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Wed Jun 13 20:40:06 BST 2007

Dr. Smith,

Well stated as always.  I would counter, though, that diverting a
prolonged trauma center trajectory in favor of prompt and proper damage
control might itself represent functional overtriage.  

Options like these, which would undermine a typical urban trauma model,
are conversely the mark of highly sophisticated rural systems.  They're
just INCREDIBLY difficult to systematize in rustic environs, for all the
reasons that they're needed: low volume, dilute resources, shifting
provider availability, and so on.  

In contemporary trauma systems, geography is destiny -- unless you're
both lucky AND good.  And with trauma, almost by definition, luck is
elusive.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
Sent: Wednesday, June 13, 2007 11:33 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: EMS management/crush injury

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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