This is a reminder to all that I am publishing the results of the Trauma PI Coordinator Survey next week. This white paper will be distributed in lieu of the usual monthly newsletter. And it will only be sent to current subscribers! Unlike normal newsletter issues, it will not be available via the usual blog post. For those that miss out, you will still be able to obtain it by subscribing to the newsletter at any time in the future.
Yesterday I discussed nonstandard first responders (police). Today I’ll share some info on nonstandard ambulances.
In this day and age of ride sharing apps like Uber and Lyft, it is possible to get a cheap ride virtually anywhere there is car service and a smart phone. And of course, some people have used these services for transportation to the hospital in lieu of an ambulance ride. What might the impact be of ride services on patient transport, for both patient and EMS?
A paper in preparation suggests that ambulance service calls decreased by 7% after the introduction of UberX rides. Now, there are a lot of questions here, because the full paper has not yet been peer reviewed, and the results write-up is pretty sketchy. But it does beg the question.
Ambulance rides are expensive. Depending on region, they may range from $500-$5000. And although insurance may reduce the out of pocket cost, it can still be expensive. So what are the pros vs the cons of using Uber or Lyft for medical transport?
- Ride shares are inexpensive compared to an ambulance ride
- They may arrive more quickly because they tend to circulate around an area, as opposed to using a fixed base
- Riders may select their preferred hospital without being overridden by EMS (although it may be an incorrect choice)
- May reduce EMS usage for low acuity patients
- No professional medical care available during the ride
- May end up being slower due to lack of lights and siren
- Damage fees of $250+ for messing up the car
Bottom line: Uber and Lyft are just another version of the “arrival by private vehicle” paradigm. Use of these services relies on the customer/patient having very good judgment and insight into their medical conditions and care needs. And from personal experience, this is not always the case. I would not encourage the general public to use these services for medical transport, and neither do the companies themselves!
(This paper remains unpublished! Hmm… but the link will take you to a copy of the manuscript)
When I was at Penn 30+ years ago, I was fascinated to see that police officers were allowed to transport penetrating trauma patients to the hospital. They had no medical training and no specific equipment. They basically tossed the patient into the back seat, drove as fast as possible to a trauma center, and dropped them off. Then they (hopefully) hosed down the inside of the squad car.
Granted, it was fast. But did it benefit the patient? The trauma group at Penn decided to look at this to see if there was some benefit (survival) to this practice. They retrospectively looked at 5 years of data in the mid-2000’s, thus comparing the results of police transport with reasonably state of the art EMS transport.
They found over 2100 penetrating injury transports during this time frame (!), and roughly a quarter of those (27%) were transported by police. About 71% were gunshots vs 29% stabs.
Here are the factoids:
- The police transported more badly injured patients (ISS=14) than EMS (ISS=10)
- About 21% of police transports died, compared to 15% for EMS
- But when mortality was corrected for the higher ISS transported by police, it was equivalent for the two modes of transport
Although they did not show a survival benefit to this practice, there was certainly no harm done. And in busy urban environments, such a policy could offload some of the workload from busy EMS services.
Bottom line: Certainly this is not a perfect paper. But it does add more fuel to the “stay and play” vs “scoop and run” debate. It seems to lend credence to the concept that, in the field, less is better in penetrating trauma. What really saves these patients is definitive control of bleeding, which neither police nor paramedics can provide. Therefore, whoever gets the patient to the trauma center in the least time wins. And so does the patient.
Reference: Injury-adjusted mortality of patients transported by police following penetrating trauma. Acad Emerg Med 18(1):32-37, 2011.
Yesterday, I described a novel technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.
A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique. Note the cool music!
I keep getting requests regarding this technique, so I’m reposting this updated article today and tomorrow.
Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for a few weeks before decannulation is safe.
Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.
The technique is straightforward:
- After initially intubating the patient orotracheally, a 1.5cm incision is created just off the midline in the submental area under the chin.
- Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue.
- A 1.5cm incision is then made at the puncture site, parallel to the gum line of the lower teeth.
- The ET tube is removed from the ventilator circuit, and the connector at the proximal end of the tube is removed.
- The hemostat is placed through the chin incision again. The proximal end of the ET tube is curled into the oropharynx and grasped with the hemostat, then pulled out through the skin under the chin, leaving the distal (balloon) end in the trachea.
- The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again.
- The tube is then secured using a stitch under the chin.
After a final position check, the surgical procedure can commence. Cool!
There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.
A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.
Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!
Tomorrow: Submental intubation – the video!
Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.
Photo source: internet