Today’s big headlines involve the recognition (finally) that law enforcement officers have risky jobs. But not just in the ways you might think. Sure, they frequently deal with criminals who have ill intent or deadly weapons. But some of the risks they face can be mitigated by simple actions.
Here are some factoids:
- 42% of police officers killed in auto crashes were not wearing seat belts
- Overall seat belt compliance among law enforcement officers is about 50%, whereas the general public’s compliance is 86%
- 36% of officers killed are not wearing body armor
Unfortunately, a culture has developed among law enforcement (and prehospital / EMS professionals) that seat belts are not necessary (for them). The sad truth is that these professionals are at much higher risk for injury, especially in car crashes, because they must drive faster and in more stressful situations on a regular basis. And police officers (especially in the US) are more and more often confronted with firearms.
Why on earth would they not want this simple protection? Body armor is hot, unwieldy and uncomfortable, especially in warm weather climates. And police officers complain that seat belts complicate getting out of their vehicles, and can get snagged on their utility belts and uniforms.
A number of major police departments and police unions are now pushing for mandatory requirements for seat belts and body armor use at all times. There is now broad recognition that using these devices may cut fatalities in half. Agencies are beginning to check body armor at roll call, and random checks are sometimes performed on the streets by inspectors.
Unfortunately, we need to recognize this problem in EMS as well. And the culture there needs to change, so that protecting the trauma professionals becomes as important as helping the patients that they treat.
Reference: Characteristics of Law Enforcement Officers’ Fatalities in Motor Vehicle Crashes. US Dept of Transportation – National Highway Traffic Safety Administration, publication DOT HS 811 411.
Extreme Seat Belt Fail:
EMS policy and the trauma center verification process requires that all trauma patients delivered to a trauma center must have a copy of the EMS run sheet. Two parameters that are commonly used to monitor performance improvement (PI) in EMS are:
- accurate record of scene physiology (SBP, HR, RR, GCS)
- request by on-scene BLS for ALS assistance
A study looked at the impact of those criteria on patient survival. A total of 4744 patients from the National Trauma Data Bank were analyzed.
Physiologic data: About 28% had at least one missing physiologic data point, with respiratory rate being most commonly missed. They found that the mortality in the group with missing data was over twice as high (10.3%) as it was in the group with complete date (4.5%).
BLS call for ALS assistance: This assist was called for in 17% of cases. These cases were less likely to involve penetrating injuries and more likely to involve car or motorcycle crashes. Injury Severity Score was the same. Eventual patient mortality was the same for BLS calling ALS and ALS response alone.
So why does failure to record physiologic data translate into higher mortality? The initial response may be that the patient was sicker, and so they needed more intense care during transport with less time to record vitals. However, the researchers controlled for this and found it was not a factor. Other issues that may be a factor are EMS training and proficiency, leadership at the scene and enroute, and available staff and resources, among other things.
The researchers speculate that documentation might be a good global measure of appropriate or inappropriate prehospital care that rolls all of these possible factors into one easily identifiable audit filter. They recommend that this be used to focus performance improvement efforts and hopefully improve survival.
Bottom line: I have visited a number of states where EMS often does not leave their run sheet at all! I recommend that the results of this study be taken to heart and used to help persuade EMS programs to get religious about recording complete vital signs and leaving the run sheet at the trauma center every time a patient is delivered. Documentation should be evaluated regularly, and all cases with any missing vital signs should be reviewed closely. Trauma Center PI programs should work with EMS to analyze this data and look for the patterns that increase mortality.
Reference: Lack of Emergency Medical Services documentation is associated with poor patient outcomes: a validation of audit filters for prehospital trauma care. Journal of the American College of Surgeons, 210(2):220-227, 2010.
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.
CPR has increased the survival rate of patients suffering cardiac arrest, and early bystander CPR has been shown to double or triple survival. The sad truth is that CPR is not frequently performed by the general public. The American Heart Association has attempted to simplify CPR to the point that even untrained bystanders can administer chest compressions without a pulse check and without rescue breathing.
But what happens if that well-intentioned bystander starts CPR in someone who has not arrested? How often does this happen? Can the patient be injured?
The Medical College of Wisconsin reviewed the charts of all patients who received bystander CPR in Milwaukee County over a six year period. There were 672 incidents of bystander CPR. Of those cases, 77 (12%) were not in arrest when assessed by EMS personnel, and the researchers focused on those patients.
EMS response time averaged 5 minutes, and was greater than 10 minutes in only 2 cases. Average patient age was 43(!). The male/female ratio was just about 50:50, and the majority of the incidents took place in the home or residence.
Hospital records were available for further analysis in 72 of the patients. A quarter were sent home, a quarter admitted to a ward bed, and half were admitted to an ICU. Only 12 (17%) had a cardiac-related discharge diagnosis. The next most common discharge diagnoses were near-drowning, respiratory failure and drug overdose. Younger patients (<19) were usually near-drowning victims, and older patients (>54) were most commonly diagnosed with syncope. Five patients did not survive. Only one CPR injury was identified, which was charted as rhabdomyolysis “secondary to having received CPR” (a weak injury diagnosis, in my opinion).
Bottom line: The potential benefit of bystander CPR outweighs the risk of injury or performing it on a victim who is not in arrest. This study shows that, although these patients may not need CPR, they are generally very ill. Given the rapid EMS response times and the younger average age of the victims, no real injuries occurred. The new American Heart Association recommendations are beneficial and should be distributed widely.
Reference: The frequency and consequences of cardiopulmonary resuscitation performed by bystanders on patients who are not in cardiac arrest. Prehosp Emerg Care 15:282-287, 2011.
Every trauma professional knows that seat belts save lives. Numerous studies have borne out the survival benefits of wearing them. But do those same professionals practice what they preach?
A study by NHTSA study showed that at least 42% of police officers killed in car crashes were not wearing their seat belts. The number of officers killed in traffic accidents in 2010 has increased by 43% over 2009 numbers. Possible reasons may be that seat belts impede the process of getting into and out of the car quickly, and that the belt may get tangled in utility and gun belts.
What about paramedics and EMTs? I couldn’t find any studies looking at this group. However, observation tells me that medics in the patient care compartment don’t always buckle up. The reason typically given is that wearing a belt may compromise patient care by limiting access to equipment, using the radio, or performing CPR. However, I think that patient care is even more limited if the EMS professional is disabled or killed in a rig crash. The patient is much more likely to survive such a crash since they are firmly strapped into place.
How can you stay safe in the back?
- Make a commitment to your colleagues (and family) to always belt in
- If appropriate, try to do as much of your assessment and interventions as possible before moving
- Organize your work area so that commonly used and critical equipment is within easy reach
- Use a cell phone for communication if the radio mic is too far away
- If you absolutely do need to unbelt, try to do so only when the rig is stopped at a light or stop sign.
I’m interested in your comments about how common of a problem this really is. Unfortunately, I don’t think NHTSA will be doing any studies on this one.