The number of elderly patients needing care at trauma centers is skyrocketing. Many are on anticoagulants for medical conditions, most commonly atrial fibrillation. When one of these patients is seriously injured, anticoagulation can cause serious and life-threatening complications that might otherwise not occur.
Reflexively, many trauma professionals decide to just stop the medication, especially if they believe that the patient may injure themselves again (and again, sometimes). However, this may not always be a good idea. Remember the good old juice to squeeze ratio. Look a the risks (reinjury) vs the potential benefits (stroke prevention). The easiest way to assess this is to use CHADS2.
CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:
- C – congestive heart failure – 1 point
- H – hypertension (treated or untreated) – 1 point
- A – age >= 75 – 1 point
- D – diabetes mellitus – 1 point
- S2 – history of stroke or TIA – 2 points
Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:
- Score = 0: low risk, no therapy needed or just take aspirin
- Score = 1: moderate risk, aspirin or oral anticoagulant
- Score >= 2: moderate to high risk, take oral anticoagulant
Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.
Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.
So after two days of pros and cons about helicopter EMS (HEMS), we lead up to this. The American College of Surgeons Committee on Trauma, Emergency Medical System subcommittee, has released a set of guidelines on appropriate use of HEMS. It’s been endorsed by the National Association of EMS Physicians and looks like a lot of thought has gone into it.
Here are the factoids about the HEMS guidelines:
- Must be integrated with your trauma system
- Must utilize standardized field triage guidelines that should be applied consistently throughout your trauma system
- Is blind to the insurance status of the patient
- Uses a regional dispatch system. Self-launch should never happen.
- Referring physician to receiving physician conversations must occur when considering transportation mode (air vs ground) for interfacility transfers
- There must be good online medical direction from a physician
- Offline medical direction must be based on protocols and policies developed by the trauma system
- There must be regular PI review of all HEMS transports to ensure compliance
- HEMS crews must have regular training opportunities
- A culture of safety must be maintained
Bottom line: We absolutely must take a critical look at our patient transport practices and procedures. To ensure even-handed application of best practices, our state trauma systems are going to have to step up and address this issue so the right patient will get to the right hospital at the right time, safely and cost effectively.
Reference: Appropriate use of Helicopter Emergency Medical Services for transport of trauma patients: Guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma 75(4):734-741, 2013.
Yesterday, I wrote about the (unclear) benefits of helicopter EMS transports. Today, I’ll cover the risks. The number of medical helicopters in the US has grown dramatically since 2002.
As can be expected, the number of mishaps should go up as well.
Although it looks like the fatal and injury accidents peaked and then declined, it does not look as good when compared to the rest of the aviation industry. Consequently, being on a helicopter EMS (HEMS) crew has become one of the more dangerous professions.
And unfortunately, the numbers have not improved much during the past five years. So what to do? Make it a big PI project. Approach it systematically, analyze the issues, and create some guidelines and protocols for all to follow.
Tomorrow, I’ll review new guidelines for HEMS released by the American College of Surgeons Committee on Trauma.
Reference: Medical helicopter accidents in the United States: a 10 year review. J Trauma 56:1325-1329, 2004.
The use of medical helicopters has grown at an astonishing rate in the 10+ years since Medicare got involved with payment for this service. All high level trauma centers have helicopter landing facilities, and many either own or are a part owner in at least one helicopter EMS service (HEMS).
Here’s a state by state breakdown of the number of medical helicopters:
It’s gotten to the point where the indication for summoning a HEMS service seems to be the presence of a patient to ride on it!
A lot of papers have been published in the past 20 years trying to justify the benefits of using these services. As is the usually case when a lot of papers are published on one subject, most of them are not very good. Lots of studies have been performed to try to justify their use, and most were not successful. The following items have been scrutinized:
- Interfacility transfers
- Pediatric transfers
- Pediatric trauma
- Rural trauma
Most of these papers found little, if any, benefit. The ones that did tended to be published by institutions that owned these services, raising the question of bias. The one thing that was always significantly different was the cost. HEMS costs at least 10 times more that ground EMS transport.
So the benefits are not very clear. What about the risks? I’ll talk about those tomorrow.
Click here to view the interactive state map of medical helicopters. See where your state is with respect to number of ships and services, and how busy they are.
Our population is aging, and falls continue to be a leading cause of injury and morbidity in the elderly. Unfortunately, many elders have significant medical conditions that make them more likely to suffer unfortunate complications from their injuries and the procedures that repair them.
A few hospitals around the world are applying a more multidisciplinary approach than the traditional model. One example is the Medical Orthopaedic Trauma Service (MOTS) at New York-Presbyterian Hospital/Weill Cornell Medical Center. Any elderly patient who has suffered a fracture is seen in the ED by both an emergency physician and a hospitalist from the MOTS team. Once in the hospital, the hospitalist and orthopaedic surgeon try to determine the reason for the fall, assess for risk factors such as osteoporosis, provide comprehensive medical management, provide pain control, and of course, fix the fracture.
This medical center recently published a paper looking at their success with this model. They retrospectively reviewed 306 patients with femur fractures involving the greater trochanter. They looked at complications, length of stay, readmission rate and post-discharge mortality. No change in length of stay was noted, but there were significantly fewer complications, specifically catheter associated urinary tract infections and arrhythmias. The readmission rate was somewhat shorter in the MOTS group, but did not quite achieve significance with regression analysis.
Bottom line: This type of multidisciplinary approach to these fragile patients makes sense. Hospitalists, especially those with geriatric experience, can have a significant impact on the safety and outcomes of these patients. But even beyond this, all trauma professionals need to look for and correct the reasons for the fall, not just fix the bones and send our elders home. This responsibility starts in the field with prehospital providers, and continues with hospital through the entire inpatient stay.
Reference: The medical orthopaedic service (MOTS): an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures. J Orthopaedic Trauma 26(6):379-383, 2012.