erraticating trauma alerts

[Just Plain Ruff]

It appears that having a physician call them is not a bad idea especially if there were lots of trauma alerts that were called which never never should have been called. All you can do is recommend a trauma alert or give the doc what you have and let him make the call.

If he doesn't call the alert and things go sour for the patient then who's butt is on the line, not yours unless you didn't give him all the info.

Vent, I think the above is important - if EMS gives a good radio report with the trauma criteria listed out and the physician doesn't call a trauma alert then who's issue is it.

But what I was thinking is what if there was a study done that looked at this.

Number of trauma alerts called by EMT's versus the number of Trauma alerts called by paramedics.

[Scaramedic]

I was going to comment but I had to enter a patient into the trauma system with a c/c of big toe laceration. I think he is going to make it but it was touch and go for a while. Anyway the call just wore me out.

Seriously though if you do not understand the dominoes in motion that Vent spoke of and how they can or cannot benefit your patient you should not be calling trauma alerts.

[Richard B the EMT]

Perhaps neither here nor there, but I forgot to mention when FDNY EMS calls in the "note", we are telling our dispatch personnel to Land Line the hospital, and relay it the information. Other areas call the hospital directly via what I think is called the HEAR, or Hospital Emergency Alerting Radio (can someone give me a confirmation on that?) from the inbound ambulance crew itself.

[Mateo_1387]

The system I work for uses "Trauma Alert" and "Trauma One." When a paramedic calls either in, it is because the patient meets certain criteria, and only that criteria. This way everyone is on the same page, and trauma's are categorized properly. The statistics we see each month show that our alerting system is accurate. Only one or two traumas a month get downgraded or upgraded.

The trauma notifications can work. I would just think that getting everyone on the same page would be the right idea. At least giving the trauma notification gets the gears into motion to get the patient into surgery, and definitive care.

[sevenball]

vent: "A trauma center will have most of the essential personnel inhouse to get the party started. By the time the necessary tests are done, all players should be in place if needed. On a busy shift in a trauma center, resources can be stretched thin by unfounded "Trauma Alerts". Think of it as all those ambulance calls that you don't believe warrant an ALS Rescue but you must respond because someone called 911. Not every call requires a trauma surgeon and 6 other team members immediately at bedside. Many of these team members are leaving the bedsides of other critically ill patients only to find the "Trauma Alert" patient has no immediate distress and will probably be triaged to the general ED for the rest of their workup."

Makes total sense. I often use that argument when going on what I would consider "useless" runs. It's nice to see that when using this forum, a strong argument can pull out multiple points of view never before thought of.

I still stand by the point that I know how to call a trauma alert, and that my gut tells me alot about a sick person, but hey, thats just me. Perhaps they should change the trauma alert criteria to trauma "alert" meaning I'm bringing in a potential surgical candidate, and a trauma "stat" which means call me in the world. Thats the way we used to do it in my region in Mass. It seemed to work out alot better.

[Doczilla]

For us, traumas are paged out by the following criteria:

Cat 1: airway compromise, intubated, hypotensive, penetrating injury to head, neck, chest, or abdomen, uncontrolled hemorrhage. This gets the trauma team (including the trauma attending), 2 respiratory terrorists, and 2-3 OR nurses in anticipation of the patient going direct to OR. The ER attending steps in and has ultimate responsibility for the airway, but that's about it.

Cat 2: everything else that still falls under head trauma or multisystem trauma. This gets at least one trauma resident or PA along with the usual trauma team: 2 rad techs, 1 lab tech, 3 ER nurses (including the charge nurse), 1-2 ER techs. The ER attending is the only attending in the room, and has ultimate authority over patient care. That said, we usually just poke in, make sure that things are being done to our liking, and piss off. We have a lot of faith in the trauma residents and PAs (as well as in the nurses, who can tell when it's not being done right and will come get us).

The ER doc has the option to call or cancel the alert, work up the patient like any other ER patient, and consult Trauma as necessary for eval or admission. The trauma team here is primarily surgery, but does include 2-3 ER residents per month.

There are many places that have the ER perform the initial evaluation and resuscitation on all trauma patients (including cat 2) without the surgery folks, and contact or consult them only when necessary. This "tiered" response has been studied:

2 Tiered Trauma Protocol

2 tiered pediatric trauma protocol

Patient outcomes with tiered trauma protocol

Non-tertiary hospitals also may overtriage trauma patients as well:

Secondary Trauma Overtriage

And there may be ways to improve this:

Secondary traige: early identification of high risk trauma patients presenting to non-tertiary hospitals

Tiered trauma protocol, part deux

What the trauma center should be:

http://jama.ama-assn.org/cgi/content/full/289/12/1515

From the American College of Surgery

The fact is that we accept a certain amount of overtriage from field providers to make sure that undertriage is done as little as possible. At a trauma center undertriage is no big deal, since the patient will be evaluated and if necessary the level of care quickly ramped up with little time lost. It's a bigger deal if the patient is taken to a non-tertiary hospital, who lacks the resources and regular experience to manage these patients, then has to transfer them out.

There is also an understanding that we have on the trauma team: people survive some horrific s#it, some with hardly a scratch. EMS gets them out and to the hospital so fast that the hypovolemia has not had time to take hold and indicate the immediate need for surgery. We complain very little about overcalled trauma alerts by EMS, because we know that the mechanism was there and the patient wont declare the severity of his injuries for some time.

'zilla

[Dustdevil]

I still stand by the point that I know how to call a trauma alert, and that my gut tells me alot about a sick person, but hey, thats just me.

And I still stand by the indisputable point that you aren't the only medic in your system.

Consequently, how awesome you personally are is irrelevant to systemwide policy. This is just like the helicopter EMS argument. Nearly three decades of experience shows us that a shockingly large percentage of providers are incapable of accurately determining who needs HEMS and who does not. Yes, I am positive that I am capable of it, but regardless, the numbers still show that I am in the minority. And the same thing apparently applies to the trauma alerts in your system. Too many protocol monkeys who are well versed at running down a memorised protocol checklist, but incapable of the clinical judgement necessary to competently interpret the results. And, of course, just too many of the so-called "trauma junkies" get some sort of perverse thrill from being able to say they called a trauma alert (or a helicopter), whether it was medically justified or not.

Trauma alerts are well proven to be a good thing. But only if those initiating them know wtf they are doing and why they are doing it. It's simply not enough for you to be teh aw3some. You have to prove a statistical need and benefit. If it is there, that shouldn't be a problem. If it isn't, then all the whining in the world is going to do you no good.

[sevenball]

dust devil,

I fear that you mistaken my confidence for cockiness. that is not my intention at all. I just happen to hate when those emt's of which you speak, endanger other compitent emt's ability to function to our full potential. You and I both claim to be able to determine with great accuracy the need for trauma alerts and helicopters.

There must be something to your claim however, because we've gotten out butts chewed out for calling a helicopter in without transporting them to the hospital first. Now if what I know about helicopter crews is correct, they need all the pertinent information before accepting a mission. However, our hospitals seem to believe that we cannot accurately assess our pt.'s and determine that need. So clearly, somewhere along the way we've messed up as a profession and have created an evironment that does not foster faith in our abilities, and thats a shame.

[Dustdevil]

Just for clarification, I'm not questioning the justification for your confidence, or confusing it with cockiness. I'm taking you at your word that you are a competent practitioner. I am only questioning the wisdom of ascribing that competence to every medic in your system simply because it applies to yourself. Doing that is exactly what results in the medical community to come back and rein us in like this.