Hare Traction – Putting It On, Taking It Off
Femoral traction devices have been around for a long time. One reader has asked about the timing of removal of these devices after they arrive at the hospital. I learned a number of things while reviewing the literature to answer this question.
Most importantly, there is really only one indication for applying a traction splint to the femur: an isolated, relatively mid-shaft femur fracture. Unfortunately, there are lots of contraindications. They consist of other injuries or fractures that could sustain further damage from traction. Specifically, these include:
- Pelvic or hip fracture
- Hip dislocation
- Knee injury
- Tib/fib, ankle or foot fracture
I did find one interesting study from 1999 that looked at how useful these splints really were. Of 4,513 EMS runs, only 16 had mid-thigh trauma and 5 of these appeared to have a femur fracture. Splint application was attempted in 3, and only 2 were successful. This was the experience in only one city (Evanston, IL) for one year. However, it mirrors what I see coming into our trauma center.
Unfortunately, when it comes to removal, there are very few guidelines out there. My advice is to have your orthopedic surgeon evaluate as soon as imaging is complete. They can help decide whether converting to some type of definitive traction is necessary, or whether it can be changed to a more conventional splint. In any case, the objective is to minimize the total amount of time in the traction splint to avoid any further injury to other structures.
Reference: Prehospital midthigh rauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med, 19:137-140, 2001.
Helicopter EMS (HEMS) transport of trauma patients is used primarily to decrease the amount of time between injury and arrival at the trauma center. Unfortunately, efficacy studies have provided conflicting answers as to whether this is actually true. Last year, the CDC completed a large sample study of this issue using the National Trauma Data Bank (NTDB) in an attempt to determine if HEMS flights are effective.
Using almost 150,000 entries in the NTDB for 2007, they were able to isolate over 56,000 adult records with complete data points. They looked for mortality patterns based on age, injury severity, and revised trauma score, comparing patients who were transported by air vs ground.
They found the following:
- Odds of dying in-hospital were 39% lower overall when transported by helicopter
- This survival advantaged disappeared for patients age 55 and older, possibly because of decreased reserve, comorbidities, more complications, or medications that interfere with successful resuscitation
- Regardless of type of transport, males always fared worse than females
Bottom line: This is a large and intriguing study. About 85% of the US population has access to a Level I or II trauma center within an hour. However, a third of those can only get there in that period of time if transported by air. This mode of transport has a significantly lower mortality rate. However, there are cost and safety considerations as well. The key now is to figure out which patients will have the best outcomes after air transport. This will require more work, looking at more than just mortality (e.g. disability, complications).
Reference: Reduced mortality in injured adults transported by helicopter emergency medical services. Prehospital Emerg Care 15(3):295-302, 2011.
Ambulance 2.0: The “Super Ambulance” of the Future
Lifebot Technology has been working to upgrade the prehospital environment and connect it more closely with trauma professionals in the trauma center. They have done this by developing a so-called “super ambulance.” These ambulances are outfitted with new variations of tried and true technology. This includes a special Hewlett-Packard Slate tablet computer, multiple cameras inside the ambulance, cameras that are wearable by medics, and a state-of-the-art telemedicine system.
The Slate tablet allows for hand-held patient monitoring, GPS positioning, high resolution imaging via its built-in camera, patient medical record charting, and connection to the trauma center base station. At the base, the emergency physician or trauma surgeon can view monitoring information, control any camera in the ambulance to focus in on the action, and even draw on the Slate’s screen to show the crew areas of interest (telestration).
The system is pricey ($50,000 US), but is extremely valuable in rural areas where the nearest trauma center may be quite far away. In theory, a doctor could walk a medic through a procedure to resolve a problem that may kill their patient before they can get to the hospital. The system is already in use in select areas in Arizona, Florida and Texas.
Reference: Displayed at the HIMSS 2011 (Healthcare Information and Management Systems Society) annual meeting, February 20-24, 2011 in Orlando, FL.
Disclosure: I have no financial interest in Lifebot Technology or Hewlett Packard
Fatigue is a major problem for many healthcare providers, from prehospital those working in post-discharge institutions. Some interesting and underappreciated statistics about work-related injuries and shift work:
- Work related injuries increase on off-shifts. Compared to day shift, 15% more injuries occur on evenings and 28% more on nights.
- When working long shifts, there is a 13% increase in injuries after 10 hours, and a 30% increase after 12 hours.
- When working consecutive nursing shifts, there is an 8% increase in injury risk the 2nd night, a 38% increase the 3rd night, and a 70% increase the 4th night.
We know sleep deprivation and fatigue are bad. The laundry list of adverse effects is lengthy and includes confusion, memory problems, depression, weight gain, headache, diabetes, cardiovascular disease, and as we’ve discussed all week, serious performance problems.
What can be done about it? The key is to raise awareness, along with acceptance of the remedies. Many hospital workplaces are doing something about it. Here are some successful interventions that reduce workplace fatigue:
- Authorize a real break system. A break is a 30 minute period which is ideally away from the immediate work setting, where there are no disturbances (phone, pager)
- Ensure effective “handoffs” between co-workers when taking breaks
- Encourage workers to identify fatigue in their co-workers and find ways to decrease it
- Modify schedules to adhere to the Institute of Medicine’s standards
* No more than 20 hours of overtime a week
* Limit the number of 12 hours shifts
* No double shifts
Some workplaces are unfortunately not as progressive, and the work culture takes pride in showing how individuals can “power through” even when tired. Just remember, this is bad for you and bad for your patients. As you grow older, it becomes even more difficult and dangerous. It’s only a matter of time before someone, somewhere goes too far, and they or their patient will end up “dead tired.”
EMS providers across the country are assigned to a variety of schedules, ranging from shift work to continuous 24 hour service. Overnight duty, rotating schedules, early awakening and sleep interruptions are common. Unfortunately, there are not many studies on the effects of fatigue on EMS. I did manage to find an interesting study from last year that I’d like to share.
A group of about 3,000 providers attending a national conference were surveyed using 2 test instruments (Pittsburgh Sleep Quality Index (PSQI) and Chalder Fatigue Questionnaire (CFQ)). The PSQI measures subjective sleep quality, sleep duration, disturbances, use of sleeping meds and daytime dysfunction. The CFQ measures both physical and mental fatigue.
Only 119 surveys were completed, despite the fact that a $5 gift card was offered (not enough?). The most common certification was EMT-Basic (63%) and most had worked less than 10 years. Most were full-time, with most working 4-15 shifts per month. The following demographics were of interest:
- Self-reported good health – 70%
- Nonsmokers – 85%
- Moderate alcohol or less – 62%
- Overweight or obese – 85%
A total of 45% reported experiencing severe physical and mental fatigue at work, and this increased with years of experience. The sleep quality score confirmed this fact. Also of interest was the incidental finding of a high proportion of overweight or obese individuals. Sleep deprivation is known to increase weight, and increased weight is known to increase sleep problems, creating a vicious cycle.
Bottom line: This is a small convenience study, but it was enough to show that there is a problem with fatigue and sleep quality in EMS providers. Federal law mandates rest periods for pilots, truck drivers and tanker ship personnel. The accrediting body for resident physicians has guidelines in place that limit their time in the hospital. Prehospital providers perform a service that is just as vital, so it may be time to start looking at a more reasonable set of scheduling and work guidelines to protect them and their precious cargo.
Reference: Sleep quality and fatigue among prehospital providers. Prehos Emerg Care 14(2):187-193, April 6, 2010.