Tag Archives: prehospital

Prehospital Lift-Assist Calls

September 19, 2012 The Trauma Pro Leave a comment

Here’s something I was completely unaware of until just a few years ago. 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 results:

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.

General

Prehospital Attitudes About Analgesia

September 18, 2012 The Trauma Pro Leave a comment

Pain relief is important for two reasons: it’s the humane thing to do for someone who is suffering, and just as importantly, it assists in the physiologic response to trauma. There are several papers that have shown that prehospital providers may not use pain medications as much as they should. Why would this be?

Researchers at Yale released a paper describing a number of interviews with prehospital providers to get the answers to this question. They did individual and group interviews with five EMS agencies in the states of New Hampshire, Massachusetts and Connecticut. Eight individual and 2 group interviews were conducted, with a total of 15 paramedics in the study.

The results were very interesting and several themes emerged:

There was a reluctance to give opioids unless objective signs were present (deformity, hypertension)
There was a preoccupation that patients might be malingering
Paramedics were not clear on what the pain control target should be (complete relief vs “taking the edge off”)
Fear of masking symptoms with pain medicine
Reluctance to use large doses (e.g. using no more than 5mg morphine)

Bottom line: This study is very small, which is a problem. But it also used face to face interviews, so a lot of information was obtained. It’s hard to say if this work is representative of other agencies or countries, but it is thought provoking. My take is this: trauma hurts like hell. Patients really do need the medication. And they are not going to get addicted from a few doses while enroute to the hospital. Whether the cause of their injury was truly accidental or the result of poor choices, it’s not our place to judge because we don’t know the full story. Give pain medication and be generous. You’re not going to make the symptoms go away. But do use judgment to make sure they keep breathing all the way to the emergency department.

I’m very interested in EMS comments about this study. Please comment or tweet!

Reference: Paramedic attitudes regarding prehospital analgesia. Prehospital emergency care; Online ahead of print, Sep 2012.

General

EMS: Do We Actually Follow the CDC Triage Guidelines?

July 17, 2012 The Trauma Pro Leave a comment

One of the major components of any trauma system is the prehospital piece. These providers extricate, begin medical treatment, and decide where to take the patient. The choice of hospital can make a big difference, and the number of deaths can potentially be reduced by up to 25% by making the right decision. Where to take the patient is not necessarily clear cut, even though CDC guidelines exist to help. Geographic and weather factors can be a factor, as well as patient choice at times (unfortunately), local medical control, or even time of day (traffic).

Harborview and the University of Washington conducted a large retrospective review of the transport patterns for nearly 12,000 injured patients over a 5 year period. They specifically looked at whether CDC guidelines for field triage were being followed. About half were transported to Harborview, the only Level I center in the state. The remainder were transported to the 7 remaining trauma centers, levels III to V. There were a number of interesting findings:

Patients transported directly to the Level I center were more likely to be young, male, injured by a penetrating mechanism, have worse vital signs and GCS and higher injury severity
Older patients were less likely to be transported from scene to a Level I center
The oldest patients were 89% less likely to be transported to the Level I center, either directly or after initial management at a lower level center

Bottom line: For reasons that are not clear, elderly patients were far less likely to be transported to a Level I trauma center by prehospital providers in Washington state. In fact, the guidelines were obeyed only about 50% of the time! Does this happen in other states or countries? We don’t know. Is this a problem? Unfortunately, we also don’t know how much lower the mortality in these patients is when treated at higher level centers. It seems to be, especially in the more severely injured patients. What we do know is that if the guidelines exist, adhere to them unless you have good reason not to. Their life may depend on it!

Related posts:

Reference: Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Amer Col Surg 215(1):148-156, 2012.

General

Trauma Patient Transport By Police, Not EMS

April 20, 2012 The Trauma Pro Leave a comment

When I was at Penn 25 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 group now 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. They found the following interesting information:

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:

Scoop and run vs stay and play

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

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