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 ARCHIVES
TRAUMA-LISTPREHOSPITAL
CARE |
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Scene Photography
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From: John Warwick Dear Listmembers Would it be realistic to assume that having a photograph which shows damage to a vehicle involved in an MVC (MVA/RTA) conveys more information to hospital staff about the forces that acted upon the patient than would normally be gained via a verbal description given by the paramedics? If this is the case is there any evidence to support this notion? To save re-inventing the wheel I have a few questions for the list. 1) Does anyone have any experience of using photography (digital or Polaroid) as a means of recording damage to vehicles following an MVC it injury to passenger/driver/pedestrian/rider? 2) Are these photographs given to the receiving physicians/surgeons at the hospital? 3) Is there any evidence available that scene photographs in any way influence medical staff in their treatment of the trauma patient? 4) Have any studies been conducted that look at EMT or Paramedic accuracy at interpreting the mechanism of injury based solely on looking at photographs along with a brief scenario? I require as much information as possible, particularly from outside the UK, for my degree thesis so any input would be invaluable. Thanks to all John Warwick REMT-P London
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From: Daniel Cullinane I once worked at a hospital as a resident, where the paramedics would bring a Poloroid photo of the vehicle in with the patient. Although Ifound it interesting to see the vehicle, I think that it had little effect on our treatment or evaluation of the patient. I don't know of any data on the subject Dan
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From: Lucas van Rossem John, For some years the nurses in our EMS system have the possibility to make Polaroid pictures. Especially when the mechanism was high energy, or when the car is badly damaged, a picture can say more than a thousand words. Some doctors, mind you only a few who are not properly trained, sometimes think that carrying in a patient with no apparent injury is not a good action,.... until they see the picture of the remnants of the car. These pictures can remain with the patient in his or her files, No serious research has been done on the issue, but it seems as a perfect teaching tool for the in-hospital staff. Lucas G. van Rossem, RN
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From: Massey
Beveridge There were a few notes on this topic a month or two back. Seems the american hospital that tried it stopped when they found people were keeping some of the gorier photos for their private collections. As a trauma team leader it is vital to have a fast and concise description of the collision scene from the paramedics but I can read injuries off the patient much faster and more accurately than I can from a photo of the car. Minutes spent taking photos of the wreck, processing them (remember even digital and polaroid photos take time to process), then interpreting them would better be spent getting the patient to the trauma centre and diagnosing him. It is reminescent of a discussion about ballistics that took place here: detailed knowledge of mechanism is much less use than detailed knowledge of injuries and this is best gained examining the patient. Sure I can imagine sitting around in the CT scanner afterwards gawping at the photos of the wreck out of vicarious interest but I doubt I'd waste much time on them before I had a stable, diagnosed patient. As for the police/insurance type issues our police already take very detailed photos of the scene and have a professional photographer who knows how to include all the important stuff. He may spend an hour making sure he has a good photographic record. Paramedics already have their own very specialized work to get on with and shouldn't clutter their plates with scene photography. Massey Beveridge MD FRCSC
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From: K.P. Coolidge << To save re-inventing the wheel I have a few questions for the list. 1) Does anyone have any experience of using photography (digital or Polaroid) as a means of recording damage to vehicles following an MVC it injury to passenger/driver/pedestrian/rider?>> Yes.....and many of us in New Hampshire have been doing it for 10 - 15 years, thouugh not all EMT's/services do it consistently. I have also found that most of the people who do this have attended PHTLS courses. <<2) Are these photographs given to the receiving physicians/surgeons at the hospital?>> Yes, however, when the hospital keeps them they are subject to becoming a permanent part of the record, so it's important to make sure there are no "model releases" necessary. We simply try to get only the vehicle(s) and not people in the shots. There *are* ED's here who don't want to keep them...they just want to see them and we can accomodate either way. When we *do* keep them with the EMS service/department here, we do not attach the photographs to the PCR (Patient Care Record). We simply bring them back to quarters and attach them to an "Internal Memo/Incident Report", which is filed next to the PCR. Thus, so we have been told, the pictures remain confidential within the department and are not subject to subpoena (the JD's on the list can verify or debunk...please!). <<3) Is there any evidence available that scene photographs in any way influence medical staff in their treatment of the trauma patient?>> Personally, I can only offer anecdotal evidence, and the answer from me is a resounding YES. The look of amazment on the faces of the staff is well worth the effort on behalf of the patient AND the crews....particularly when we bring in a patient who looks like nothing is wrong and we have activated the Trauma Team based on MOI (Mechanism of Injury). Instead of blowing us off and chalking the high status designation assigned to the patient as the crews "tweaking", they tend to take our report a lot more seriously. Again, anecdotally, there have been 10 - 15 times in my career when "slow" bleeds and other injuries whose symptoms were time dependent have been found alot sooner than they might have been with the patient sitting in a "non-critical" bed for 15-30 minutes after drop-off, particularly abdominal, splenic and sub-dural head bleeds. For more definitve research access/information, might I suggest you look to the Docs involved with the American College of Surgeons (particularly those who helped write the NAEMT/PHTLS and the ACS/ATLS textbooks)?? Additionally, try finding Dr. Richard (Robert?) Hunt of Eastern Carolina University (North Carolina). I attended a lecture by Dr. Hunt a couple of years ago where he was advocating the use of photographic "evidence" in this exact arena....I am sure he would be able to help you. << 4) Have any studies been conducted that look at EMT or Paramedic accuracy at interpreting the mechanism of injury based solely on looking at photographs along with a brief scenario?>> Probably won't qualify as a scientific study, per se - but, a great many Instructors use this technique in teaching, including myself. In my courses, as well as others, the ability to look at photographs and accurately describe the likely injury patterns based on the visual mechanisms, is of great use when trying to get students to understand Kinematics and its relationship to same. Scene photographs taken on our actual calls (no identifying marks left, as it were) prove useful for discussion and the students are normally quite accurate regarding the patient's injuries, once they grasp the relationships between MOI and Kinematics, as diagnosed/treated by the ED/Surgeons post incident. (My favorite as a student many moons ago was a chest shot of "Positive FORD Sign" - an old photo, but still accurate in its intent. It showed the steering wheel hub design bruised onto the chest wall of a patient - the letters D R O F in the reverse from the column. Unfortunately, I couldn't talk my Instructor into parting with a copy of it, or I would send it to you. << There were
a few notes on this topic a month or two back. Seems the american
hospital that tried it stopped when they found people were keeping
some of the gorier photos for their private collections. As for the police/insurance type issues our police already take very detailed photos of the scene and have a professional photographer who knows how to include all the important stuff. He may spend an hour making sure he has a good photographic record. Paramedics already have their own very specialized work to get on with and shouldn't clutter their plates with scene photography.>> With all due respect to the Doc, the field personnel who use this (at least in my near 20 years of experience in the field) do NOT waste time taking the photographs and ignore patient care. There is , more often than not, someone designated on the service/department (the Fire Photographer, for instance) who is not involved in same, nor the extrication of same, who takes these in about 15 seconds and simply hands them to the crew at transport. To dealy patient care and transport for sake of getting the pictures would be wrong, but I have never seen it done. As for the few bad apples who choose to use this stuff for sensationalism, I can only say that the "chain of evidence" should have been tighter and those without a need to know should not have access without authorization, and only for educational purposes, IMHO. Good luck with your project. (To the list, sorry to have been so long winded) Respectfully, K.P. Coolidge NREMT-P:
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From: Tim Erskine I can't disagree with your opinion of scene pictures' usefulness but there is one thing I'd like to point out: Polaroids and digital cameras develop pictures on their own without having to hold still or use chemicals or wave magic wands, therefore, a quick point-and-shoot picture shouldn't take more than 2 seconds. These pictures are usually (at least around here) taken by fire or EMS personnel who are not currently loading the patient into the ambulance, so no time is wasted whatsoever. Further, nobody stops to analyze the picture when they've actually seen the wreck itself. And if it didn't come out, oh well, it's not required, just an additional tool. So basically, the "waste of time" arguement doesn't hold water. Now if you want to tell me that it's a waste of money because nobody utilizes this tool (which apparently you don't, and that's OK), then I'll reconsider my scene photography activities. Tim Erskine, EMT-P
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From: Eric Frykberg << Sure I can imagine sitting around in the CT scanner afterwards gawping at the photos of the wreck out of vicarious interest but I doubt I'd waste much time on them before I had a stable, diagnosed patient. >> I totally agree with this--please, once again, listen to the docs who actually evaluate trauma--and have successfully been doing it for years? Such pictures have NO value in treating a patient, as entrancing a notion as it may seem to those who have never had to take responsiblility for such a patient? As is true of CT, MRI. angios, PET scans, etc etc, pretty pictures have no correlation with real diagnostic or therapeutic benefit! Please, I'd love to hear the evidence of value from any who may disagree?
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From: Thomas J. McGuire << John: Here're three items that may help. Prehosp Emerg Care 1997 Apr-Jun;1(2):76-9 OBJECTIVES: The study was conducted to determine whether the use of prehospital instant photography of motor vehicle crashes (MVCs) by paramedics altered receiving physician (RP) perception of the magnitude of crash severity, as compared with verbal reports of vehicle damage. In addition, the study sought to determine whether altered RP perception resulted in any subsequent changes in emergency department (ED) management. METHODS: A prospective questionnaire and retrospective chart review were used at a Level I suburban trauma center receiving MVC patients from a single municipal paramedic agency. Patients injured in MVCs who required advanced life support (ALS) interventions and were subsequently evaluated by either surgical residents, emergency medicine residents, or attending emergency physicians in the ED were eligible for study enrollment. Instant photographs of interior and exterior vehicle damage were obtained by paramedics who then provided a verbal report of vehicle damage to the RP. Initially blinded from the photographs, the RP was then asked to rate the severity of the crash based on the verbal report and list planned interventions (laboratory tests, blood products, radiographs, and probable patient disposition). The RP was then shown the crash photographs and once again asked to rate the crash severity based on the addition of the photos and list changes in patient management based on any alterations in his or her perception. Hospital records were then examined to determine costs billed to patients and the length of hospital stay for those patients who were admitted. RESULTS: Instant photographs resulted in changes in physician perception in 47% (27 of 58) of the cases. Eighty-five percent of these physicians rated the MVC as more severe than the verbal report had indicated (p < 0.05 by multiple and logistic regression). The RPs who did alter their perceptions based upon the addition of MVC photos then changed their ED management in 59% (16 of 27) of the cases. Patients whose crash photographs altered RP perception of crash severity and who were subsequently released from the ED had average ED costs of $686, as compared with average ED charges of $595 for released patients whose crash photos did not alter physician perception of crash severity (p > 0.05 by Student's t-test). Inpatient charges and lengths of stay were also similar between the two groups for admitted patients: $21,363/14 days for the perception-change group and $24,726/8 days for the no-change-in-perception group (p > 0.05 for all comparisons). CONCLUSION: The augmentation of verbal paramedic reports with prehospital instant photographs frequently altered both physician perception of MVC severity and subsequent ED management of these trauma patients. However, cost to the patient and length of hospital stay were not significantly altered as a result of the change in physician perception. Photograph documentation of motor
vehicle damage by EMTs at the scene: a prospective multicenter
study in the United States. The purpose of this study was to determine if emergency medical service (EMS) personnel could take instant photographs of motor vehicle damage at crash scenes depicting the area and severity of damage of the crash under adverse weather conditions, in different lighting, and quickly enough so as not to interfere with patient care. This prospective multicenter trial involved 35 ambulances responding to motor vehicle crash scenes in rural, suburban, and urban areas in five centers in four states. Emergency medical technicians (EMTs) reported their experience implementing a protocol for use of an instant camera to photograph vehicle damage at crash scenes. Time reported by EMTs to take the photographs was 1 minute or less in 204 of 288 (70.9%) of motor vehicle crashes and 2 minutes or longer in 12 of 288 (4.2%) of motor vehicle crashes. From one EMS agency in the study, 48 scene times during which photographs were taken were, on average, 1.5 minutes shorter than 48 scene times immediately before implementation of on-scene crash photography. Photographs were taken in different weather and lighting conditions. EMTs reported they were able to determine both area and severity of damage in 260 of 290 (92.5%) crash photographs, but they were unable to determine area and severity of damage in only 2 of 290 (0.7%) crash photographs. Ann Emerg Med 1993 Apr;22(4):651-656
STUDY OBJECTIVE: To determine whether emergency medical services (EMS) run reports adequately document vehicle damage when compared with vehicle photographs by using a traffic accident scoring system. DESIGN: A prospective study consisting of three phases: photographing motor vehicle collisions and collecting their respective EMS run reports, traffic accident damage score development, and comparison of photographs to the run reports by emergency medical technicians using the traffic accident damage score. SETTING: Data were collected in North Carolina and Ohio from motor vehicle crashes to which nine different EMS squads responded during a three-year period. TYPE OF PARTICIPANTS: EMS squads ranged from basic to paramedic levels of training. MEASUREMENTS AND MAIN RESULTS: Three emergency medical technicians were unable to determine the area of vehicle damage in 48% and the severity of damage in 61% of the EMS run reports. In contrast, there were no instances in which all three emergency medical technicians were unable to determine both area and severity of damage from the photographs. CONCLUSION: Most EMS run reports do not document vehicle damage adequately. |
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From: Eric Frykberg << MVC severity and subsequent ED management of these trauma patients. However, cost to the patient and length of hospital stay were not significantly altered as a result of the change in physician perception. >> Thanks for this study confirmation of
what I've been aware of for years--I have no argument that perceptions
may change--just our managment that does not, and should not
<< Personally, I can only offer anecdotal evidence, and the answer from me is a resounding YES. The look of amazment on the faces of the staff is well worth the effort on behalf of the patient AND the crews. >> Again--how sensational a picture is has NO correlation with its actual diagnostic or therapeutic value--sure, they're "neat-o", but believe me--of no medical value. Note how the only people who seem to think and conjecture some value are those who do not have to definitively care for these patients... ERF
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From: Richard Wigle A good portion of the time a polaroid will probably be of little value but in the seemingly uninjured patient it can alert the team to look for occult injuries that might otherwise initially go unsuspected. Additionally, when the patient is referred up the line to a trauma center, it is the only first hand evidence they are going to see as to what really happened and, I think, in a truly busy emergency department, may help extract the patient with potential serious injuries from the mass of humanity flowing through the facility R Wigle MD FACS LTC
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From: Eric Frykberg A typical explanation, Richard, but I usually look at the patient, not pictures, to determine triage priorities--and we generally always have an account of the circumstances of the crash to help Interestingly, this has always worked It's not that pictures are not informative--it's that they are unnecessary once you have a patient in front of you
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From: Gordon Buduhan There is an article in the 1989 J. Trauma Vol. 25 No. 5 - "Trauma Triage: Vehicle damage as an estimate of injury" by Jones I.S. and Champion H.R. which may be of interest. They correlate amount of crush (measured in inches) to vehicle velocity changes, where a change in velocity greater than 20 mph in frontal collisions and greater than 15 mph in lateral collisions would indicate transport of patients to a trauma center. Of course, they mention that triage decisions based on vehicle damage would be made after consideration of physiologic parameters at the scene. Patients who appear hemodynamically stable at the scene may harbour occult injuries and degree of vehicle damage may lower one's threshhold for aggressive investigation. This is an interesting concept, but it seems impractical for use in emergent evaluation of trauma patients (in my extremely limited experience!). Gordon Buduhan
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From: Pret Bjorn Tom, A nice review, thanks for taking the time. I ran a couple of MedLine queries and have little to add (such is instructive of how little this idea has been studied). I'm less prepared than Eric and others to dismiss the usefulness of Polaroids offhand, but have to admit that these articles don't prove much. In all three papers the sample size is pretty small and the methodology is shaky, IMHO. Not to mention the fact that articles 2 & 3 were produced by the same principle investigator. Empirically, one would think that the more history you have in hand, the better (see also "wound ballistics"). One might also assume that a multimedia history is more "complete" than a conventional verbal report. "Effectiveness" is a whole other question, however, and proving as much is a neat trick. Here's my two cents: sophisticated, experienced, methodical trauma care systems and providers probably do fine without pictures. In less mature or sophisticated systems, photos serve to impart a respect for the disease where it otherwise may be lacking. Because modern cars tend to suffer more visually striking damage than 20 years ago, the net effect is usually positive; that is, the receiving physician experiences a "wow" effect, which results in his or her enhanced clinical diligence. The benefit of the pictures, therefore, is not as much clinical as motivational. Now go prove THAT. Just a theory, just mine. I can't figure out if I need more coffee, or less.
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From: Jack Lichter Just my two cents worth from a veteran lurker. Since none of you know me, just to put my comments into some sort of context, my background includes: Land Ambulance Manager, Nurse Practitioner responsible for both trauma and Public Health in the Canadian Arctic, Education, Epidemiology, Injury Prevention and currently Health Policy. I guess if the sole purpose of "scene photography" was to alter/improve the care and management of individual trauma cases then your right! The critical decisions have mostly been made and commited to by time you get to look at pictures. If, on the other hand, trauma specialists are at all interested in the larger picture (including the prevention of incidents that bring trauma to their unit) then scene photography can very valuable epidemiological tool. It really all depends on your parameters of interest. Think of how seatbelts, lapbelts and airbags have altered the kinds of trauma you all see and what you look for. These are the obvious ones. Perhaps pictures could show injury patterns and mechanisms you haven't thought of that might be instructive to trauma specialists. HMMMmmm!
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From: Eric Frykberg I agree with this wholheartedly--Thanks!
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From: Alastair Wilson Several Accident Research Centers use standard digital imaging to determine the nature of pedestrian impacts. Given dimensions of victim and Young's modulus for particular parts of a particular cars anatomy (and doubtless lots of physics and mechanics), the accident events and injuries sustained may all be related. Accurate evaluation of what causes injury is essential for designing more pedestrian friendly cars. "No dent without a cause" would appear to be the maxim. I suppose we should never discard evidence, be it for future accident prevention use or for bringing a touch of reality (helpful or otherwise to the ER). The absence of any known relationship between standard digital photographs and improved outcomes or increased early pick up rates of occult injury asks for a RCT, not categorical negativity. Dents and DROF signs might carry a greater significance than we realize. The problem has to be knowing the significance of all the bends and bumps and interpreting them without car model details and the brain of a mechanical engineer. Perhaps we should stick to Young's modulus for bone and human tissue? We looked at the Champion "Rule of twenties" during the early days of HEMS in London and found that it was only predictive of severe injury about a quarter of the time. Amazing what people get away with....or remarkable how cars are designed to bend. A certain Irish CT Surgeon shows a slide of a man's chest with a reverse number tattooed upon it. Evidently, he was visiting his mistress when a terrorist group blew up the house. One wonders what his wife made of the number......
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From: Rowley Cottingham I am intrigued by the people who say that they do not need on-scene photographs to help them treat a patient. I find this a quite extraordinary statement. This implies that they do not need a history from the prehospital team either, as all a photograph does is to amplify information received, and in my opinion massively. All that happens if you neglect all the information you can use is that you will fail to treat properly.Remember, Sherlock Holmes was based on a surgeon - for a reason. Why do people not think then type, instead of shooting from the hip? Best wishes, Rowley Cottingham
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From: Eric Frykberg Watch what you say, because you yourself are shooting from the hip with your words of wisdom--I understand why you would say this, but you are simply wrong--You would have a hard time showing that we are callous or anything less than excellent in our care of patients, in a Level I trauma center caring for 3500 trauma cases/year. It is a simple fact we , nor any other trauma surgeon who has answered this query yet, have just not needed this info, and I would defy you to look up our data, our state registry data, or any other source of info about us, to show "we are not properly caring for our patients". You make some hefty presumptions with no knowldge of our record. Also, we routinely obtain a history from our EMS personnel--not the same thing at all Try listening to those who do this, and you will find you will need to revise the misconceptions you have about the role of these pictures in caring for patients. Also--don't get me wrong--nobody, including me, has stated there is no worth to these scene pictures--they serve great educational value,etc--they just do not contribute to our immediate care of these patients--why use pictures when we have the patient right in front of us? If they help you. more power to you! But they are not necessary to provide state of the art care to these patients--witness the records of our trauma centers--it all depends on how well you can interpret the patient's presentation, as opposed to an image on a piece of cardboard and i would like you to show us the data on which you base your conjecture that we are not "properly caring" for our patients?
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From: Bob St. Martin Why would a picture not help with our treatments? Why ask many questions such as length of blade, type of knife, serrated or straight edge, when we could look at a picture. It seems that there may be cases that a picture would help. Just my 2 cents.
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From: Massey Beveridge Two more cents worth: What does it matter if the knife was serrated or not, or it's size? Ye can be scratched with a machete and killed with an icepick. What matters is the structures injured. I still think careful examination of the patient and appropriate investigations give a surer and quicker means to diagnosing what damage the knife did than speculation based on its dimensions - It's not how big it is but what was done with it. Same with bullets and with blunt trauma. Scene photos may help design safer cars, may help answer worthwhile questions about trauma but will not help diagnose patients' injuries faster.
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