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Sun Mar 22 22:19:23 GMT 2009

I still do not know the entire history of what exactly happened with Ms. Richardson. I only hear stories from the media, and every one I have heard has been slightly different. 

I am a paramedic from Canada, but I work out of Ontario in the Toronto area, I am not familiar with the Quebec EMS system.  Personally, the service that I work for does have a trauma centre and I have a medical directive that allows me to bypass the closest hospital under certain criteria, in order to go to a trauma centre.  I do not have any contact with the trauma surgeons.  The only contact I have with that hospital would be through a hospital patch enroute to update, or I can call an emergency physician out of the base hospital.  Having said that, as a prehospital provider, there is little that I can do other than get them to a trauma centre ASAP and provide the best care in order to prevent the patient's condition from worsening or at least slow it down. My service is currently participating in a ROC study for hypertonic saline in the pre-hospital setting, however it has not become a common practice in EMS in Ontario. The results of this study
 may change this.  

I think that there was mention by someone that every patient that has a loss of consciousness should be taken to a hospital with a neurosurgeon.  Although this would be ideal, I can bet that many paramedics have found that a large number of patients have reported a loss of consciousness when asked, however bystanders have confirmed that there was not.  If I were to bypass for every patient that reported a loss of consciousness, I would be bypassing a large majority of the time when it was not necessary. 

I can also tell you from my previous experience and from speaking to other paramedics, there have been many cases where paramedics have bypassed and gone to a trauma centre, only to have the trauma doctor rip into them stating it was not necessary and tell them they were incompetent.  On the other side, paramedics have gone to the closest hospital where the emerg physician has ripped into them for not going to a trauma centre.  

I doubt that any system is perfect, and indeed there does need to be more communication with EMS, the local hospitals and the trauma centres.  

Marty Munro, 
AEMCA, Advanced Care Paramedic

--- On Sun, 3/22/09, Stephen Hines <stephen.r.hines at ntlworld.com> wrote:

From: Stephen Hines <stephen.r.hines at ntlworld.com>
Subject: RE: Lack of INTEGRATED TRAUMA SYSTEM cost Richardson her life ?
To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
Received: Sunday, March 22, 2009, 1:55 PM

Not quite true Nick - the push to bypass for PCI came from the ambulance
service.  Unofficially we are now also seeing it for strokes.

Most paramedics and EMTs know where they would like to take their patients.
More than once have I heard people ask if they can put the patient back into
the ambulance and take them to a hospital that will not undo the care that
has been given pre-hospital.......

What is holing it up at the moment is two things - 

    Firstly the money.  Since in the UK at the moment the money does not
follow the patient, even the Royal London complains if we take them an out
of are patient.

    Second is the politics.  Everyone wants the all singing all dancing
hospital to be their local one.  Every time there is suggestion that a
hospital is downgraded to allow for improved facilities to be concentrated
at one site we are told how many people will die. The politicians the join
the fight, and nothing changes!

Regards,

Stephen

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Nicholas Macartney
Sent: 22 March 2009 15:17
To: Trauma &amp; Critical Care mailing list
Subject: Re: Lack of INTEGRATED TRAUMA SYSTEM cost Richardson her life ?

I remember taking part in meetings about how to arrange trauma better,  
bypass hospitals within 20 mins of the trauma centre, etc etc. Died a  
death.
Triage seems to be "take the patient to the nearest hospital". The  
exception is in cardiology, where they bypass to get to a hospital  
that can do emergency PCI.
I would suggest that this has happened because the cardiologists have  
demanded it. I have never seen any sign of neurosurgeons in this area  
demanding transfer to them. In fact, they are happy to say they are  
full - goodbye.
Nick Macartney
On 22 Mar 2009, at 14:21, Robert Smith wrote:

> Nick,
>
> We were recently in London for international trauma conference that  
> Karim helped host. I know London was working toward implementation  
> of a full trauma system but had not achieved this yet. I'm unclear  
> as to who oversees triage and how it is done. But if someone had  
> LOC, was lucid, and then was unconscious, I assume that would imply  
> a low GCS currently. Why wouldn't such a person be taken to a trauma  
> center?
>
> Rob Smith
> On Mar 22, 2009, at 9:23 AM, Nicholas Macartney wrote:
>
>> Dear Pret,
>> While I know that I live in a third world country, in London,  
>> England at least a head bump with short term loss of consciousness  
>> would not go to a neurosurgeon. It would go to the nearest  
>> hospital. And a head bump, followed by a lucid interval, followed  
>> by loss of consciousness would go to the nearest hospital too.
>> Bear in mind that in London, there are 6 hospitals with  
>> neurosurgeons I can think of. One ( National Hospital for Neurology  
>> and Neurosurgery ) does not have an ER, so never accepts patients  
>> that have not gone via another hospital.
>> With the notable exception of the Royal London ( where the trauma  
>> listowner works ) one has to think that some neurosurgeons do not  
>> want to get all the emergencies, as it would impede the elective  
>> work/private work.
>>
>> Nick Macartne
>> On 22 Mar 2009, at 12:46, Pret Bjorn wrote:
>>
>>> Let's start from the ground up, an decompress this conversation a  
>>> bit by
>>> admitting that (from all that the public has been allowed to know)  
>>> Ms.
>>> Richardson herself played a huge part in her own trajectory.  She  
>>> was both
>>> exceedingly unlucky and tragically unwise.
>>>
>>> She was unlucky, not for cratering on a bunny slope, or even  
>>> incurring a
>>> mortal head injury in the mix; but rather, for (apparently)  
>>> showing little
>>> or no loss of consciousness followed by a truly world-class lucid  
>>> interval.
>>> Bright lucidity, we must admit, can occasionally be wasted on the  
>>> owner.
>>>
>>> As for that, her un-wisdom traces to at least two bad decisions:  
>>> first, to
>>> not spend eight bucks renting a helmet (though why a ski school  
>>> wouldn't
>>> provide this free of charge is beyond me); and second, to decline  
>>> medical
>>> treatment in the immediate aftermath of her crash -- presumably  
>>> because she
>>> felt largely uninjured, at least moderately embarrassed, and  
>>> didn't want to
>>> dampen her vacation over a bump on the head.  Here, a show of  
>>> hands: who
>>> among us would have done otherwise?
>>>
>>> So.  Four hours later, as her brainstem squeezes out the bottom of  
>>> her
>>> skull... WHERE are the SURGEONS?
>>>
>>> Forgive me when I suggest that this is at least an unnecessarily  
>>> obtuse, if
>>> not altogether silly, question.  There is zero assurance that her  
>>> outcome
>>> would be any better had she been injured in any resort in Montana,  
>>> Utah,
>>> Colorado, or Maine.  Speaking only for Maine, I'm confident that  
>>> she would
>>> have been at a trauma center in well under an hour (probably half  
>>> of that)
>>> from the time of the second EMS call.  (Sorry, Ken, but I base this
>>> exclusively on the integration and efficiency of our HELICOPTER  
>>> program.)
>>> Yet I think we're all flattering ourselves if we think that would  
>>> have made
>>> much difference so late in the game.  There are indeed miracle  
>>> recoveries in
>>> such stories; but there are also fates worse than death.
>>>
>>> I'm less willing to criticize the Quebec EMS system because I'm  
>>> more than
>>> 90% ignorant of its architecture.  Generally speaking, though, I  
>>> hope that a
>>> mechanical fall with objective and isolated loss of consciousness --
>>> anywhere in the world -- would be triaged in favor of the closest  
>>> hospital
>>> with a neurosurgeon.  (Practically anybody can do a head CT these  
>>> days; but
>>> that's the problem.)  I'd prefer the destination be a trauma  
>>> center; but if
>>> that's gonna add hours to the trip, she can be out-transferred  
>>> after the
>>> burr holes.  And all this admits that I have no idea whether or to  
>>> what
>>> extent the Canadian healthcare system has centralized the  
>>> neurosurgery
>>> resources of one of the largest nations on the face of the earth...
>>>
>>> These are generalizations, of course, and defy systematization in  
>>> the
>>> absence of a broad enthusiasm from local, regional, and provincial
>>> government; prehospital and EM providers; and yes, SURGEONS.  But  
>>> I should
>>> think they'd all have significant and very useful input.
>>>
>>> Pret Bjorn, RN
>>> Bangor, ME USA
>>>
>>>
>>> -----Original Message-----
>>> From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org 
>>> ]
>>> On Behalf Of KMATTOX at aol.com
>>> Sent: Saturday, March 21, 2009 10:50 PM
>>> To: trauma-list at trauma.org
>>> Subject: Re: Lack of INTEGRATED TRAUMA SYSTEM cost Richardson her  
>>> life ?
>>>
>>> WHERE are the SURGEONS ???
>>>
>>>
>>> In a message dated 3/21/2009 12:45:42 P.M. Central Daylight Time,
>>> c_brault at yahoo.com writes:
>>>
>>> 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"
>>>
>>>
>>> **************Feeling the pinch at the grocery store?  Make dinner  
>>> for $10
>>> or
>>> less. (http://food.aol.com/frugal-feasts?ncid=emlcntusfood00000001)
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>>
>> Dr NJD Macartney
>> ICU Director
>> Chase Farm Hospital
>> The Ridgeway
>> Enfield
>> EN2 8JL
>> +4420 8375 1074
>>
>>
>>
>>
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>> http://www.trauma.org/index.php?/community/
>
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> trauma-list : TRAUMA.ORG
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>

Dr NJD Macartney
ICU Director
Chase Farm Hospital
The Ridgeway
Enfield
EN2 8JL
+4420 8375 1074

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