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Prehospital Report (vs Triage?)

Mike Smertka medic0947969 at yahoo.com
Mon Feb 4 23:16:06 GMT 2008


I thought I was the only free radical on the site. :) good to meet another. 
   
  Mr. Waddell, 
   
  From day one of my EMS training, back when ships were wood and men were iron, it was drilled into our brains that the ultimate goal was the hospital. No matter what. It is still that way today. I have heard everyline. "you don't know as much as a doctor," "you don't have an xray or lab," "the only thing you can do is keep air going in and out and blood round and round." Now as I have noticed n the US, paramedics particularly are more and more the finger that keeps getting plugged in the leaky dyke of medical care. They exist because back in 68 somebody decided a funeral service was not a good ambulance. (talk about a conflict of interest) In the last 5 years, in addition to teaching,I have looked at working on oil rigs, helicopters, and have some experience in the far reaches beyond civilization. I have worked in industrial clinics, where the goal was to send people back to work, not the hospital. I have also worked in the hospital.  (big ivory tower looking like thing)
 :) where transferring out was absolutely unheard of. 10 hours of "ED ICU" being preferable to sending them to a facility that might already have open ICU beds. The hospital has some of the best, at all levels, but you just don't get ICU care in the ED. No matter how good we think we are. Clearly there is nothing we can do for a critical multisystem trauma in the street at 0 dark 30. But over my career more and more patients need a primary care visit, or a dentist, not an ED. But nobody wants the responsibility of telling them that.  So when stuff hits the fan is it any wonder, we pack as many as we can in the squad and cart them off to the already overful ED? The nearest one!!! because not only is it the Level I facility, but if you can fill up the hospital in 5 minutes you have done an outstanding job. (haven't won a toaster yet)Of course when your hospital in in a bad neighborhood. Who needs the hospital more. Certainly not the upper middle class suburbanite. When a
 disaster hits EMS (prehospital, I hate that word) everyone stands around after and says "what a great job we did wth no training, no lab, or xray, and having to make extreme decisions." But why are these decisions extreme? If i remember correctly the military medics didn't always and still don't get instant hospital evacuation. So they seem to be trained to all eventualities. Now I won't be so bold as to call some innercity neighborhoods I have worked in combat zones. (nevermind I ca recognize common guns by the sound it makes) But I would say it is a liitle piece of the third world which is casually ignored by people who don't have to go in it. Resources of all kinds are limited and overstretched. So why aren't people taught how to manage them under day to day events, instead of being left to the mercy of figuring out how during a Katrina? Why have I seen disaster plans written by physician medical providers with every credential except disaster management, with no input
 from the lowly prehospital people? Some plans I have seen are laughable. "Upon a recognized disaster the director of human resources will be notified by phone, ( I assume called by the secretary trying hard to register the patients, the nurse trying to take care of them, the physician doing the triage, or me) he will drive his personal vehicle to the hospital and call other providers to come in from home." I'm sure.  Call by phone eh? Not to mention with no prior agreement come from your home to the hospital. (in your car?) With the police directing everyone away? In the ensuing chaos is somebody going to hear ? "I work at the hospital!" Let me give you an escort in. But it is up to you how to cross the river when multiple bridges are now outbound only, or destroyed. 48 hours later FEMA or whoever will now decend from the sky deus ex machina, to save the world. when it comes to a proper triage and disaster planning, lets face it, we are mostly talk. I am not always quick
 on the uptake, so maybe somebody can help me... If you don't do something regularly you lose the skill. If you regularly show up "out of hospital" with a cursory assessment and beat feet to the hospital irregardless of the problem. Is it anywonder The whole system is breaking down or that retriaging is being done at every interval Not that I am saying don't re-evaluate. But maybe a doc could be ambulanced out to the scene, of course that takes a car eprovider away from the hospital, but if he/she is not doing care anyway, who cares? 1/2 hour for an ambulance for an MI, people dying in overcrowded EDs, (been there seen it) because the nurse was so busy with the trauma patients continuously coming through the door, she didn't check on her post arrest patient in hours while waiting on an ICU bed. Now when the big one comes and all the little hospitals and EDs cannot send every patient to the big facility, why in the aftermath do we sit around boosting our egos with what a
 great job we've done in such an unpredictable event? Why am I standing in an ED treating an unstable patient as Mike the paramedic during a non simulated disaster when a physician is standing at the triage desk? Seems counter intuitive. In my opinion a physician has far more knowledge, skill, and experience, why is the physician not treating the patient? He has got to be incharge? What does the "charge nurse" do? I'll leave you to imagine the response I would get calling a surgeon in theatre and explaining to him I think I have another case for him. EMS is just as much to blame. "We don't want the responsibility." well want it or not, it has come. Maybe we should move on to acceptence, and maybe some legal changes for protection before getting hauled into court. Now EMS is a pretty poor lobby, for resons I'll leave out here, but maybe some more established ones could help out. Of course then we will have to work for the common good instead of what is good for our part. I
 have not sat in one class here in school on how to manage a disaster. None are even offered. "So just load them up and take them to the hospital," where perhaps Harry Potter will show up, wave around his wand, and all will get better. 
   
  Call me a synic, but don't call me late for dinner,
  Mike

Bob Waddell II <bobwaddell at bresnan.net> wrote:
  I have the OBVIOUS conflict of interest - see my signature.

I personally whole heartily agree with the discussion, the issues which I
feel are blatantly being ignored or specifically denied are where's the
evidence? We proclaim to be working towards evidence based Prehospital and
Emergency Medicine, yet it appears we selectively choose which, what, and
who's evidence meets our needs at which or what time we choose to use it.
Is triage in the US a process by which we simply move the victims from the
original scene to somewhere else, i.e. the hospital and make the victims
someone else's problem or is it about increasing the patient survival
potential within the resources available? Reducing the chaos and
housecleaning is easy, make it some one else's problem and fault; we're
extremely good at that.

With two foreign wars and 10's of thousands of wounded soldiers being
treated at all levels of trauma care, with war zone like streets in the US
and 10's of thousands of civilians being treated at all levels of trauma
care, with numerous honest researchers studying (at least parts of) the
issues one would think we look at the evidence being analyzed and the true
reality, our patients. Besides it being my day job, I am disappointed that
ego's, personal preferences, old dynasties, laziness, and the age old "smoke
and mirror games" are not put to the same scrutiny of increasing patient
survival that other, less heroic aspects of health care are.

Purely my personal opinions

Take care, 

Bob 

Robert K. Waddell II 
Vice President - 
Emergency Preparedness and Response 
"The Sacco Triage Methodology" 
ThinkSharp, Inc 

Wyoming Office: 
1302 East 5th Avenue 
Cheyenne, Wyoming 82001 
(307) 920 - 2020 cell 

bwaddell at sharpthinkers.com 
or bobwaddell at bresnan.net 
www.sharpthinkers.com 





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