Police rapid trauma transport

[paramedicmike]

It seems that this study was recently undertaken in Philadelphia. Results will be published (if they haven't been already) in the Annals of Emergency Medicine.

It certainly opens the door for further study.

Thoughts?

[island emt]

There was a study done in cities like Cleveland, Chicago ,memphis &Atlanta back in the late 80's that looked at mortality outcomes from trauma pt's dropped off at ER's by their friends and those delivered by Paramedic level ambulances.

The gang banger with a penetrating GSW dropped at the ER door by his crew had a better chance of survival than one treated by ALS.

They determined that the ALS crews were taking almost twice as long to deliver them to definitive care.

This was about the same time they looked at the effectiveness of Mast trousers & decided to do away with them.

Philly does it because they are so understaffed with ambulances.

[Just Plain Ruff]

I also think that because we are so saddled with protocols and the thought process that we must get such and such done and if we don't get an IV and a tube that we are somewhat less of a medic, then that's why it takes us more time to get the patient to definitive care.

If we scooped and ran and got them to the hospital like the gang bangers friends did, then I think outcomes would be different, but we have 21'st century medicine on our side which saves lives dammit

[History Nut]

I have been retired for over ten years now but still remember the frustration of having to follow full protocol when I knew that the patient would best benefit from rapid transport. The study cited looks at end outcome which is the kind of study that is in fashion in medicine for the last 15-20 years. Results do speak for themselves but the conclusions drawn are flawed. The police unit that gets on scene first AND has the proper training/experience to recognize the need for rapid transport is the correct solution in those circumstances. However, the LEOs I worked with catagorically didn't want to be involved in patient care in any way. Granted, if a fellow officer was the patient, they thought nothing of scooping them into the police car and taking them to the hospital. Their problem was not understanding the Trauma system and they often took them to the ER that they 'liked' instead of the best for the patient.

ALS units took longer times because they risked more in the form of censure/discipline if they didn't "check all the boxes" in their patient care. Sometimes we tried to scoop and run only to be met with demands for a full report by the base station while performing an emergency transport. Then when we arrived at the ER, we were met with a lot of questions like: "no I.V.?", "he should be in full c-spine?" and others. I tried to make the point at a tape review once that it took time to apply everything the base ordered in the field and then we still had to transport. Requiring base personnel to ride along more often would have helped the understanding of the different roles but it didn't happen enough.

The study of outcomes only leaves out the most important part: why is there a difference?. I hope they are going to look into the why beyond the short-sighted idea that "ALS must not work because outcomes are poorer." There needs to be training not so much with the field personnel but with ER staff that just because the patient arrives by ALS unit they shouldn't demand full ALS treatment to have been applied and instead to rely on the good judgement of their trained and experienced medics.

[ERDoc]

History, I agree and disagree with you. You can draw valid conclusions from the study. They looked at pts transported by PD because it is a convenient population for comparison. It was basically a way to compare a population that received no care in the field other than rapid transport versus a population that received ALS. It's not saying that ALS is bad, it is saying that it is important that the pt get to the ER (probably the OR) as soon as possible and staying on scene to provide a full ALS transport may increase mortality. It is not the ALS that is the problem, it is the time required to provide the ALS that is the issue. I do agree that if an ALS crew rolls in with such a pt that they will get a ration of shit from the hospital staff. This will take a culture change at the hospital, more from nursing than the physicians. As an aside, I discussed this article on a LinkedIn group and here was a comment provided:

"Philly PD has been doing this for literally years. When I was an EMT in Cherry Hill in the 70s and early 80s, Philly often transported trauma and other serious medical patients in the back of PD vans. We saw it all the time. They may have started the study recently, but the practice is well over 40 years old. Part was necessitated by a lack of ambulances in the city back then (since resolved) and LOTS of trauma. To my knowledge they never stopped doing it. Also, this was common practice in Westchester County in the 70s. Bronxville, Mt Vernon and White Plains often did the same thing."

[paramedicmike]

The lack of ambulances in the City of Philadelphia has not been resolved. They are still woefully short in both ambulances and crews. However, the rest of the thoughts ERDoc posted are pretty spot on.