How Long Does It Take EMS To Get To A Scene?

How long does it take for EMS to get to the scene of an emergency? That’s a loaded question, because there are many, many factors that can impact this timing. If you look at the existing literature, there are few, if any, articles that have actually looked at this successfully.

A group from Aurora, IL and Wake Forest reviewed EMS records from across the country, spanning 485 agencies over a one year period. Only 911 responses were reviewed, and outliers with arrival times of more than 2 hours and transport times of 3 hours were excluded. Over 1.7 million records were analyzed, and 625 were excluded for this reason.

Here are the factoids:

  • In 71% of cases, the patient was transported to a hospital. In one quarter of cases, they were evaluated but not transported. 1% were dead on arrival, and in 2% no patient was found at the scene (!)
  • 4% of patients were transported in rural zip codes, 88% in suburban ones, and 8% from urban locations
  • Overall response time averaged 7 minutes
  • Median response times were 13 minutes for rural locations, and 6 minutes for both suburban and urban locations
  • Nearly 1 in 10 patients waited 30 minutes for EMS response in rural locations

Bottom line: There is an obvious difference in EMS response times between rural and urban/suburban locations. And there are many potential reasons for this, including a larger geographic area to be covered, volunteer vs paid squads, etc. Many of these factors are difficult, if not impossible to change. The simple fact that it takes longer to reach these patients increases their potential morbidity and mortality. Remember, time is of the essence in trauma. The patient is bleeding to death until proven otherwise. It is far easier and cost-effective to equip bystanders with the skills to assist those in need (basic first aid, CPR, Stop the Bleed, etc) while waiting for EMS to arrive.

Reference: Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas.  JAMA Surg 152(10): 983–984, 2017.

The July 2020 Trauma MedEd Newsletter: ATLS In The COVID Age

The July Trauma MedEd Newsletter is now available! It provides information on producing an Advanced Trauma Life Support (ATLS) course in the times of the Coronavirus. It describes how to adhere to various safety guidelines and details the technology needed to pull it off.

Topics covered include:

  • In-Person Education And COVID
  • The Planning Phase
  • The Equipment
  • Execution
  • Post-Course Evaluation

Subscribers received this issue last week.  If you want to get your copy earlier than most, subscribe now  by clicking this link right away to sign up and/or download back issues.

And please send me your comments, updates, or tips you have found helpful at your hospital! I’ll include them in the next newsletter.

To download the current issue, just click here! Or copy this link into your browser: http://bit.ly/TME202007.

Trauma Education In The COVID Age

Trauma education has gotten significantly more difficult in the face of the Coronavirus. In-person education offerings like ATLS and PALS courses, TNCC courses, and major trauma conferences are routinely being cancelled or delayed. And many of them have decided to move to a virtual format.

Until early this year, I traveled around the country as a speaker for numerous trauma education conferences. The bulk of these have been cancelled for the remainder of the year. A few have opted to try an online format, and I will be giving several online talks in the coming months.

The American Association for the Surgery of Trauma (AAST) has converted their physical meeting in Hawaii to a virtual one (sigh). I will definitely be participating anyway!

Here are two conferences I will be speaking at, using the new virtual format. If you are in need of some quality education, check them out:

Virtual Excellence in Trauma Care Conference
Intermountain Medical Center – Salt Lake City UT
September 17-18, 2020
Presentations:
1. Keynote Address: Massive Bleeding Associated With Pelvic Fractures
2. Trauma Mythbusters
Registration Info: click here
Brochure: click here

Stormont Vail Trauma Symposium
Stormont Vail Hospital – Topeka KS
October 16, 2020
Presentations:
1. New Trends in Trauma
2. Mobility of the Trauma Patient in ICU
Registration and brochure: available soon

And if your hospital or organization is interested in putting your own grand rounds or other educational conference together, I am now focusing on providing presentations via telepresence.

Please check out the FAQ on my speaking engagements by clicking here.

Granted, telepresence is not the same as being there in person. It’s so much nicer to meet people in person, and it’s much more satisfying to make that more personal connection. But in-person conferences won’t be in the cards for a while. In the meantime, I hope to see you all soon via WebEx or Zoom! Please reach out!

Vascular And Nerve Injury After Knee Dislocation

There’s lots of dogma in trauma care, as well as in the field of medicine generally. The knee dislocation dogma is that the incidence of vascular injury is high (around 50%) with posterior dislocation, and somewhat lower with non-posterior dislocation.

At least that’s what I learned way back when. After recently finding myself spouting off those numbers, I wondered if it was really true. Our diagnostic imaging and vascular care has increased considerably in the last few decades, so I decided to check it out.

This nice image from EMDocs.net shows the various dislocation types. It also gives you an idea of why an associated vascular or nervous injury is so common.

(The nomenclature of the dislocation is based on the direction the tibia and fibula move with respect to the femur.)

The orthopedic surgery group at UCLA performed a meta-analysis of the literature relating to knee dislocation complications. They identified 7 papers describing the injuries of 862 patients.

Here are the factoids:

  • The overall incidence of vascular injury with knee dislocation was 18%, and nerve injury was 25%
  • The incidence of vascular injury with the various types of dislocation was:
    • Posterior dislocation: 25%
    • Anterior dislocation: 19%
    • Lateral dislocation: 18%
    • Medial dislocation: 7%
    • Rotatory: 14%
  • Disruption of both cruciate ligaments as well as the lateral or medial collateral ligament had a very high incidence of vascular injury (32% and 26% respectively)
  • About 80% underwent surgical repair of the popliteal artery, but the amputation rate was 12%(!)

Bottom line: The old dogma regarding vascular injury after knee dislocation may be a little exaggerated. However, it is still common after knee dislocation, and can lead to devastating complications.

If your patient tells you that they felt a popping sensation in their knee, or if they have a mechanism consistent with knee dislocation (e.g. pedestrian struck), be very suspicious for this injury. A thorough yet gentle exam should be performed, including good neurologic and vascular exams. Calculation of the Arterial Pressure Index (API) may be helpful, but will not keep you from obtaining imaging studies. Multi-plane imaging of the knee is required, and a CT angiogram/runoff study should be performed to exclude a vascular problem.

Reference: Vascular and Nerve Injury After Knee Dislocation: A Systematic Review. Clin Orthop Relat Res 472(9):2621-9, 2014.

The Peri-Mortem C-Section

The perimortem C-section (PMCS) is a heroic procedure designed to salvage a viable fetus from a moribund mother. Interestingly, in some mothers, delivery of the fetus results in return of spontaneous circulation.

The traditional teaching is that PMCS should be started within 4-5 minutes of the mother’s circulatory arrest. The longer it is delayed, the (much) lower the likelihood that the fetus will survive.

The reality is that it takes several minutes to prepare for this procedure because it is done so infrequently in most trauma centers. Recent literature suggests the following management for pregnant patients in blunt traumatic arrest (BTA):

  • Cover the usual BTA bases, including securing the airway, obtaining access and rapidly infusing crystalloid, decompressing both sides of the chest, and assessing for an unstable pelvis
  • Assess for fetal viability. The fundus must measure at least 23 cm.
  • Assess for a shockable vs non-shockable rhythm. If shockable, do two cycles of CPR before beginning the PMCS. If non-shockable, move straight to this procedure.

Bottom line: Any time you receive a pregnant patient in blunt arrest, have someone open the C-section pack while you assess and try to improve the mother’s viability. As soon as you complete the three tasks above, start the procedure! You don’t need to wait 4 minutes! And by the way, this is usually a procedure for surgeons only. They have the speed and skills to get to the right organs quickly. If unavailable, do what you need to do but recognize that the outcome may be even worse than it usually is.

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