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Wed Jun 13 19:42:37 BST 2007

Phil,

Re the refs:
Nopacsurg. This is a retrospective study which develops a new mathematical
model to fit the old data. So by definition the model will do well since it
was created to fit the data base retrospectively. Then it needs to be tested
prospectively. (I hate using ISS = 15 as an indicator of whether someone was
over/under triaged or really sick)

Emj.bmj. Um, I don't see how this paper exercise of a mass casualty incident
comparing performance of docs, nurses and paramedics in England is relevant.

Utah State. I love this sentence: "Most importantly, over-triage robs local
hospitals of valuable experience and needed revenue." 

Phil, I don't want to put words in your mouth. To over simplify, the view
point of many papers on over-triage is that if the pt. didn't need an
operation or ICU then they probably didn't to go to .... fill in the
blank... level of care. I don't agree with that position. I believe that big
time trauma centers have a wealth and depth of experience and resources that
lower level trauma centers probably don't have. Measuring outcomes in terms
of mortality rates is attractive only because it is so concrete.
Scientifically evaluating other kinds of positive outcomes is often very
very hard and takes someone as smart as Ellen Mackenzie. From a systems
administrators point of view I wouldn't care so much about making a lot of
hospitals pretty good. I'd want to make a few hospitals really really
fucking great and then stuff them full of patients until they hollered. And
if they're not hollering, then I'm sending everybody there that is feasible
and safe. My lone contribution to science helped show that higher volumes
had a positive effect on outcomes so maybe that is my bias. I guess I need
more convincing that this patient's triage to the Level I could be an
example of a process that is putting the system in jeopardy.

Rob

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of pjcabdds at mchsi.com
Sent: Wednesday, June 13, 2007 1:49 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: EMS management/crush injury

Rob,
Here are some interesting references on the subject of triage:

www.nopacsurg.org/Abstracts/0619.pdf

http://emj.bmj.com/cgi/content/abstract/19/4/348?ck=nck

www.health.state.ut.us/ems/traumasystems/ factsheet_over_under_triage.pdf

The system has been set up to get the patient to the right level. My concern
is 
that patients are just being directed to the highest level, using the
protocols 
only and not employing any critical thinking or at least not seeking any
input. 
Some of this represents a change in approach, which I regard as a
deterioration 
of the system. An assumption, made by local EMS and by some members of this 
list, was that this horrific injury could have only received care at the 
tertiary level. This assumption needs to validated or refuted. That's what
the 
discussion should be about without anyone pointing fingers. I am familiar
with 
the numbers. Under triage is dangerous. Over triage wastes time, money and 
resources. I am not concluding that the case presented is over triage, but
it 
must be considered. If not, the entire system is being jeopardized. 

--
Kind regards,
Phil
Phil Caropreso, MD, FACS
1813 Grand Avenue
Keokuk, Iowa, USA, 52632
pjcabdds at mchsi.com

----------------------  Original Message:  ---------------------
From:    "Robert F. Smith" <rfsmithmd at comcast.net>
To:      "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
Subject: RE: EMS management/crush injury
Date:    Wed, 13 Jun 2007 15:59:47 +0000

> Phil,
> 
> This is an important point that has sort of bothered me with the thread.
> 
> Of course if you simply send everyone to a particular hospital and they
are
> overwhelmed that is an issue. However, from a systems perspective, a
> significant degree of over triage IS necessary to ensure that EVERY
patient
> that needs it gets to the highest level of care that they need. Some
experts
> recommend rates as high as 25% I believe. Most would agree that 12% - 15%
is
> necessary. Looking at an individual patient and saying he/she was over
> triaged can be problematic therefore. If the receiving hospital is
> complaining about the volume they are receiving that is a different issue
> and triage protocols can be revised and then the results of that change
> monitored.
> 
> To me it seems your system worked well for this patient. She had a very
> serious injury and was taken directly to a hospital that could address
every
> aspect of her complex and prolonged care.
> 
> Rob Smith
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
> On Behalf Of pjcabdds at mchsi.com
> Sent: Wednesday, June 13, 2007 11:44 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: EMS management/crush injury
> 
> Rob,
> Over and under triage are both problems. I agree that I would take over
> rather 
> than under because under can kill. I don't think that either can be
> completely 
> eliminated, but personally I would not use "desirable" to describe
> overtriage. 
> The University of Iowa Hospital and Clincs is the primary tertiary center
in
> 
> the entire state-essentially the only one for 3 million people. Beds can
be 
> scarce, and the staff overworked. Triage must be appropriate. Appropriate 
> triage is the goal of the Iowa trauma system. Overtriage will sink UIHC
> trauma 
> team. Thanks for the reply.
> 
> 
> --
> Kind regards,
> Phil
> Phil Caropreso, MD, FACS
> 1813 Grand Avenue
> Keokuk, Iowa, USA, 52632
> pjcabdds at mchsi.com
> 
> 
> ----------------------  Original Message:  ---------------------
> From:    "Robert F. Smith" <rfsmithmd at comcast.net>
> To:      "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
> Subject: RE: EMS management/crush injury
> Date:    Wed, 13 Jun 2007 15:34:07 +0000
> 
> > The only thing I would add is that I think the patient is best served by
> > going directly to the place that is going to provide definitive care.
> Pret's
> > caution about the patient dying because of the length of transport taken
> > into consideration. But that would be a long transport in a
> physiologically
> > unstable pt. Over triage is necessary and desirable because under triage
> > kills.
> > 
> > It sounds great that you'll all be able to discuss this!
> > 
> > Rob Smith, MD
> > 
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> > On Behalf Of pjcabdds at mchsi.com
> > Sent: Wednesday, June 13, 2007 11:17 AM
> > To: Trauma &amp; Critical Care mailing list
> > Subject: RE: EMS management/crush injury
> > 
> > Pret,
> > Everyone's feelers may be out a little too far. I can understand some 
> > sensitivities or defensiveness. Too often I've seen pre-hospital beaten
up
> > by 
> > physicians, who need to do more education and team building.
Nevertheless,
> > if a 
> > mistake does happen, it needs to be identified,corrected, and accepted. 
> > Everything must happen in the right way to accomplish some good. 
> > I had been the medical director for Air Evac Iowa. I knew that I was
> > ultimately 
> > responsible for everything that was done in the field. Paramedics were 
> > operating on my medical license. As much as I could, I was involved in 
> > education and support. Air Evac has a central dispatch in Missouri. In 
> > individual cases there is likely to be variation about who is in charge,
> > with 
> > the medical director only getting into matters of dispute. EMS tend to
> rely
> > on 
> > local direction, which is guided by the state system. Check this out:
> > www.idph.state.ia.us/ems/common/pdf/inttriag.pdf
> > 
> > --
> > Kind regards,
> > Phil
> > Phil Caropreso, MD, FACS
> > 1813 Grand Avenue
> > Keokuk, Iowa, USA, 52632
> > pjcabdds at mchsi.com
> > 
> > 
> > ----------------------  Original Message:  ---------------------
> > From:    "Bjorn, Pret" <pbjorn at emh.org>
> > To:      "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> > Subject: RE: EMS management/crush injury
> > Date:    Wed, 13 Jun 2007 12:22:52 +0000
> > 
> > > Who assumes medical control for the air program in this case?  
> > > 
> > > In many systems, the nearest EM clinician is in charge of treatment
and
> > > destination decisions; but in at least one state I'm familiar with,
air
> > > medical supervision is centralized and largely separate.  This fosters
> > > some consistency and efficiency, but predictably at some cost to
> > > communication and local logistics.  I'd like to know more about the
Iowa
> > > system. 
> > > 
> > > And Jules, I admit that I'm late to the table and something of a
> > > skimmer, but I think that much of the escalation here is from
> > > sensitivity, not persecution.  "EMS is a(t) fault?"  "EMS screwed up?"
> > > Those are your characterizations, aren't they?  Consider the
possibility
> > > that the "lynch mob" is in your head.
> > > 
> > > Just me, just now.
> > > Pret
> > > 
> > > -----Original Message-----
> > > From: trauma-list-bounces at trauma.org
> > > [mailto:trauma-list-bounces at trauma.org] On Behalf Of Jules K. Scadden
> > > Sent: Tuesday, June 12, 2007 8:03 PM
> > > To: trauma-list at trauma.org
> > > Subject: Re: EMS management/crush injury
> > > 
> > >  
> > > Roy says:
> > > >Phil:  This is how I see it.  Sit down with EMS and talk
> > > communications.
> > > >EMS people on this thread are going to come to the defense of
> > > theircolleagues.
> > > >I'm going to play the devil's advocate and tell you that
> > > >they over-stepped their boundaries.  The reason you and your hospital
> > > >are called "medical control" is because you are there to help them
make
> > > >decisions.  Not all the time...not for every patient.  This was
hardly
> > > >and "every patient" encounter and they would be wise to learn from
this
> > > >>situation.
> > > 
> > > 
> > >  I agree....talk about communications between the field and the
> > > hospital/EDs..that should be done 
> > > continuously anyway. And ALL trauma's, especially ones such as this
> > > should be reviewed and CQI'd..
> > > ?EMS people agree with discussing these things, that would be why they
> > > have CQI policies.
> > > 
> > > I think the benefit of this thread has rapidly escalated into an "EMS
is
> > > as fault" instead of what
> > > I "thought" the intent was, a frank, beneficial discussion.
> > > 
> > > Yes, EMS people will come to the defense of their colleagues,
especially
> > > those of us that work in Iowa 
> > > and understand how our system works and why they probably made the
> > > decision they did. But then I've seen 
> > > doctors, nurses, & plumbers all come to the defense of their
colleagues
> > > also, especially when
> > > ?NO evidence has been presented they did anything WRONG and as far as
> > > we've been told, 
> > > detrimental to the patient.
> > > 
> > > ?If this is a 'what can we do better" discussion, lets lose the "EMS
> > > screwed up" piece in it
> > > ?and perhaps ask THEM why they called for a helicopter, before passing
> > > judgment without all
> > > the facts or reasons.
> > > 
> > > We have very little actual first hand information OR patient outcome
> > > information. Could we try to
> > > lose the lynch mob mentality?
> > > 
> > > I do believe you feel there needs to be a strong partnership between
> > > EMS, ED and physicians, 
> > > unfortunately, this discussion is no longer promoting that..if feels
> > > alot like trying to point
> > > a finger at a "perceived" wrong...unsubstantiated as that!
> > > 
> > > I'm sorry Dr. Caropreso, I do understand what your intent was with
this
> > > thread.
> > > 
> > > Julie 
> > > 
> > > 
> > > 
> > > 
> > > 
> > > 
> > >  
> > > 
> > > 
> > >
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