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Sat Mar 21 17:45:08 GMT 2009

Be advised

One of the things Quebec has done right is instauring a Trauma System back in the 90's
And did document a corresponding increase in Trauma survivals (Sampalis, Lavoie et al !?)

In fact
This patient should have been transfered DIRECTLY from the Mont-Tremblant Hotel to the St-Jerome hospital (not the Ste-Agathe hosp.)
(The St-Jerome hosp. is a Trauma level 2... neurosurgey in the weekend !!!??? Not sure)

So, the Trauma systems IS in place
But the ambulances being ALL BLS the prioritization transport to Trauma centers is short circuited by reality (BLS Crews)
So Trauma prioritisation rapidly becomes limited in the outlying regions where there are practicaly no direct Trauma Center transports (Ambulance or Helicopter)

In fact
Once in a while you hear stories through the EMS grapevine that EMS crews were sanctions for bypassing local regional hospital and taking the wild risk of doing diret transport to the Level 1 Trauma Center (this can only happen in certain regions near Montreal and Quebec city)

When I came back from the States 1988
Their were no Board recognised Emergency Physicians that were allowed to exercise as such (McGill Univ has the 2nd oldest EM program through)
Basicaly, I found that the GPs did not trust themselves and there emergency medicine very much (and rightly so)

They
Therefore

Did not trust their nurses either (French Quebec nurses have clearly less autonomy than their Anglo counterparts)

And

They absolutely did not trust the "Ambulance Drivers"

A lot of this mistrust is persisting

There is not much meat on the Emergency Medicine bone (No Medics, very little nursing protocols, No Emergency Transfer crews)
And the bone is not very strong (Weak Emed certificate for the MDs*, and recent trickle of Board Certified EMed specialist)

* Hint to this: You still have MDs that end-ip doing there first intubations alone in some god forsaken ER and with Godforsaken patients

Charles

----- Original Message ----
From: "KMATTOX at aol.com" <KMATTOX at aol.com>
To: trauma-list at trauma.org
Sent: Saturday, March 21, 2009 12:42:05 PM
Subject: Re: Lack of INTEGRATED TRAUMA SYSTEM cost Richardson her life ?

IF there is a lesson to be learned from THIS and many other highly visible  
cases ( i.e. Princess Diana, etc) it is the lack of an integrated organized  
TRAUMA SYSTEM.  Such a system integrates EMS, dispatch,  Emergency Medicine, 
surgeons, and area wide trauma  centers.    With such a system, the paramedics 
in the  ambulance that finally did transport this patient would have been in  
communication with the TRAUMA SURGEON at the area regional verified trauma  
center for advice and orders.  This EMS vehicle then might have  administered 
Hypertonic Saline on the way to Montreal Trauma Center.    With a case with 
such a history and findings at the time the transporting  ambulance arrived, 
stopping at the closest hospital is a SYSTEM  failure.      We all must learn 
from this tragic  lesson.    Let us build, not point  fingers.    This area of 
Canada is not the only place in  highly civilized environments that do not have 
an integrated trauma  system.      

k

In a message dated 3/21/2009 11:36:32 A.M. Central Daylight Time,  
c_brault at yahoo.com writes:

Indeed
The Richardson case is not clear cut
Namely we do not  know how long she spent in the local hospital
When, the confirmatory  cat-scan was done
Or time form onset of symptomes to  herniation

This said
Quebec (largest geographical jurisdiction  in North America has access to 0 
(zero) Medevac Helicopters

Patient  needing emergency PTCA in the regions are condemned (time is muscle)
ALL  intracranial bleeds are condemned
Some Internal hemorraghes, at night and  on weekend arer condemned 
(These events are not measured or  re-assessed)
Some Trauma (non-urban) would benefit for a rapid transport to  specialised 
care
AND AVOID THE ABSOLUTELY WELL MEANING BUT DEADLY SMALL  HOSPITALPIT STOPS 

As the life(death) clock is set I believe we  have discovered that :
Many deaths are (near) instanteneous
Even more  are resistant to time (1/2 day?)
Either of wich do not beneficiate from  rapid transport to specialised care

But there still exists avoidable  deaths where the opportunity to intervene 
are calculated in  30min-1hours
For those
Intelligently applied there are ways to save  lives 

and

AND

Improve on morbidity, pain and  distress

Albeight, these last three depend more on cultural and  financial resources
And where the personalizing "VIP" cases have a tendency  to punctualy have 
the society ask itselvf the question

The other  point is that "specialised" care is sorely absent in some 
peripheral hospitals  and some of the time (indice of absence of system)
(Nobody answered my  "emergency cranial decompression" question!?)
These hospitals could be, but  are not better prepared for those emergencies
And know enough, often, to  just make things worse
The hability to bring in a Emergency ICU  Response Team
Is somewhat valid in large hospital but definitely more  so in far away small 
hospitals

And that is also part of what an  intelligent Medevac team provide

IIRC you are against emergency needle  chest decompressions
So I am not sure you are going to be an advocate of  general surgeons doing 
emergency cranial decompressions  either

Charles
Note: Quebec have recognised Emegency Medicine as  a speciality in early 2000 
only and a very limited number of emergency  physicans are allowed to 
graduate each year
They are NO advanced care  Paramedics whatsoever
They are no Critical Care transfer ambulance (except  for 2 neonate transfer 
teams based in Montreal only)
The Emergency medical  speciality is a one year certificate course tagged 
onto the family medicine  module
The roads are the worse in N-A

-----  Original Message ----
From: "KMATTOX at aol.com"  <KMATTOX at aol.com>
To: trauma-list at trauma.org;  EMED-L at LISTSRV.UCSF.EDU; 
Paramedicine at yahoogroups.com;  DailyBrief at yahoogroups.com; FLIGHTMED at FLIGHTWEB.COM
Sent: Saturday, March  21, 2009 11:59:32 AM
Subject: Lack of accepting ground EMS cost Richardson  her life ?

THe initial headline cited something about the lack of a  CHOPPER cost  
Richardson her life.    

Be Careful to  pass judgment or draw conclusions, especially on VIPs until  
you have  all of the data.    My information is different from  some that  is 
in 
the press.  It is apparent that there was patient  delay  at a time an 
ambulance arrived.  It is the timing of the  ambulance  arrival (actually two 
arrivals) 
that is (are) in  dispute.    Ambulance attendants saw her setting up on one 
of  the occassions and she apparently refused to be  transported.  That 
decision node if true is the  crucial one.  If that data is correct, there 
was 
time to get her to a  place for  evaluation and observation.    

Except in military zones, I  have found very few if any situations where the  
lack of a helicopter  air ambulance cost a patient their  life.      I would 
be  
happy to debate,  discuss, etc. this subject with anyone at any  time.    

For most situations for EMS transport in the United  States, ground  
ambulance 
is more effective, rapid, and integrated  with the existing trauma  systems 
than air ambulance.  

k

In a message dated 3/21/2009 10:49:45 A.M.  Central Daylight Time,  
jimmnn at comcast.net  writes:

>From  today's Globe &  Mail:

http://tinyurl.com/c9zrt7

Jim<  

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Lack of INTEGRATED TRAUMA SYSTEM cost Richardson her life ?