EMS management/crush injury

[pjcabdds at mchsi.com]

Scott,
You make many good points. Information for me is not available either. I will
find out hopefully during a committee meeting. This should be a learning
experience for everyone involved. 
"Why make a helicopter sit on a pad?" However, better on a pad at the hospital
than in a city street a few blocks from the hospital. This is not something done
here. The patient may have been transferred or may have stayed locally. It's
unknown to me currently.
"Independent of physician oversight." I don't feel like there was a waste of
time or money. It did turn out to be a drill. Who has oversight and who makes
the decision to transfer? Even though Iowa has a state trauma system, these
questions need answers and clarification.
"directly from the scene to the tertiary care facility" I will gladly
acknowledge that someone in pre-hospital made an appropriate decision in this
regard. I will learn. Hopefully, if the opposite is concluded, pre-hospital
personnel can say the same. 
"What intervention would you have offered?" Should this be a debate about "stay
and play" versus "scoop and run"? Without more information, which did not come
from from pre-hospital, it is not possible to answer the question. I can tell
you that there is a well organized, long established trauma team, guided by
state derived protocols, to manage the injured. The capabilities at the local
facility can manage anything in the post injury period, and not merely secure an
airway. 
"Pangram" Boy, I am glad that I didn't make an alphabetical list! Great word. I
don't come from a place like you describe. Great efforts have been made in Iowa
to standardize trauma care throughout the entire state as a system. I have
worked on the systme for 12 years. What I see potentially happening now are
defections from the system, from protocols, and guidelines, because someone
knows better, and acts without going through the system. This applies to
everyone from pre-hospital, to hospitals, to surgeons.
"Needless and a waste" It appears that in your environment this statement may be
often true. I know that this still happens in this state, but attempts are being
made to decrease such events-that is, make the transfer to the appropriate
center. A few years ago, an Iowa surg resident presented a paper on "triple
jumps", ie, level 4 to level 3 to level 1. The lesson was not lost on any of us.
The questions remain: what were the injuries, what were the indications for
transfer, who has authority for transfer, and what were the benefits and risks
of the managment selected. 
I appreciate your input and the opportunity to discuss this with you. 


Kind regards,
Phil
Phil Caropreso, MD, FACS
1813 Grand Avenue
Keokuk, Iowa, USA, 52632
pjcabdds at mchsi.com


----------------------  Original Message:  ---------------------
From:    HAXScott at aol.com
To:      trauma-list at trauma.org
Subject: Re: EMS management/crush injury
Date:    Sun, 10 Jun 2007 06:01:24 +0000

> Phil,
>  
> I don't have any knowledge of your local area, your hospital, or the  
> specialty or subspecialty services represented there. I've actually never been  
> to 
> your state and it's probably one of the very few places where I don't have a  
> professional connection. You don't present nearly enough information for me to  
> comment on the actions taken by your local ground EMS providers or the flight  
> crew.
>  
> Firstly, why make the helicopter come to sit on your helipad to likely  
> eventually transfer the patient if they could have just as well responded to the  
> scene, which they apparently did?
>  
> Secondly, what's the issue? That you mobilized a team and someone  
> independent of direct physician oversight from your institution made a  decision 
> to 
> transport the patient directly to a facility other than yours? I'm  sorry you 
> wasted time and money mobilizing for a patient you admit you would  likely have 
> transferred anyway. 
>  
> If there was poor judgment on someone's part, or a protocol deviation, or  
> some political crap at play, then I applaud any effort you address the system  
> issues and do what is right by the patient - which may, in fact, be  to admit 
> that someone made an appropriate decision to triage the patient  directly from 
> the scene to a tertiary care facility.
>  
> >From the sounds of it, your institution is very well organized and  committed 
> to the critically injured patient, and that is absolutely commendable  and 
> something to be proud of - but, what intervention would you have offered  this 
> or any critically injured patient, aside from airway control and assurance  of 
> effective ventilation and oxygenation prior to transfer, that  may produce a 
> measurable difference in outcome when your regional resource  tertiary center 
> is a mere 45 minute air hop? 
>  
> I know you'll not respond with "a pangram!" but I come from a place in the  
> world where critically injured patients who ought to go directly to the  trauma 
> center are "stabilized" prior to transfer with a bunch of plain films and  
> labs, a couple liters of cold saline for "tachycardia" and, occasionally,  
> "sedation" with "vecuronium".... 
>  
> I think a stop in an ED for "evaluation and stabilization" is needless and  a 
> waste of time and money when tertiary center management is indicated and a  
> resource is available to expeditiously and safely move such patient directly to 
>  definitive care. Exceptions? Absolutely! Lives saved by stopping in a  
> non-tertiary center ED for airway control or tactical hemostasis?  Absolutely.
>  
> Regards
>  
>  
>  
>  
> 
> 
> 
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