Speed and Time in Prehospital Trauma Care

[Sasha]

Driving really fast with pretty lights and loud sirens seems to be the focus and livelyhood of many EMTs and Paramedics, along with the "load and go!" mentality. We all know that speed can kill you, and that rushing leads to mistakes and sloppy work. Found this article, thought I would post. A 4 minute response time is totally unrealistic, but should we kill lights and sirens response and transports totally?

I do think it's a double standard to preach scene safety and personal safety while advocating for rapid responses to medical emergencies.

Speed and Time in Prehospital Trauma Care

Full Article: http://www.ems1.com/ems-products/ed...57-Speed-and-Time-in-Prehospital-Trauma-Care/

One of the most fundamental tenets of EMS has been the attempt to get the patient to the hospital as quickly as possible. This concept was bolstered by R. Adams Cowley with his "Golden Hour" scheme. The trauma folks soon developed catchy phrases like "load and go" and "scoop and run." But, several recent studies have shown that total out-of-hospital time has little or no impact on most subsequent patient outcomes and mortality.

In a soon-to-be-published study in Annals of Emergency Medicine, Newgard and colleagues looked at outcomes of prehospital trauma patients and correlated these with various out-of-hospital time intervals. The study included a total of 3,565 trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. The inclusion criteria were a systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, a Glasgow Coma Scale score less than or equal to 12, or the need for an advanced airway intervention.

They looked at various defined prehospital time intervals (activation interval, response interval, on-scene interval, transport interval, and total EMS interval). The study concluded, "Among injured patients with physiologic abnormality prospectively sampled from a diverse group of sites and EMS systems across North America, there was no association between EMS intervals and mortality."1 This was the largest study with the greatest validity on this topic conducted thus far.

 

[Jeffrey_169]

I wonder how many of those who "conducted" this research have ever been in the back of truck pumping chest on a patient with his/ her family member there looking to you save them.

These people think judge situations by numbers on paper, not from practical functionality and experience.

 

[VentMedic]

I wonder how many of those who "conducted" this research have ever been in the back of truck pumping chest on a patient with his/ her family member there looking to you save them.

So you drive faster to get the family out of your truck quicker?

Did it really change the outcome of the patient?

Was the patient still dead when you got to the ED?

 

[firetender]

Back to Basics

I thought the idea was you're bringing the hospital to the patient?

Once you're there, the patient is in the system. It's like rushing through the hospital's crowded hallways - endangering everyone else - to get to X-ray. If the pt. ain't gonna make it to the hospital, it's unlikely the hospital can improve the prognosis.

Smooth over speed, always!

 

[JPINFV]

I wonder how many of those who "conducted" this research have ever been in the back of truck pumping chest on a patient with his/ her family member there looking to you save them.

These people think judge situations by numbers on paper, not from practical functionality and experience.

Science > emotion. The plural of "anecdote" is not "data." Additionally, if you're "pumping chest" then the patient shouldn't be transported outside of very specific conditions.

 

[DV_EMT]

I think its kinda psychology based.... i think that based upon the fact that most people get comfort out of L/S and seeing the "cavalry" show up and come slowly jogging to the front door to "save" their loved one. when my wife had her cardiac episode and we had to call 911... i was comforted knowing that EMS got to the place in a quick and timely manner. the transport to the hospital was no l/s... but still I think that the general public just likes the L/S because it gives them a certain amount of relief that someone has "come to their rescue".

I'm not saying that L/S makes pt quality improve, but moreso, puts the family at ease that help is there.

hence why L/S should be run only when going to a scene, and away if the pt is critical.

 

[Jeffrey_169]

Okay, perhaps I was unclear in my point earlier. No, I would not endanger the public to save a pt. It would be counterproductive to injure (or worse) other people in order to save 1 pt. I have never, in several years, ever been in an accident (knock on wood) while driving, on a code or anything else. I am careful, yet expedient when necessary. All I am saying is common sense should dictate. These analysts look at a variety of numbers and yet they have no practical experience. I have yet to meet one vol. / prof. ff, EMT, Medic, or anyone else with a any degree of common sense place the pts life over that of the general public. We have a responsibility to the pt, but also to everyone else.
I realize I should have been clearer in my framing of the response in question, and in so I apologize. However if it was someone I cared about I would want to know my loved one is going to get the best care possible in the shortest period of time, but safely so. Everyone is someone to someone.
To answer the question, I was a Basic on an all Basic Vol. Rescue squad. Back then we did not even have AEDs, but if I recall the pt did survive after reaching the ER; this was several years ago. I have no doubt the Lord above gave us some help on that one.

 

[CAOX3]

Whizzing around the city with lights and sirens blaring is dangerous for everyone involved.

However in my area responding can reduce transport times by up to thirty minutes during some times of the day.

 

[EMTinNEPA]

The Golden Hour is a myth. Some patients have days, some patients have hours, some patients have minutes, and some patients will be dead before you get there. Base your transport mode on patient condition.

As for cardiac arrests, if their condition hasn't improved in 25-30 minutes, just call it on scene. By that point they'll be vegetables anyway.

 

[Shishkabob]

I don't see how anyone can argue against l&s in the initial response to the scene. Time to first interventions does make a difference, especially when it comes to cardiac episodes. Add on top of that, dispatch information or even caller information can, and is, wrong at time to where it can be called as a fever and end up being a cardiac arrest.


Now, the only thing that I can see be debated to a code return to the hospital after contact has been made and interventions established. But no, never the initial response.

 

[EMTinNEPA]

My service hardly ever runs lights and sirens to BLS calls unless we are out of ALS units and we have a paramedic coming in from another town. I completely advocate this because there's no point in responding with lights and sirens to a stubbed toe, especially if your quick response gets you only halfway to scene really really fast.

Now, as for transporting with lights and sirens, there are situations where emergent transport would be indicated... STEMIs, CVAs, flash pulmonary edema, hypovolemia, etc... situations where time DOES make a difference or the hospital is MUCH better equipped to treat the patient than you are.

 

[Foxbat]

I don't see how anyone can argue against l&s in the initial response to the scene.

http://www.bryanbledsoe.com/data/pdf/mags/Myth4.pdf
The article addresses response to scene time as well.

 

[MrBrown]

I wonder how many of those who "conducted" this research have ever been in the back of truck pumping chest on a patient with his/ her family member there looking to you save them.

Sounds like the system you work in is a wee bit antiquated; never transported a non-ROSC primary or traumatic arrest, whats the point?

 

[Sasha]

I don't see how anyone can argue against l&s in the initial response to the scene.

Don't you think that an ambulance crash while going lights and sirens would delay care even more than a safe and smooth ride to the scene? Also for the EMTs/Paramedics who finally DO get to the scene, what their state of mind would be knowing that their coworkers were in an accident? And how many extra units would that take out of service?

I have trouble risking a life for someone who'se already dying.

 

[CAOX3]

Don't you think that an ambulance crash while going lights and sirens would delay care even more than a safe and smooth ride to the scene? Also for the EMTs/Paramedics who finally DO get to the scene, what their state of mind would be knowing that their coworkers were in an accident? And how many extra units would that take out of service?

I have trouble risking a life for someone who'se already dying.

I agree but until our medical director feels non emergent responses are beneficial, there isnt much we can do about it. We proceed cautiously to and from all calls whether emergent or non-emergent.

 

[CollegeBoy]

Now the article that I read stated slightly different findings. Its not that out of hospital time has little or no effect. It is true that there is that "golden hour", however, that is different than one would think. The article I read stated that the "golden hour" is actually way less than an hour, it is closer to 15-30 minutes. If I could find the link I would post it.

 

[Shishkabob]

http://www.bryanbledsoe.com/data/pdf/mags/Myth4.pdf
The article addresses response to scene time as well.

Actually, while that article discusses l&s response, it really only argues against l&s transport. Two different things.

That article states between a 1 min and 3 min difference in l&s resonse as opposed to non-l&s response. That's a decent time saved and can make a difference in a few of the calls we run, such as severe respiratory distress or cardiac arrest, where a minute very well can mean the difference between life, death, and even future quality of life.


Otherwise let's stop responding to cardiac arrest in urban areas such as Dallas and others. I mean, what's the point in going if you have to stop and wait at every light? It'll sure pass 10 min response in many areas, speaking from personal experience. Dallas traffic sucks, as does Detroit, LA, and other metropolitan areas.



Transport is different than response, don't confuse the two.

Ps- not saying l&s response to every call. I'm still an advocate for EMD and having specific guidelines for l&s calls.

 

[Jon]

Don't you think that an ambulance crash while going lights and sirens would delay care even more than a safe and smooth ride to the scene? Also for the EMTs/Paramedics who finally DO get to the scene, what their state of mind would be knowing that their coworkers were in an accident? And how many extra units would that take out of service?

I have trouble risking a life for someone who'se already dying.

True Story. Been There. Done That.

I wonder how many of those who "conducted" this research have ever been in the back of truck pumping chest on a patient with his/ her family member there looking to you save them.

These people think judge situations by numbers on paper, not from practical functionality and experience.

Jeffery,

You transport family with a patient in arrest?

From AHA Guidelines 2000 (http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-58):

Emergency medical response systems should not require field personnel to transport every victim of cardiac arrest to a hospital or emergency department (ED). Transportation with continuing CPR is justified if interventions are available in the ED that cannot be performed in the field, such as cardiopulmonary bypass or extracorporeal circulation for victims of severe hypothermia (Class IIb).
Unless special situations are present (eg, hypothermia), for nontraumatic and blunt traumatic out-of-hospital cardiac arrest, evidence confirms that ACLS care in the ED offers no advantage over ACLS care in the field. Stated succinctly, if ACLS care in the field cannot resuscitate the victim, ED care will not resuscitate the victim. Civil rules, administrative concerns, medical insurance requirements, and even reimbursement enhancement have frequently led to requirements to transport all cardiac arrest victims to a hospital or ED. If these requirements are nonselective, they are inappropriate, futile, and ethically unacceptable. Cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems.

More and more, the tide is suggesting that lights-and-siren transport of a patient in cardiac arrest is an unnecessary risk.

CPR compressions are less effective when done in a moving ambulance. Especially when a moving ambulance is doing the stupid things and taking dumb risks we do when we drive emergent.

Jeff - "Numbers on paper" is where its at. Actual research into what we do can see MUCH more than one EMT or medic... and they can justify their opinion, rather than just saying "from what I've seen".

 

[DrParasite]

I am a firm believer in L&S to EVERY emergency call. Call screeners get it right about 95% of the time, but there are some dumb callers who don't provide the correct information to the EMD. But every agency plays the numbers game, with the total number of units it staffs at any given time, to all ALS vs ALS and BLS, or even if they will use a first responder program.

as for transporting, I think it's a crap shoot. if you work in a busy urban service, then the justification becomes "the sooner you arrive at the hospital, the sooner you become available for the next one. This can be important for agencies that stack or hold BLS jobs because they have no units available (and mutual aid is not used for BLS jobs).

for slower rural and suburban services, going L&S might make sense on minor calls. longer transport times means longer time their primary area is unprotected for the next one, so L&S means quicker times to the hospital and quicker times out of the hospital and back to their primary area.

personally, I would rather go without L&S unless it's a time critical medical emergency for transporting, but often the use of L&S are made by others, who are often using them for other reasons besides the best interests of the current patient.

 

[Akulahawk]

In a system I've worked in, I've occasionally heard operational orders to have all units go Code-3 to all calls, all returns to hospitals, and all posting assignments... all due to low numbers of units available...

Back in those days, the EMS system was SERIOUSLY stressed...

Generally, I support judicious use of L&S going to calls, and case by case ONLY on returns to the ED.