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EMS management/crush injury

Ronald Gross Rgross at harthosp.org
Mon Jun 11 17:54:47 BST 2007


Hi Phil,

I have been following this thread for a while (or should I just say lurking"?).  Two thoughts:
1.  Murphy had a cousin, O'Leary, who wrote the correlate to Murphy's Law.  Simply stated, "Murphy was an optimist!"  Given the event, one must assume and plan for the care of a long bone fracture or two, at the very least, knowing that one leg was trapped.  What you cannot tell me is that it will only be the trapped extremity that was injured;  the other could have been struck as the equipment rolled, as could the pelvis and the abdomen, etc, etc....  Now add in all of the issues of ischemia, revasularization and/or reperfusion issues, and you are looking at a patient that will need facsiotomies, is at risk for ARF, fat emboli, and all of the other issues that would mandate transfer, at some point in time over the course of this patient's care, to a Level I facility.  As stated by several people already, I would suggest that immediate transport to the Level I facility by air and bypassing your hospital might have been the prudent move.  It might have actually shortened the time to difinitive care.  In addition, the immediate transport to the Level I facility might have  provided the patient with the level of care and CONTINUITY of care that is so crucial in that type of patient.

2.  However this comes down after a thorough review of all of the scene facts in retrospect, I think that the pre-hospital personnel must be commended in their ability to make a decision as significant as this one was; I have no doubt that they realized that they would come under intense scrutiny for this decision and yet they made it just the same.  That means one of two things: (a) they are cowboys, or (b) they based their decision on what they were seeing and hearing on scene in real time, and were wise enough to send the patient to a higher level of care in spite of the fact that they had already activated a full team at the closed health care facility with resources (optimal or otherwise - only time and review will tell us that) available for care of their patient......I would tend to assume that the latter is the thought to go with.

Keep us posted on what you hear, and please let us know what actually happened to the poor patient!

Best wishes,
Ron



>>> "Shelley Sides" <ssides at midmaine.com> 6/11/2007 10:28 AM >>>
It sounds like one of the major problems here is communication. Medical
Control should be used as a resource for such decisions. The situation
sounds as though very little information was offered initially and then
there was no follow up on patient status before the decision was made. Maybe
a discussion with all of the local EMS crews in regards to role of Med.
Control as well as professional communication would benefit. There are so
many variable in the patient "pot" of potential injuries and the decisions
made for treatment. As some of you have written, EMS may have been following
protocol which is great. However, every call is a learning call. The take
home message may be to communicate better with all of your resources. Once
the call is made to the trauma center then they should in fact be used as a
member of the team and thus be involved in the decision tree that ensues.

 

-------Original Message-------

 

From: Jules K. Scadden

Date: 6/10/2007 6:21:13 PM

To: trauma-list at trauma.org 

Subject: Re: EMS management/crush injury

 

  I understand what you are wanting to look at Dr. Caropreso, and applaud
you for following up with this or any case in question. What is in the best
interests of the patient must be re-evaluated often and I am happy to see
this is being done.

 

Just to clarify a couple points....Mercy Medical Center in Sioux City is our
designed Level II. I believe St. Luke's is a Level III, now, but could be
mistaken.

 

The closest hospital to me is approx a 65 minute ground transport to any
Level II or III. They do not "often" call trauma alerts at all but when they
need to, they? have a very good policy in place that aids their EMS
providers in making the determination on when that should happen AND it also
supports the OOHTTP as well. I do not know how many trauma alerts you have
in your area and personally feel each area needs to determine their own
policies best suited to their location.

 

Again, I applaud you for following up. Continued evaluation of ANY program
is important.

 

Patient outcome will indeed be interesting to hear about.

 

I guess my question is whether the scene flight is being questioned because
of "unwarranted" need or a feeling of mismanagement of resources?

 

I was taught, many, many moons ago, if there is a question as to whether to
call for a scene flight, because the patient is unstable, or potentially
unstable, rule on the side of what is in the patient's best interests. That
doesn't mean, in this case, flight was warranted, but one has to wonder if
your EMS people were not taught and thinking along the same lines, based on
what they were seeing and interpretation of the state protocol..

 

It will, indeed, be interesting for all, including Iowa's Trauma system, to
hear the committee thoughts on this..

 

Thanks for sharing it.

 

 

 

 

 

Jules

 

 

 

 

 

 

-----Original Message-----

From: pjcabdds at mchsi.com 

To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>

Sent: Sun, 10 Jun 2007 5:00 pm

Subject: Re: EMS management/crush injury

 

 

 

 

 

 

 

 

 

 

Thanks for the note, Jules. I wish that I could give you more information,
but I

suppose it's the only conclusion that can be made: >20 minutes extrication
and

two long bone fractures, go to the level 1. Now, I don't know where the two

fractures came from. Perhaps, it's an assumption. I hope to get some info
from

UIHC.

If you are calling trauma alerts often and not utilizing them, I hope that
such

events are being analyzed. You can do only so many drills. I do know your
part

of the state, and was involved in the verification of St.Luke's. Iowa is
rural

and similar. But everything may not be the same. Are you 100 miles from your

level 2's? You're right: I would never to past a level 2 to get to a level 3


With the protocols not ignored in the least, the questions remain: what were
the

injuries, what were the indications for

transfer, who has authority for transfer, and what were the benefits and
risks

of the management selected. I hope that I will be able to provide these
answers

when I can get followup.

 

--

Kind regards,

Phil

Phil Caropreso, MD, FACS

1813 Grand Avenue

Keokuk, Iowa, USA, 52632

pjcabdds at mchsi.com 

 

 

----------------------  Original Message:  ---------------------

From:    "Jules K. Scadden" <jkaymdc at aim.com>

To:      trauma-list at trauma.org 

Subject: Re: EMS management/crush injury

Date:    Sun, 10 Jun 2007 21:37:44 +0000

 

>

>  I am also from Iowa, as well as a rural area similar to Keokuk..I agree
with

> Rob, as I have learned and taught the OOHTTP in Iowa, they did as the
protocol

 

> directed, and as we would have done on the NW side, with only Level IV and

maybe

> a level III, almost as close as the Level II....

>

> We also call trauma alerts that can and often are not utilized after
further

> scene evaluation that indicates perhaps scene flight. ...

>

>

>

>

>

>

> Jules

>

>

>

>

>

>

> -----Original Message-----

> From: Rob Farnum <latigo at firehousemail.com>

> To: trauma-list at trauma.org 

> Sent: Sun, 10 Jun 2007 10:58 am

> Subject: re:EMS management/crush injury

>

>

>

>

>

>

>

>

>

>

> I think in this case, you should look at the Iowa Bureau of EMS Out of

Hospital

> Trauma Triage Protocol.? This is a state protocol, not local, and could
shed

> some light on the decisions made for you.? It would appear this Pt falls
out

in

> 2 categories:? "Suspected 2 or more Long Bone Fx", and "Extrication time >
20

> minutes".? Both of these direct the crew to expedite transfer to a Trauma
Care

 

> Facility.? It does state in the Protocol that "If time can be saved, or
level

of

> care needs exist, tier with ground or air ALS service." with the suspected
2

or

> more long bone Fx.

> According to the Iowa Department of Public Health, the hospital in Keokuk
is

an

> "Area Trauma Facility" which appears to translate into a Level III
Facility.?

> With some knowledge of your area, knowing how far it is the the University
by

> ground, I would have probably done the same thing.? If you feel there was

> "Over-triage on scene" then you should approach the ambulance director for
the

 

> service FIRST.? I work in a Level 4 facility in Iowa, and I would without
a

> doubt call for a chopper, and a scene flight is a good option here.? Even

after

> calling a trauma alert.? It isn't unknown for us to call one and then
stand

down

> when we get on scene and perform a scene flight due to extended
extrication.?

If

> you feel the crew doesn't understand the Out of Hospital Trauma Triage

Protocol,

> then by all means offer to give more education on it.? But, from your

> description of events, it sounds to me like they performed correctly.

>

> ?

>

>

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