Tag Archives: EMS

Cool EMS Stuff: The Backboard Washer!

Backboards are made to get messy. And every time your friendly EMS provider brings you a patient, they invariably have to swab it down to give the next patient a reasonably sanitary surface to lie on. But sometimes the boards get downright nasty and the cleanup job is a major production.

Enter… the backboard washer. I recently saw one of these for the first time at a Level III hospital in Ohio. Fascinating! Pop the board inside and seven minutes later it’s clean. And I mean really squeaky clean. You may think it looks clean and a good hand wash, but just take a look at the effluent water coming out of this washer!

These units use standard 100V 20A power and only require a hot water hookup and a drain. They can wash two boards at once.

Hospitals in the know need to locate one of these next to a work area for completing paperwork and some free food. What could be better?

Reference: Aqua Phase A-8000 spec sheet. Click to download.

Trauma Patient Transport By Police, Not EMS

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.

Related posts:

Reference: Injury-adjusted mortality of patients transported by police following penetrating trauma. Acad Emerg Med 18(1):32-37, 2011.

What Is The Safest Extrication Method From A Car Crash?

Today’s post is directed to all those prehospital trauma professionals out there.

Car crashes account for a huge number of injuries world-wide. About 40% of people involved in them are initially trapped in the vehicle. And unfortunately, entrapped individuals are much more likely to die.

There are four basic groups (and their category in parentheses) of trapped car occupants:

  • those who can self-extricate or extricate with minimal assistance (self-extrication)
  • individuals who cannot self-extricate due to pain or their psychological response to the event, but can extricate with assistance (assisted extrication)
  • people who are advised or choose not to self-extricate due to concern for exacerbating an injury, primarily spine (medically trapped)
  • those who are physically trapped by the wreckage who require disentanglement (disentanglement and rescue)

Prehospital providers have several choices to help extricate patients  in the second and third categories: encourage self-extrication, rapid extrication without the use of tools, or traditional extrication where the vehicle is cut away to allow egress. The fourth category always requires tools for extrication.

Although rescue services try to minimize or mitigate unnecessary movement of the patient, stuff happens. Large and forceful movement is considered high risk, but smaller movement do occur. This is of particular concern in patients who might have a spine injury.

There have been a number of recent papers suggesting there might be greater benefits to self-extrication. A group of authors in the UK and South Africa designed a biomechanical study to test these methods of extrication in healthy volunteers.

The authors wanted to find out exactly how much movement occurred using the various extrication techniques. The volunteers were fitted with an Inertial Measurement Unit, which measures the orientation of the head, neck, torso, and sacrum in real time.  The IMU can detect even very small changes in orientation of the body. The volunteers were placed in a standard 5-door hatchback sedans that were prepared for each type of extrication as seen above.

Here are the factoids:

  • A total of 230 extrications were performed for analysis
  • The smallest amount of maximal and total movement of body segments was seen in the self-extrication group
  • The greatest amount of movement was found in the rapid extrication group, with 4x to 5x the movement in the self-extrication group
  • The difference in body movement between the self-extrication group and all others was significant
  • In general, movement increased as extrication techniques progressed from roof removal to B post removal to rapid extrication

The authors concluded that self-extrication resulted in the smallest amount of movement and the fastest extrication time, and that it should be the preferred technique.

Bottom line: This is the first study that specifically evaluated spinal movement occurring with commonly used extrication techniques. Other similar studies have used a variety of measurement techniques, none of which are as precise as this. One potential weakness with this one is that it used healthy volunteers. But obviously, it is not practical to attempt anything like this with real, injured patients. 

Since we know that patients trapped in cars are more likely to die, time is of the essence. This study shows that self-extrication is both fast and safe with respect to spinal movement. The information will assist our prehospital colleagues in making the best decisions possible when faced with patients trapped in their car.

Reference: Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers. Scand J Trauma  open access 30: article 7, 2022.

Uber / Lyft For Medical Transport???

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?

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?

Pros:

  • 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

Cons:

  • 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

A very interesting paper suggests that ambulance service calls decreased by 7% after the introduction of UberX rides.  The authors mapped out areas where UberX rides were launching, and examined emergency response data in these areas. They used a complex algorithm to examine trends over time in over 700 cities in the US, and used several techniques to try to account for other factors. Here is a chart of the very fascinating results:

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!

Reference: Did UberX Reduce Ambulance Volume? Health Econ 28(7)L817-829, 2019.

Trauma Activation vs Stroke Code

Let’s look at an uncommon scenario that crops up from time to time. Most seasoned trauma professionals have seen this one a time or two:

An elderly male is driving on a sunny afternoon, and crashes his car into a highway divider at  25 miles per hour. EMS responds and notes that he has a few facial lacerations, is awake but confused. They note some possible facial asymmetry  and perhaps a bit of upper extremity weakness. No medical history is available. Witnesses state that he was driving erratically before he crashed. Medics call the receiving trauma center in advance to advise them that they have a stroke code.

Is this a reasonable request? Stroke centers pride themselves on the speed of their stroke teams in assessing, scanning, and when appropriate, administering thrombolytics to resolve the problem. But if there are suspicions of stroke in a trauma patient, which diagnosis wins? Trauma team or stroke team?

Lets analyze this a bit further, starting with diagnosis. Remember the first law of trauma:

Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.

Could the symptoms that the paramedics are observing be due to the car crash? Absolutely! The patient could have a subdural or epidural hematoma that is compressing a cranial nerve. There might be a central cord injury causing the arm weakness. His TBI might be the source of his confusion. The facial asymmetry could be due to a pre-existing Bell’s palsy, or he could have had a stroke years ago from which he has only partially recovered.

If the stroke team is called for the patient, they will focus on the neuro exam and the brain. They will not think about trauma. They will follow the patient to CT scan looking for the thing that they do best with. If they don’t see it, the patient will return to the ED for (hopefully) a full trauma workup. If there are occult injuries in the abdomen, then the patient may have been bleeding for an hour by then. This elderly patient will then be way behind the eight ball.

And let me pose the worst case scenario. The patient is taken to CT by the stroke team, and lo and behold he has a thrombotic stroke!  This patient had a stroke, which caused him to lose control of his car and explains most of his findings. Again, the stroke team will do what they are trained to do and give a thrombolytic. They are still not thinking about trauma. Within minutes the patient becomes hypotensive and his abdomen appears a bit more distended. He is rushed back to the ED (remember, no CT in hypotensive patients even if you are in the scanner) and a FAST exam is very positive for free fluid throughout the abdomen. Imagine the look you will get from the surgeon as they run to the OR to perform a splenectomy on this fully anticoagulated patient!

Bottom line: If you have a patient who is trauma vs stroke, trauma always wins! Remember the first law and try to find traumatic reasons for all signs and symptoms. Perform your standard trauma workup and incorporate the appropriate head scans into your evaluation. Then and only then should the stroke team be called.