Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?
For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?
Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%).
Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!
Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.
Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?
A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.
Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.
We’ve been pondering this question for nearly 30 years. In 1983, trauma surgeons at UCLA looked at a number of devices available at that time and tested them on normal volunteers. They measured neck motion to see which was “best."
Here’s what they found:
- Soft collar – In general, this decreased rotation by 8 degrees but insignificantly protected against flexion and extension. Basically, this keeps your neck warm and little else.
- Hard collars – A variety of collars available in that era were tested. They all allowed about 8% flexion, 18% lateral movement, and 2% rotation. The Philadelphia collar allowed the least extension.
- Sandbags and tape – Surprisingly, this was the best. It allowed no flexion and only a few percent movement in any other direction.
The Mayo clinic compared four specific hard collars in 2007 (Miami J, Miami J with Occian back, Aspen, Philadelphia). They found that the Miami J and Philadelphia collars reduced neck movement the best. The Miami J with or without the Occian back provided the best relief from pressure. The Aspen allowed more movement in all axes.
And finally, the halo vest is the gold standard. These tend to be used rarely and in very special circumstances.
- For EMS: Rigid collar per your protocol is the standard. In a pinch you can use good old tape and sandbags with excellent results.
- For physicians: The Miami J provides the most limitation of movement. If the collar will be needed for more than a short time, consider the well-padded Occian back Miami J (see below).
- Efficacy of cervical spine immobilization methods. J Trauma 23(6):461-465, 1983.
- Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. J Trauma 63(5):1120, 1126, 2007.
A number of 9-1-1 calls (quite a few, I am told) are made, not for injury or illness, but because the caller needs help getting back into bed, chair, etc. It is also common that prehospital providers are frequently called back to the same location for the same problem, or a more serious one, within hours or days.
Yet another study from Yale looked at the details of lift-assist calls in one city in Connecticut (population 29,000) during a 6 year period. The town has a fire department based EMS system with both basic and advanced life support, and they respond to 4,000 EMS calls per year.
Some interesting factoids:
- Average crew time was about 20 minutes
- 10% of cases required additional fire department equipment, either for forced entry or for assistance with bariatric patients
- About 5% of all calls were for lift-assist, involving 535 addresses
- Two thirds of all calls went to one third of those addresses (174 addresses)
- There were 563 return calls to the same address within 30 days (usual age ~ 80)
- Return calls were for another lift-assist (39%), a fall (8%), or an illness (47%)
Bottom line: It looks to me that we are not doing our elderly patients any favors by picking them up and putting them back in their chair/bed. Lift-assist calls are really a sentinel event for someone that is getting sick or who has crossed the threshold from being able to live independently to someone who needs a little more help (assisted living, etc). Prehospital personnel should systematically look at and report the home environment, and communities should automatically involve social services to help ensure the health and well being of the elder. And a second call to the same location should mandate a medical evaluation in an ED before return to the home.
Reference: A descriptive study of the “lift-assist” call. Prehospital Emergency Care, online ahead of print, September 2012.
Prehospital providers follow protocols for securing and transporting trauma patients. These may include cervical spine stabilization and short or long backboards. Every once in a while they can’t follow protocol, and in my experience it usually means that something is very wrong.
There are three typical problems leading to nonstandard transport positions:
- Occult airway injury – These patients have either blunt injury to the neck, smoke inhalation, or penetrating injury to the submandibular area. They tend to have problems protecting their own airway when they are supine, so they insist on being transported in an upright position.
- Impalement – Since the general rule is to leave foreign objects in place to avoid potential bleeding, the patient is positioned in an odd way to accommodate both them and the impaling object.
- Life-threatening bleeding – Patients with exsanguinating hemorrhage who are awake tend to insist on transport in certain positions. Most with serious chest hemorrhage complain that they can’t breathe and want to sit upright. Those with severe pelvic fractures complain of pelvic or back pain and may prefer lying on their side during transport.
Bottom line: If prehospital providers bring a trauma patient to you in a non-supine position, be very afraid. If not done already, activate your trauma team. Talk to the medics to find out why they had to use a nonstandard position. Then rapidly assess the patient to rule out life-threatening issues.
One of the critical maneuvers that EMS providers perform is establishing initial vascular access. This IV is important for administering medications and for initiating volume resuscitation in trauma patients. Prehospital Trauma Life Support guidelines state that every trauma patient should receive two large bore IV lines. But is this really necessary?
The upside of having two IVs in the field is that the EMS provider can give lots of volume. However, a growing body of literature tells us that pushing systolic blood pressure up to “normal” levels in people (or animals) with an uncontrolled source of bleeding can increase mortality and hasten coagulopathy.
The downside of placing two lines is that it is challenging in a moving rig, sterility is difficult to maintain, and the chance of a needlestick exposure is doubled. So is it worth it?
A group at UMDNJ New Brunswick did a retrospective review of 320 trauma patients they received over a one year period who had IV lines established in the field. They found that, as expected, patients with two IVs received more fluid (average 348ml) before arriving at the hospital. There was no increase in systolic blood pressure, but there was a significant increase in diastolic pressure with two lines. The reason for this odd finding is not clear. There was no difference in the ultimate ISS calculated, or in mortality or readmission.
Bottom line: This study is limited by its design. However, it implies that the second field IV is not very useful. The amount of extra fluid infused was relatively small, not nearly enough to trigger additional bleeding or coagulopathy. So if another IV does not deliver significant additional fluid and could be harmful even if it did, it’s probably not useful. Prehospital standards organizations should critically look at this old dogma to see if it should be modified.
- Study of placing a second intravenous line in trauma. Prehospital Emerg Care 15:208-213, 2011.