Category Archives: General

Are We Wasting Valuable Helicopter EMS Resources?

March 13, 2015 The Trauma Pro Leave a comment

The use of helicopters for transporting injured patients dates back to World War II. Thirty years later, this concept was translated into civilian practice. Today, there are hundreds of helicopter EMS (HEMS) services across the US, and thousands world-wide. Unfortunately, the indications for using this service are not strictly defined, and it is very expensive compared to ground EMS transport. In the US alone, there are over 400,000 HEMS transports per year. This creates the opportunity for use in patients who are not seriously injured, as well as the potential for wasted resources.

The University of Arizona at Tucson examined 6 years of transport data to their center, by both ground and air. They were interested to see if they could identify a group of HEMS-transported patients that could have safely and more reasonably been transported by ground ambulance. They defined this group of “minimally injured” as having an injury severity score (ISS) of 5 or less.

Here are the factoids:

A total of 5,202 patients were transported, 19% by air and 77% by ground
Overall, the hospital length of stay was significantly longer for HEMS patients (3 vs 2 days), as was ICU length of stay (2 vs 1 days) [Hmm..]
ISS was significantly higher in the HEMS group as well (9 vs 5) [Hmmmmm…]
There was [of course] no difference in mortality between the two groups
By their definition, 28% of HEMS patients were minimally injured, compared to 39% of ground transfers
The average charge for a HEMS transport was $18,000

Bottom line: This is another paper that just doesn’t deliver on what it’s title suggests. But this one is an underestimation of the result, not an overestimation, for once. From personal experience, I see lots of examples of patients who don’t need air transport but get it anyway. But if you dive more deeply into the data in this paper, you can see why it’s just not good enough. Sure, they’ve got a lot of patients. But if you look at the clinical reality of the numbers, none of the patients were really that sick. The maximum ISS in the HEMS group was 17! The GCS for every patient in the study was 14 or 15. The maximum hospital LOS was 7 days. And the clinical significance of a 3 day vs a 2 day hospital stay is negligible.

These were just not very sick patients. It looks to me like none of their patients needed HEMS transport, other than for extreme distance issues. The authors needed to set a better definition of minimally injured patients, and if they had, they would have found that most of their HEMS transfers could have been shifted to ground ambulance.

This paper really points out (more than the authors anticipated) the potential resources being wasted. There are already some suggested rules for optimal use of HEMS. But unfortunately, we tend to ignore them! It’s time to start a concerted effort to more wisely use this valuable and expensive resource.

Related posts:

Reference: Overuse of helicopter transport in the minimally injured: a health care system problem that should be corrected. J Trauma 78(3): 510-515, 2015.

General

A Cool Way To Look At Injury Data

March 11, 2015 The Trauma Pro Leave a comment

Governmental agencies everywhere collect trauma related data. The US federal government maintains a number of databases, such as the Fatal Accident Reporting System (FARS), the Census of Fatal Occupational Injuries (CFOI) and many others. States collect similar but smaller datasets. Even towns and municipalities collate injury information in the form of prehospital run sheets.

But reams of data are of no use unless you can learn something from it. Unfortunately, most of this data is tucked away in database management systems, or in some cases just stacks of paper forms locked up somewhere. In order for humans to make sense of it and do useful things with it, we need to transform it into forms that we can easily interpret and make sense of.

Fortunately, there are lots of visual, electronic tools available to help us do just that. One of the most helpful tools is the programmable geographic information system (GIS). An example of this is Google Maps. Most of us have used this or a similar tool in some form, usually to get directions from here to there. But you may not be aware that Google provides a programming interface so a savvy user can place any type of geography-related data on the map, creating what is called a mashup.

Imagine crossing the FARS database, which contains extensive data points on every fatal road accident in the US, with a mapping system. This would allow creation of a map showing where every person lost their life in a road accident, along with additional pertinent information about the event. A great example of this is demonstrated below. It was created by ITO World Ltd., based in the UK. They crossed fatality information with geographic map data in both the US and the UK.

This map shows fatal road events around Minneapolis from 2001 to 2009. The type of event (pedestrian struck, motor vehicle crash, etc.) is displayed along with age, year and sex. It is movable and zoomable so it can be viewed it in great detail. Click on the map above to open a new window to the full map.

Bottom line: Using trauma data / map mashups is a great way to visualize complex information. It also allows us to plan meaningful prevention activities based on local information (a requirement for ACS trauma center verification). Imagine looking over such a map of your city, and identifying a cluster of pedestrian fatalities. Then you notice that this cluster is 2 blocks away from an elementary school. This could prompt you to work with the school to implement automobile awareness programs for the children, have the city review signage and obstructions to view in the area, and optimize the number and placement of crossing guards. Then redo the map afterwards to judge the impact. Wow!

Website: http://map.itoworld.com/road-casualties-usa#fullscreen

Reference: Using geographic information systems in injury research. J Nurs Scholarsh 39(4):306-311, 2007.

General

Conservative Management Of Pancreatic Injury

March 10, 2015 The Trauma Pro Leave a comment

There has been a slow shift toward nonoperative management of many injuries that used to demand a quick trip to the operating room. Liver and spleen injury is one of the best examples, with extremely good success rates (95%). Kidneys fall into this category, too.

The pancreas is another solid organ. Perhaps we can do the same thing? A number of pediatric surgeons have been attempting to manage children with pancreatic injury. Low grade injuries (principally contusions) have been managed expectantly for some time. Could higher grade injuries (duct injury) be managed this way as well? How about using repeat imaging, percutaneous drainage, stenting via ERCP, and TPN to avoid the OR in hemodynamically stable kids?

A recent paper looks at this practice critically. Nine years of registry data at two Level I pediatric centers was reviewed to identify all high grade (III-IV) pancreatic injuries. They isolated 39 children with this injury (which is quite a few!). They were separated into two groups based on initial management plan, operative (15) or nonoperative (24). Here are the results of interest (all statistically significant):

Average ISS was higher in the nonop group (23 vs 15)
Hospital length of stay was longer in the nonop group (28 vs 15 days)
TPN was required for a longer period in the nonop group (22 vs 8 days)
There were more complications in the nonop group (17 vs 4 children), with 13 developing a pseudocyst (none in the op group)

Bottom line: Nonoperative management of high grade pancreatic injury in kids is just not ready for prime time. It may seem that avoiding a big abdominal operation would be a good thing. Distal pancreatectomy usually keeps children in the hospital for 5-7 days, and then they are done unless they have other serious injuries. Nonoperative management results in a lengthy stay in the hospital, multiple imaging studies (radiation), getting stuck with big drainage needles, and TPN with its attendant infection risks. The old fashioned way, going to the OR, is still the best!

Related post:

Pancreatic injury case

Reference: Non-operative management of high-grade pancreatic trauma: is it worth it? J Ped Surg 48:1060-1064, 2013.

General

How Long Are Trauma Patients At Risk For VTE?

March 9, 2015 The Trauma Pro Leave a comment

Venous thromboembolism (VTE) and its complications are one of the banes of the trauma professional’s existence. Trauma centers have initiated extensive systems of risk assessment, screening, prophylaxis, and treatment of patients at risk for this problem. But typically, much of this management ends at or shortly after discharge from the hospital.

How long do we need to worry? Some trauma programs continue prophylaxis on at-risk patients until they are ambulating well, or for an arbitrary period of time, like one month. But until recently, we’ve had no guidance based on actual numbers. A California study may shed some light on this gray area.

A large dataset from a state of California hospital discharge database was massaged, looking at 6 years of data from patients at the highest risk for VTE (injuries of the pelvis, spine, and spinal cord). The authors looked forward in time after the initial discharge to see if there were any future admissions for VTE and its complications.

Here are the factoids:

Patients with spinal cord injury had the highest risk of VTE, pelvic fractures were mid-range, and vertebral fractures the lowest risk.
Occurrence of VTE was associated with a significant risk of mortality, but it was not possible to determine why.
In all groups, the risk of VTE remained for the first 3 months after injury, then declined rapidly.
VTE risk returned to the level of the general population after about 12 months in patients with pelvic and vertebral injuries.
VTE risk in spinal cord injured patients followed a similar curve, but never completely returned to the population baseline.

Bottom line: Obviously, this is not a clinical study. But it’s size and duration is unprecedented and provides valuable information anyway. This information calls into question our existing treatment intervals for prevention of VTE. However, it does not provide real and actionable guidance yet. Additional clinical studies will be needed to parse out the best drugs and duration of treatment.

Related posts:

Reference: Can we ever stop worrying about venous thromboembolism after trauma? J Trauma 78(3):475-481, 2015.

Home of the Trauma Professional's Blog