Quick decision at a MVC

[zippyRN]

Isn't there any concept in your country (as I recall we have at least USA, Canada, Australia, NZ, UK, Netherlands and Mexico here) to occasionally add transport capacity for non-regular emergencies in your area despite mutual aid?

We have rapid response squads specialised in transport, prepared for multi casualty scenarios. Two ambulances per squad can be sent out in 10-30 minutes, volunteer based (mostly EMT level). In our little district we have two of those squads, so I can easily double transport capacity within short time. Additionally we have two volunteer treatment units that each may buffer 25 patients until transport could be set up. All of them have a call volume of about 2 per year (the vollies serve in regular EMS to keep in shape). That is even where we have a lot of ambulances (ground and air) available on mutual aid basis.

Wonder if such things exists and/or are commonly used in your country. If not, and if you encounter such scenarios often, it may be a good idea...what does you hinder?

EDIT: typo

UK point of view and speaking purely from the point of view of SJA equipment

2007 Floods we put 4 ambulances (3 type B CEN and 1 pre CEN A+E vehicle) an RRV (double manned) and a PTS bus out in under an hour from the call being recieved by the crewing co-ordinator. we've also excercised and had standabys where the same response has been ready...

there's also all the kit for rest centres and /or 'field hospital' either ready packed in the incident support vehicles / trailers or there on the shelves to be loaded

there's also all the CBRN and USAR kit that NHS HART have prepacked on their support tenders

Edited November 5, 2011 by zippyRN

[mobey]

Wish I could give ya'll a run down of what really took place, but the reality is, I was a Paramedic responding with 2 BLS ambulances that day. Little technical/political as to how that happened... but it will never happen again.

What I DID do was get 2 fixed wings in the air before we even arrived at hospital. Seems petty, but it was the first time fixed wing has been dispatched from scene in this area.

Thought: Does patient #1 or Patient #2 present a clear "need" for ALS intervention?

QUOTE DFIB;

I would like you guys to help me a little with this.

Ask and ye shall recieve

My rationale for the BLS transporting the decorticate patient is that his prognosis is poor in survival and quality of life,

Time to learn how to learn!

Indulge me: Find 2 articles from reliable sources (NOT Wiki!) that patients with head injuries presenting with decorticate posturing, have a poor prognosis and copy the links into this thread.

If he is stable the BLS should be able to handle bagging him without a tube and CPR if needed.

Is he stable?

If the medics protocol allow him to load some meds to help with edema he should have additional advantages.

You will have to explain this a little further......??

Patient two on the other hand has the possibility of surviving and having a decent recovery. I would place the most experienced care with him.

There is a Paramedic with 1 year experience, and an EMT with 14years experience. So who takes him?

Looking forward to your responses

Edited November 6, 2011 by mobey

[HellsBells]

From an Alberta point of view? I'd say pt #1 needs ALS, The second pt would initially require some BLS type NaCl, at least to get the systolic above 90mmHg, the aggressiveness of which should be titrated as to whether you think its high space shock, or a bleed (assuming thats possible). If the BP doesn't respond to fluid, there is of course some ALS options here, but to me the altered GCS guy seems like the priority here.

[mobey]

From an Alberta point of view? I'd say pt #1 needs ALS, The second pt would initially require some BLS type NaCl, at least to get the systolic above 90mmHg, the aggressiveness of which should be titrated as to whether you think its high space shock, or a bleed (assuming thats possible). If the BP doesn't respond to fluid, there is of course some ALS options here, but to me the altered GCS guy seems like the priority here.

Initially I was with you on this one, but then got thinking about it further.

DD of Patient #2 is high space shock. NaCl bolus may get us to our desired MAP initially, but with a 30min transport, it is a temporary fix. The guy is showing a clinical need for a pressor, and we can be certain that it will only get worse.

If Patient #1 is oxygenating/Ventilating on his own with OPA and NRB or BVM, then why does he need ALS at this point? Although he is unCx, I would consider him the more "stable" at this point since his hemodynamics are condusive with life as compared with our other patient.

I think I initially leaned towards Patient#1 since Airway is an area we can make a real difference in, however feild intubation in TBI is a controversial subject at best, and without trismus or vomiting, it is pretty hard for me to justify walking away from a critical hypotensive neurogenic shock, to "ALS up" an airway that is being managed by BLS.

Great discussion!

[rock_shoes]

Initially I was with you on this one, but then got thinking about it further.

DD of Patient #2 is high space shock. NaCl bolus may get us to our desired MAP initially, but with a 30min transport, it is a temporary fix. The guy is showing a clinical need for a pressor, and we can be certain that it will only get worse.

True it is likely to get worse. With a 30 minute transport time I would still probably send this patient with the BLS crew. First off fluid therapy is most likely going to do the trick within a 30 minute window. The receiving facility, even if it is a D&T, should be able to run pressors on arrival if need be. Secondly, outside of Alberta, few ALS units stock pressors, nor do they have guidelines/protocols that allow for their use with a history of trauma.

If Patient #1 is oxygenating/Ventilating on his own with OPA and NRB or BVM, then why does he need ALS at this point? Although he is unCx, I would consider him the more "stable" at this point since his hemodynamics are condusive with life as compared with our other patient.

I think I initially leaned towards Patient#1 since Airway is an area we can make a real difference in, however feild intubation in TBI is a controversial subject at best, and without trismus or vomiting, it is pretty hard for me to justify walking away from a critical hypotensive neurogenic shock, to "ALS up" an airway that is being managed by BLS.

How long can we really expect this patient’s airway to remain patent on its own? How long before this patient seizes? This patient’s already exhibiting s/s of a serious TBI. I understand intubation in TBI is controversial but no airway still equals dead.

In an ideal world both these patients would go ALS but more often than not the rural/remote environment simply doesn’t provide those resources.

[DFIB]

Wish I could give ya'll a run down of what really took place, but the reality is, I was a Paramedic responding with 2 BLS ambulances that day. Little technical/political as to how that happened... but it will never happen again.

What I DID do was get 2 fixed wings in the air before we even arrived at hospital. Seems petty, but it was the first time fixed wing has been dispatched from scene in this area.

Thought: Does patient #1 or Patient #2 present a clear "need" for ALS intervention?

QUOTE DFIB;

Thanks for getting around to giving it a stab! I was begining to wonder if anyone was going to give some rationale. I was beggining to enjoy watching folke measure their ambulances

I would like you guys to help me a little with this.

Ask and ye shall recieve

My rationale for the BLS transporting the decorticate patient is that his prognosis is poor in survival and quality of life,

Time to learn how to learn!

Indulge me: Find 2 articles from reliable sources (NOT Wiki!) that patients with head injuries presenting with decorticate posturing, have a poor prognosis and copy the links into this thread.

http://www.utmedicalcenter.org/your-health/encyclopedia/general/003300/

http://www.merckmanuals.com/professional/injuries_poisoning/traumatic_brain_injury_tbi/traumatic_brain_injury.html

If he is stable the BLS should be able to handle bagging him without a tube and CPR if needed.

Is he stable?

His vitals are stable. Of course his condition could deteriorate quickly. If the medic could load the meds before transport this could be retarded. “I would consider him the more "stable" at this point since his hemodynamics are conducive with life as compared with our other patient.” MOBEY

If the medics protocol allow him to load some meds to help with edema he should have additional advantages.

You will have to explain this a little further......??

Under the suspicion of cerebral edema, if the medic could give him a dextrose solution, osmotic diuretic and corticosteroid like Dex it would in my opinon prolong the stability of the patients vital signs.

Patient two on the other hand has the possibility of surviving and having a decent recovery. I would place the most experienced care with him.

This guy gets the one year medic. In a lot of places where the rig is run by an EMT and a medic. All the EMT does is drive the truck and carry stuff. This would be different from a unit where the EMT is the "in charge on every call" So being an EMT with 14 years experience could mean he is a really good ambulance driver and had 14 years to forget all the stuff he learned in school. I am still going with the medic because empirical experience will not make up for education and extended protocols.

There is a Paramedic with 1 year experience, and an EMT with 14years experience. So who takes him?

lookin

Looking forward to your responses

[mobey]

I see your sources, and raise you these:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014350/pdf/jnnpsyc00500-0049.pdf

Instead of another study, I will ask you to re-read your first source, and examine whether it truly indicates a prognosis or not?

I do not have a problem with ALS taking Patient #1, as you can see in my later posts.

I do have a real problem with you sending him BLS because he has less of a chance of walking out of the hospital. In a way your kind of "writing off" this patient with very limited education of head injuries. Just doing quick google searches we were able to find science that is conflicting on decorticate posturing as a prognostic indicator in TBI. Yet your 1st instinct was to send the guy BLS because..... well, because that was your instinct!

That is why we treat with science (Evidence based medicine, where the evidence exists).

His vitals are stable. Of course his condition could deteriorate quickly. If the medic could load the meds before transport this could be retarded. “I would consider him the more "stable" at this point since his hemodynamics are conducive with life as compared with our other patient.” MOBEY

Not to be taken out of context DFIB.

You did not answer the question though

Under the suspicion of cerebral edema, if the medic could give him a dextrose solution, osmotic diuretic and corticosteroid like Dex it would in my opinon prolong the stability of the patients vital signs.

Ahhh... I see!

I can say with confidence that you will not see Cerebral edema treated pre-hospitally in the early phases of head injury.

These drugs/solutions used for reducing ICP have some heafty side effects and when used improperly can do irreversible damage. I would be veeeery surprised to hear anyone out there giving mannitol or other such drugs in this setting.

As a side note... You would be hard pressed to find a Medic who would swing such a large hammer at the patient, then turn the patient over to the BLS crew.

This guy gets the one year medic. In a lot of places where the rig is run by an EMT and a medic. All the EMT does is drive the truck and carry stuff. This would be different from a unit where the EMT is the "in charge on every call" So being an EMT with 14 years experience could mean he is a really good ambulance driver and had 14 years to forget all the stuff he learned in school. I am still going with the medic because empirical experience will not make up for education and extended protocols.

Thought we were gonna have to have a discussion on education vs experience..... Glad to see no one has led you down the wrong path.

[DFIB]

I see your sources, and raise you these:

http://www.ncbi.nlm....c00500-0049.pdf

Instead of another study, I will ask you to re-read your first source, and examine whether it truly indicates a prognosis or not?

I do not have a problem with ALS taking Patient #1, as you can see in my later posts.

I do have a real problem with you sending him BLS because he has less of a chance of walking out of the hospital. In a way your kind of "writing off" this patient with very limited education of head injuries. Just doing quick google searches we were able to find science that is conflicting on decorticate posturing as a prognostic indicator in TBI. Yet your 1st instinct was to send the guy BLS because..... well, because that was your instinct!

That is why we treat with science (Evidence based medicine, where the evidence exists).

His vitals are stable. Of course his condition could deI mean teriorate quickly. If the medic could load the meds before transport this could be retarded. “I would consider him the more "stable" at this point since his hemodynamics are conducive with life as compared with our other patient.” MOBEY

Not to be taken out of context DFIB.You did not answer the question though Thirty minutes is a long time. Hard to say. I mean all I can go with are the vitals and the tel Aviv prognosis that he is 94% gonna make it so I guess he is stable at the moment and could be in the 6% the next. What do you think.

Prety impressive study with important results. It is a pretty old study. Why hasn't it permiated more of the literature. I mean the links I gave you were not hand picked. Just the first two that popped up that were not "Wiki" one marks a poor prognosis, and the other sais the final result is frequently coma and all kinds of nasty stuff. I mean if the Tel Aviv results were the norm I would expect to see the prognosis listed as positive in most instances. Could the Tel Aviv study been an exception?

So here is a question for you. Can you find two studies from other hospitals that are not "wiki" links. that support the Tel Aviv study results. Please post the lnks in this thread.

Under the suspicion of cerebral edema, if the medic could give him a dextrose solution, osmotic diuretic and corticosteroid like Dex it would in my opinon prolong the stability of the patients vital signs.

Ahhh... I see!

I can say with confidence that you will not see Cerebral edema treated pre-hospitally in the early phases of head injury.

These drugs/solutions used for reducing ICP have some heafty side effects and when used improperly can do irreversible damage. I would be veeeery surprised to hear anyone out there giving mannitol or other such drugs in this setting.

As a side note... You would be hard pressed to find a Medic who would swing such a large hammer at the patient, then turn the patient over to the BLS crew.

Ok so it can't be done. Would a medic use any of these methods if the patient was going to be transported under his own care? Do ALS ambulances carry osmotic diureticsIs? Is just the mannitol problematic or the Dex and hypertonic solutions as well?

This guy gets the one year medic. In a lot of places where the rig is run by an EMT and a medic. All the EMT does is drive the truck and carry stuff. This would be different from a unit where the EMT is the "in charge on every call" So being an EMT with 14 years experience could mean he is a really good ambulance driver and had 14 years to forget all the stuff he learned in school. I am still going with the medic because empirical experience will not make up for education and extended protocols.

Thought we were gonna have to have a discussion on education vs experience..... Glad to see no one has led you down the wrong path.

Good bait, excelent presentation, water temp is right, no bite.

Edited November 7, 2011 by DFIB

[HellsBells]

Well, here is another thought... I still stand by my plan to take the head injured pt ALS, but yes the neurologically impared pt does deserve a ALS care, however this is obviously not a perfect world and somebody has to go in the BLS unit. I agree with Mobey that intubations on trauma pts are controversial, but in many instances that is because they delay your transport time. If youre already looking at a half hour transport, push any RSI drugs you may need while moving, pull over to place the tube, shouldn't delay you that much.

The thing that I find kind of amusing out of this whole discussion is that in the actual situation, Mobey's service had to transport both pts in BLS units anyway. That said, do you know what the pts outcomes were, post fixed wing transport?

[systemet]

Initially I was with you on this one, but then got thinking about it further.

(...)

I think I initially leaned towards Patient#1 since Airway is an area we can make a real difference in, however feild intubation in TBI is a controversial subject at best, and without trismus or vomiting, it is pretty hard for me to justify walking away from a critical hypotensive neurogenic shock, to "ALS up" an airway that is being managed by BLS.

I think you can definitely make the counter-argument that paramedic RSI in head-injured patients is associated with poor outcomes in one historically-controlled study, and minimal benefit in the only RCT that's been performed. Furthermore, the patient appears to be oxygenating / ventilating appropriately at the current time. We know that this may be tenuous, and we know that there's likely multisystem trauma here. So there's a good argument for controlling the airway. We know that if this is done with RSI in the hospital environment that it improves outcomes. In EMS the data is less clear.

The second patient is decompensating, but is still only borderline unstable, as they're GCS 15. It's also likely that this may change. Though their initial managment is going to be a fluid bolus, it's possible that pressors may be needed +/- airway control, depending on what other injuries declare themselves during transport. There's indication for ALS here.

I think I still stand by my original choice, though. I think the distinction is we know we'd like to RSI the head injury. We know we'd like to give analgesia to the spinal injury. Life over limb. There's a potential the spinal cord injury may need pressors, which may be life-saving --- but we probably need to fluid bolus first, and evaluate whether there are other injuries before we proceed down that path. The problem here is that we would like to have two ALS rigs, a pair of incoming helicopters, and maybe a couple of BLS backup rigs for extra hands, and a whole ton of resources that just aren't available. Established triage guidelines allow us to declare the obvious DOA, and devote our limited resources to the two remaining criticals. But beyond that, we don't have tools to make a judgment as to which patient is going to benefit the most. As I said earlier, I think that unfortunately you end up getting judged on how well you chose based on the patient's final dispositions, which is monumentally unfair.

With a decent medical director / supervisory chain, it should be enough that you can justify and motivate your choices. It's not your fault that an accident of this magnitude occurs in an area / time when there's not enough resources to manage it in an optimal manner. It sounds like by launching fixed wing you saved valuable time.