanted on us giving vitals. I repeated, it was a traumatic arrest. they insisted on vitals. pulse 0, BP 0, resp 0. amazing.

As for the bypass concept, we don't do that, nor do I think we should. for traumas, we have the trauma surgeons come down to the ER for all trauma alerts. while there is an ER attending present (usually), the trauma surgical residents are running the show. once the patient is sufficiently stablized, they are transported to the OR, and if they are too unstable to be transported, they can do the work in the unsterile ER, and deal with the infections later.

 

[Veneficus]

I can top that one. many years ago, we took a a traumatic arrest to the closest hospital. BLS and ALS crews. had dispatch tell the ER we were bringing in a traumatic arrest. ER wanted on us giving vitals. I repeated, it was a traumatic arrest. they insisted on vitals. pulse 0, BP 0, resp 0. amazing.

As for the bypass concept, we don't do that, nor do I think we should. for traumas, we have the trauma surgeons come down to the ER for all trauma alerts. while there is an ER attending present (usually), the trauma surgical residents are running the show. once the patient is sufficiently stablized, they are transported to the OR, and if they are too unstable to be transported, they can do the work in the unsterile ER, and deal with the infections later.

That is one of the different ways of doing it. I have seen it done that way.

The biggest drawback is not the infection, it is not having all the stuff you are used to having in the OR or not being able to find it.

 

[Brandon O]

EMS does not have to be a component. This is necessitated by cookbook providers still hell bent on getting a tube on scene at all costs. But with the reinforcement of "just go to the hospital protocols" it can work.

I would disagree. Unless most of your patients are self-presenting to the hospital, trauma patients who arrive by EMS need to have the problem recognized, need to be handled emergently, need to be brought to the right destination (and preferably notify them before arrival), and when possible have bleeding managed. EMS can't do a ton as far as interventions in these people, but they can do a ton in appropriate triage and transport, and that's the core of this business anyway.

I agree that this population is decreasing worldwide, even in developing countries, but I wouldn't say it is very few. At the last US hospital I worked at a handful of these patients would show up every shift or two.

I feel like we're describing different patient types, then. I mean the truly emergent, OBVIOUSLY surgical trauma patient whose primary lesions are absolutely self-evident, and for whom seconds/minutes could actually mean life or death -- just one slim step down from a fully obstructed airway or cardiac arrest. Unless you're in South Africa or somewhere, I think these are few.

Speaking more broadly, the more emergent the patient, the more streamlined the decision process. So for the most dire cases, it's clear what needs to be done, and getting it done as quickly as possible is mainly about logistics and balls. But there are far more patients who aren't as obvious, and while some of them might benefit from an expedited path to surgery, it's not necessarily clear (except in retrospect) who they are.

What I see as the 2 biggest problems in order:

1. Community facilities that try to manage because they underestimate the severity of the pt or try to run 10,000 diagnostic tests to figure out how severe they are.

This is a common problem in all regionalized systems of care. The biggest delay in STEMI systems isn't really the EMS interval or door-to-balloon in the PCI centers, it's delay at transferring hospitals, especially for patients who walk in. You need a predefined protocol for these people that sidesteps much of the rigmarole and explicitly lays out how it should be done. I've seen crews called for the stat transfer begging the sending physician to let them take the patient while he sits filling out paper or waiting to get the patient accepted. Not okay.

2. EMS transporting to the closest hospital out of fear because they do not see these types of patients very often and either overestimate the capabilties of the local ED or simply don't care in their effort to punt.

Yep. The important thing is to get people away from asking, "is the patient sick?" and asking instead, "what does the patient need?" (cf. the question of whether a patient needs ALS.) Restrictive protocols can play a role here as well, of course. But I will bend over backwards and walk on coals to avoid letting a patient touch a community hospital that lacks what he needs, because merely by passing through the doors there, I'll invariably add many minutes to the delay until he gets to where the good stuff is available. (It doesn't help that those community hospitals beg us to bring sick patients there, or even apply business pressures on local services, but then when we roll 'em in, they freak and transfer.)

I think it would help if EMS providers took it upon themselves to become familiar with exactly what the capabilities of recieving hospitals were. For example, knowing a hospital has a a service like PCI doesn't mean they are prepared or comfortable to do emergent cases. Just becase a hospital has a surgeon in house doesn't mean that surgeon is able to handle every type of surgical emergency.

Agreed wholeheartedly. You mainly see this from the really experienced folks, I think, particularly if they also work in one of the area hospitals (tech or RN maybe). It's the little stuff -- who knows the actual requirements to be a Level I/II/III? What hours on what days are what services available? How busy do they tend to be at certain times? What's the lag time to spin up various processes? Who can get records from where? It can make a real difference, but it's not easy to develop that body of knowledge.

 

[Veneficus]

I would disagree. Unless most of your patients are self-presenting to the hospital, trauma patients who arrive by EMS need to have the problem recognized, need to be handled emergently, need to be brought to the right destination (and preferably notify them before arrival), and when possible have bleeding managed. EMS can't do a ton as far as interventions in these people, but they can do a ton in appropriate triage and transport, and that's the core of this business anyway.

Most really sick patients either self present or a referred by transfer from another facility.

Most hospitals only get 10-15% of their ED traffic via EMS, if you take the commonly accepted 5% of EMS being "true emergencies" and break that down to surgical emergencies vs. medical, you may find the busiest facilties anywhere only see between 4-6K surgical emergencies a year.

Not a lot for EMS to do there is busy systems, how much does suburban or rural add to this?

I feel like we're describing different patient types, then. I mean the truly emergent, OBVIOUSLY surgical trauma patient whose primary lesions are absolutely self-evident, and for whom seconds/minutes could actually mean life or death -- just one slim step down from a fully obstructed airway or cardiac arrest. Unless you're in South Africa or somewhere, I think these are few.

in terms of ED and surgical traffic they are few. But you are still talking about 10s of thousands of people a year in the US.

Speaking more broadly, the more emergent the patient, the more streamlined the decision process. So for the most dire cases, it's clear what needs to be done, and getting it done as quickly as possible is mainly about logistics and balls. But there are far more patients who aren't as obvious, and while some of them might benefit from an expedited path to surgery, it's not necessarily clear (except in retrospect) who they are..

This is a common problem in all regionalized systems of care. The biggest delay in STEMI systems isn't really the EMS interval or door-to-balloon in the PCI centers, it's delay at transferring hospitals, especially for patients who walk in. You need a predefined protocol for these people that sidesteps much of the rigmarole and explicitly lays out how it should be done. I've seen crews called for the stat transfer begging the sending physician to let them take the patient while he sits filling out paper or waiting to get the patient accepted. Not okay

I agree, but that is not what drives delays. It is all about reimbursement and requirements for transfer.

This was caused by small private hospitals dumping patients who could not pay on larger institutions who would then have to eat the cost. To prevent this, all kinds of "safeguards" were added. But it is about the money not the patient.

It also depends on who and how assessments are done. Surgeons are pretty quick to decide who should/can be operated on and for what. It's what they do.

Then you add in anesthesia requirements.

Not all doctors are equal. If you have people following common treatment protocols for the most likely disease until it proves ineffective, a lot gets missed.

Yep. The important thing is to get people away from asking, "is the patient sick?" and asking instead, "what does the patient need?" (cf. the question of whether a patient needs ALS.) Restrictive protocols can play a role here as well, of course. But I will bend over backwards and walk on coals to avoid letting a patient touch a community hospital that lacks what he needs, because merely by passing through the doors there, I'll invariably add many minutes to the delay until he gets to where the good stuff is available. (It doesn't help that those community hospitals beg us to bring sick patients there, or even apply business pressures on local services, but then when we roll 'em in, they freak and transfer.).

Always follow the money.

 

[Brandon O]

Most really sick patients either self present or a referred by transfer from another facility.

Most hospitals only get 10-15% of their ED traffic via EMS, if you take the commonly accepted 5% of EMS being "true emergencies" and break that down to surgical emergencies vs. medical, you may find the busiest facilties anywhere only see between 4-6K surgical emergencies a year.

I think 10-15%, although appropriate in other contexts, is far too low for major trauma in the US. Except for the gang members who want to avoid police, and tough old farmers who'd rather steer with one hand when they leave the other in a combine, most people still call for an ambulance when they get shot or impaled.

If you have some concrete figures showing otherwise I'm willing to be wrong.

 

[Veneficus]

I think 10-15%, although appropriate in other contexts, is far too low for major trauma in the US. Except for the gang members who want to avoid police, and tough old farmers who'd rather steer with one hand when they leave the other in a combine, most people still call for an ambulance when they get shot or impaled.

If you have some concrete figures showing otherwise I'm willing to be wrong.

those were the figures discussed at the last conference I was at.

Especially in the inner city, the homeboy ambulance service is very busy.

Most of the self presenting patients are also still compensating.So the initial presentation doesn't seem to them as bad as it is. But they find out.

 

[Brandon O]

those were the figures discussed at the last conference I was at.

Especially in the inner city, the homeboy ambulance service is very busy.

Most of the self presenting patients are also still compensating.So the initial presentation doesn't seem to them as bad as it is. But they find out.

Okay, in any case, this would just further reinforce the idea that the ED usually needs to play some role in assessment and management. Presumably the trauma surgeon isn't down in the waiting room, rolling around an empty wheelchair and looking for blood.