Mechanism as an activation factor

[jwraider]

Hey guys,

I'm starting in a new county which will be my third so far and I'm starting to notice a trend that many EMS systems handle trauma very differently.

For example my internship was in a busy urban county where the trauma center accepted all ranges of trauma patients most coming from "paramedic opinion" no questions asked. It was a teaching hospital so maybe they liked the business. Outside of a broken toe this is where trauma went for the county.

I work currently in a second county that is urban and rural and spells out 4 categories for activations including physiological, anatomical, mechanism and co-morbid factors. They want detailed reports and reasons for coming in and the only catch all is "significant blunt force trauma" if you want to activate someone on sound paramedic judgement. The non trauma hospitals tend to freak a bit when anything trauma comes in yet complain about losing business when a non activation trauma bypasses them. The trauma center decides on whether or not to activate based on the radio report and this can be hit or miss. My point being the non trauma hospitals are trying to avoid dealing with trauma and the trauma center is trying not to over triage... The county seems to be aiming at perfect triage and controlling activations very closesly.

So now the third county only lists physiological and anatomical factors as straight activations and requires MD contact for everything else. Their theory is mechanism is a poor indicator of a patient needing a trauma team and that if a significant mechanism is present the patient should have a physiological or anatomical problem (they are the common ones such as hypotension or penetrating trauma etc). They also claim that the trauma center would be over worked if anything more than these two categories was showing up at their door step. They don't apparently trust paramedics to bring them what they want.

Which of these systems do you feel is the most progressive?

Which system do you like and what type do you work in?

What do you think about the third system would that help you or hinder you in making decisions?

And for the title of the thread.... Do you feel a patient should activated based on mechanism only? For example a death of someone in the same car.

My thoughts are it's interesting how all three systems actually work fairly well where they are. It looks like the second two are starting to aim at bringing non critical trauma patients to outlying facilities and transferring them in as needed. I had no idea this issue was still so underdeveloped. I guess EMS is a newer profession but seeing as these counties operate so differently when they all follow the same ACLS protocols is interesting.

I think mechanism is a decent indicator but needs something to go with it. For example this weekend I activated an elderly man who fell from a leaning over position onto his face while petting a cat (age 87, on coumadin, bleeding did not stop on forehead or in mouth). I did not activate a mother and son (40 and 5) who were in a 40 mph roll over as they came out unscathed.

I wonder what paramedics could do to gain more confidence from trauma physicians and become more of an asset to the system. This is similar to STEMI patients. The cardiologists are the experts by far but I'm wondering if the same is true for trauma. Reason being we see the actual scene and gain a feel for potential injury something a trauma physician will see but a handful of times in his career.

I think paramedics should be given the resource of seeing the results of their patients hospital stay and there should be better recording equipment and data handling methods so trauma physicians can see the incident. I have a feeling these two things would help tremendously.

[VentMedic]

Florida

http://www.doh.state.fl.us/demo/Trauma/protocols.htm

http://www.doh.state.fl.us/demo/Trauma/transports.htm

Adult

http://www.doh.state.fl.us/demo/Trauma/PDF...riaMeth1202.pdf

Pedi

http://www.doh.state.fl.us/demo/Trauma/PDF...oreMeth1202.pdf

[CBEMT]

They also claim that the trauma center would be over worked if anything more than these two categories was showing up at their door step.

Bullshit. I don't know about anybody else, but our trauma center functions just like a community hospital, except they get all the bad stuff too. They get the train wrecks and the bullshit "My neck/my back/my lawyer" MVAs; the STEMIs and the stuffy noses.

If they didn't, our system would collapse in a day. Yeah, sometimes the less serious patients can be stacked 10 deep in Ambulance Triage on busy days or when one of the community facilities goes on divert. I guess you could call that overworked, but they can ultimately handle it better than the other ERs with their 10 or so total ER beds in some cases. I certainly don't think it justifies a policy that says trauma centers can only get "TRAUMA!"

[HERBIE1]

ANy trauma center worth it's salt needs volume- both critical and not- in order to stay sharp. They also need a certain patient volume in order to receive certain state and federal funds and to keep their trauma status. Does this wide net mean some paitents are brought to Level ones unnecessarily? Yep, but a quick look by the trauma team should be enough to "deescalate" the trauma activation and keep costs down.

[Just Plain Ruff]

My view is it is better to activate a trauma team than to have to activate it after you get there.

If it's a trauma center (level 1) then the team is already there, in house and ready to go.

The level 2's in our area have all but certain specialties in house 24 hours a day. The "certain specialties" neuro and ortho are usually in house but may be less than 15 minutes or is it 25? I'm not sure of the actual number but they can usually run a trauma until those "certain specialties" get there.

So when in doubt call a trauma and they can quickly de-escalate it. But to be behind the 8 ball when you need the team is not a ball I want to be behind if I was the patient.

[cosgrojo]

To provide my opinion on the question you posed... I do not think that mechanism should be the sole deciding factor in calling a trauma alert. Where I work in Northeastern Mass. they have been trying to go away from this trauma/treatment modality. The problem with the system up here is that the state is is broken into regions that like to run things their own way, and that tends to wreak havoc with the providers that work in multiple regions. Also throw into the mix that not all providers keep up on what the region is requesting of you... and we run into many situations that the local EMS and the Local hospitals are at odds.

That being said, I think that mechanism should play a part in the algorithm, but maybe a slightly lesser role than the physiological and anatomical concerns. In the example you brought up of the death in the car, passenger trauma alert... I would probably err on the side of caution and call an alert. If the one patient is so dead that he's not being worked, I would play it safe... if the dead guy is being worked... heck, you already called an alert... throw another shrimp on the barby! But in most other situations, I would rely on what you see and what you find, as opposed to the suspected force involved in the mechanism. I know that is the direction the system I work in has been headed... and I'm on board with it.

Nice topic BTW.

[AnthonyM83]

If like you said it's an issue of them not believing paramedics would bring in what they want . . . well, they're probably right. A paramedic would probably use things like mechanism and co-morbidity as trauma criteria, but they only want physiological and anatomical. Thus they make their rules such.

From what I've read, it's NOT very progressive. But within their non-progressive logic, it makes sense to have patients being brought in checked off by hospital. :-/

[CBEMT]

I should add that I've read our trauma center's trauma activation criteria posted in ambulance triage, and it uses a mix of mechanism and anatomical/physiologic factors. For example, any trauma that comes in intubated is classed "Level 1A," while a fall from height without obvious signficant anatomical or physiologic will usually be a Level 2.

Anecdotally, I've had a 30-foot fall with no obvious injuries but +LOC at the time of incident go level 1, and a restrained MVA with chest pain go level 2. Many times the decision on trauma activation is made at the time of arrival at Ambulance Triage except for obvious activations from pre-arrival reports. Most EMS services will not necessarily say the words "trauma activation," because we've gotten so used to the activations on arrival and also it's not really part of established local procedure, but enough of us have a general idea of the criteria they use that we know what to say during the phone call to get them moving. I've taken to starting my trauma calls with "Hi, this is __________ with a Level 1......"

[ccmedoc]

Most Trauma centers I have been associated with use a combination of physiological criteria as well; such as vital signs and airway condition, where the injuries are, if they are penetrating or non penetrating, level of consciousness and any loss thereof.

Simply using MOI is not adequate, and puts a burden on the trauma team at times, but certainly plays into the scenario. I have also not been associated with the sublevels of trauma classes. Usually class I, class II, class III is enough.

Even though you call and indicate the patient meets the criteria in your eyes, an attending Physician needs to class it I am sure.

Why wast the time and effort with trying to activate, when simply giving a good report and pertinent findings may suffice. Any trauma patient that is stable and does not have any traumatic injuries "in the box" should be a class II at any rate. If the patient is going to an ACS certified trauma center, level I; the necessary individuals will be present when needed.

-I am not an advocate of activating the trauma team because of mechanism or even from the field. Just relaying the pertinent information and allowing the E.D. time to prepare..