Benefit for Trauma Patients

[Guest guest]

Kenny, you know more than you think. The interventions you mention are now

all now subject to serious scrutiny. There is now evidence that (1)

aggressive fluid resuscitation does more harm than good (that's OLD stuff), (2)

HEMS

makes no difference in patient outcomes at all, and (3) spinal " immobilization "

is not only a misnomer but makes no difference in outcomes in the long run.

Further, intubation is not the standard, ventilation is. And, as Dr.

Bledsoe has pointed out, recent research has shown that time on scene has no

effect

upon patient outcomes.

So where does this leave us? Are there any interventions that do make a

difference? Yes, but not those. When we can correct an immediate threat to

life, such as clearing an obstructed airway and ventilating the patient, reverse

a severe asthma attack and ventilate our patient, stop uncontrolled external

bleeding, reverse pulmonary edema, reverse an anaphylactic reaction, reverse

severe hypoglycemia, defibrillate and stop ventricular fibrillation, cardiovert

V-tach, SVT, stop seizures, and so forth, we do make a difference. And we

generally need to do those things immediately, and on scene.

None of those conditions benefit from helicopter transport. None of them

benefit from Code 3 transport.

What MAY benefit? Uncontrolled internal bleeding that must be fixed in the

OR. Fulminating increase in ICP that needs the services of a neurosurgeon.

Treatment for STEMI and strokes are dependent upon getting the patient to the

right place within certain time windows. That might involve HEMS or fixed

wing transport when long distances to hospitals with cathlab capabilities are

far away. But in urban areas, HEMS is not needed, doesn't help, and can have

a catastrophic outcome.

It is difficult not to become mesmerized by toys. We all love our toys.

The grander the toy, the more we like it. But most of the time, big toys do

not save lives.

Take a look at what EMS does in other countries, and the first thing you'll

notice is that their toys are smaller and fewer than ours; yet, in some ways

they do a better job than we do.

I submit that we should be taking a hard look at what we do and how we do it

and concentrate on those things that actually do improve patient outcomes

rather than things that make a lot of noise and create excitement.

We must stop the abuse of our systems by taking every patient involved in a

MVC at 40 mph or better, every patient in a rollover, one involved in a MVC in

which another person was killed, one who fell a certain number of feet, and

those who meet other artificial criteria to the Level I. The folks at the

Level 1 need to get a grip and stop telling us to do those things.

Instead, we need to learn to assess our patients better and make better

transport decisions. When we risk life and limb to rush a patient to a trauma

center only to have the patient walk out two hours later, we have not done

anything heroic.

Gene G.

Gene G.

In a message dated 10/22/08 3:10:43 PM, kenneth.navarro@...

writes:

>

> " spenair " wrote:

>

> >>> If you have the ability under your guidelines to perform an

> intervention that benefits your patient, a few more seconds or

> minutes on scene will not cause more harm IMHO. <<<

>

> I reached into my pocket and found two cents, so I though I would

> throw them in.

>

> This above quoted statement is very interesting and begs an important

> question. What field intervention( question. What field interventi

> patients? (I'm assuming " benefit " refers to an improvemnt in long

> term outcome.)

>

> Intuitively, we can all think of things we believe are beneficial,

> but are they really?

>

> Intubation may not be a benefit, aggressive fluid replacement may not

> be a benefit, helicopters may not be a benefit, spinal motion

> restrictions may not be a benefit (even in serious trauma patients).

>

> The more I learn, the more I realize how little I actually know.

>

> Kenny Navarro

>

>

>

**************

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[Guest guest]

" spenair " wrote:

>>> If you have the ability under your guidelines to perform an

intervention that benefits your patient, a few more seconds or

minutes on scene will not cause more harm IMHO. <<<

I reached into my pocket and found two cents, so I though I would

throw them in.

This above quoted statement is very interesting and begs an important

question. What field intervention(s) provides a benefit for trauma

patients? (I'm assuming " benefit " refers to an improvemnt in long

term outcome.)

Intuitively, we can all think of things we believe are beneficial,

but are they really?

Intubation may not be a benefit, aggressive fluid replacement may not

be a benefit, helicopters may not be a benefit, spinal motion

restrictions may not be a benefit (even in serious trauma patients).

The more I learn, the more I realize how little I actually know.

Kenny Navarro

[Guest guest]

Dudley,

I agree. This year I have had the privilege of teaching SLAM to a bunch of

Army and Air Force medics, together with some high powered physicians who are

in the forward areas. Some of those people are right now in Afghanistan and

Iraq.

In talking with the docs and PAs who have had experience there and have

returned for another tour, what you are saying is the same thing that they are

saying.

They get more blast injuries than we see, and they have to sometimes do

things like use QuikClot type stuff and pack wounds on the battlefield, and

tourniquets are now back IN and elevation and pressure points are OUT, but it is

those interventions that are saving lives. Airway and bleeding control are the

things that save trauma patients.

They are also always changing their ideas as they learn more. At one point

they were having field medics pack abdominal wounds, getting them to the field

unit, cleaning them out and stopping bleeding and then shipping them open to

the next hospital. Latest I have heard is that they are now recognizing that

infection is a problem and now going ahead and closing those folks before the

next move.

I would like to know what they are doing about spinal " immobilization " in

front-line units. Do you know how they're approaching trauma that we would

" assume " spinal injury and fully collar and board. Are they doing anything

different from that?

Where can we get up-to-date printed information on the latest battlefield

interventions and techniques?

GG

>

> Gene,

>

> Talking to the military trauma folks here in SA...they are learning some

> more things about trauma as well...when we stop the bleeding and ventilate the

> patients appropriately. Talking to the military trauma folks here Talking to

> the military trauma folks here in SA...they are learning some more things

> about trauma as well...when we stop the bleeding and ventilate the patients

> appropriately.<wbr>..trauma patients fall into 3 categories..<wbr>.those who

die

> from the trauma, those who will die, no matter what happens and no matter how

> fast they get to surgery and those who, pending unforeseen issues (infection,

> complicati

>

> Dudley

>

> Re: Benefit for Trauma Patients

>

> Kenny, you know more than you think. The interventions you mention are now

> all now subject to serious scrutiny. There is now evidence that (1)

> aggressive fluid resuscitation does more harm than good (that's OLD stuff),

> (2) HEMS

> makes no difference in patient outcomes at all, and (3) spinal

> " immobilization "

> is not only a misnomer but makes no difference in outcomes in the long run.

> Further, intubation is not the standard, ventilation is. And, as Dr.

> Bledsoe has pointed out, recent research has shown that time on scene has no

> effect

> upon patient outcomes.

>

> So where does this leave us? Are there any interventions that do make a

> difference? Yes, but not those. When we can correct an immediate threat to

> life, such as clearing an obstructed airway and ventilating the patient,

> reverse

> a severe asthma attack and ventilate our patient, stop uncontrolled external

> bleeding, reverse pulmonary edema, reverse an anaphylactic reaction, reverse

> severe hypoglycemia, defibrillate and stop ventricular fibrillation,

> cardiovert

> V-tach, SVT, stop seizures, and so forth, we do make a difference. And we

> generally need to do those things immediately, and on scene.

>

> None of those conditions benefit from helicopter transport. None of them

> benefit from Code 3 transport.

>

> What MAY benefit? Uncontrolled internal bleeding that must be fixed in the

> OR. Fulminating increase in ICP that needs the services of a neurosurgeon.

>

> Treatment for STEMI and strokes are dependent upon getting the patient to

> the

> right place within certain time windows. That might involve HEMS or fixed

> wing transport when long distances to hospitals with cathlab capabilities

> are

> far away. But in urban areas, HEMS is not needed, doesn't help, and can have

> a catastrophic outcome.

>

> It is difficult not to become mesmerized by toys. We all love our toys.

> The grander the toy, the more we like it. But most of the time, big toys do

> not save lives.

>

> Take a look at what EMS does in other countries, and the first thing you'll

> notice is that their toys are smaller and fewer than ours; yet, in some ways

> they do a better job than we do.

>

> I submit that we should be taking a hard look at what we do and how we do it

> and concentrate on those things that actually do improve patient outcomes

> rather than things that make a lot of noise and create excitement.

>

> We must stop the abuse of our systems by taking every patient involved in a

> MVC at 40 mph or better, every patient in a rollover, one involved in a MVC

> in

> which another person was killed, one who fell a certain number of feet, and

> those who meet other artificial criteria to the Level I. The folks at the

> Level 1 need to get a grip and stop telling us to do those things.

>

> Instead, we need to learn to assess our patients better and make better

> transport decisions. When we risk life and limb to rush a patient to a

> trauma

> center only to have the patient walk out two hours later, we have not done

> anything heroic.

>

> Gene G.

>

> Gene G.

>

> In a message dated 10/22/08 3:10:43 PM, kenneth.navarro@...

> writes:

>

> >

> > " spenair " wrote:

> >

> > >>> If you have the ability under your guidelines to perform an

> > intervention that benefits your patient, a few more seconds or

> > minutes on scene will not cause more harm IMHO. <<<

> >

> > I reached into my pocket and found two cents, so I though I would

> > throw them in.

> >

> > This above quoted statement is very interesting and begs an important

> > question. What field intervention( question. What field interventi

> > patients? (I'm assuming " benefit " refers to an improvemnt in long

> > term outcome.)

> >

> > Intuitively, we can all think of things we believe are beneficial,

> > but are they really?

> >

> > Intubation may not be a benefit, aggressive fluid replacement may not

> > be a benefit, helicopters may not be a benefit, spinal motion

> > restrictions may not be a benefit (even in serious trauma patients).

> >

> > The more I learn, the more I realize how little I actually know.

> >

> > Kenny Navarro

> >

> >

> >

>

> ************ *

> Play online games for FREE at Games.com! All of your favorites,

> no registration required and great graphics – check it out!

> (http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.

> http://www.games.http://wwhttp://www.gameshttp)

>

>

[Guest guest]

Gene,

Talking to the military trauma folks here in SA...they are learning some more

things about trauma as well...when we stop the bleeding and ventilate the

patients appropriately...trauma patients fall into 3 categories...those who die

from the trauma, those who will die, no matter what happens and no matter how

fast they get to surgery and those who, pending unforeseen issues (infection,

complications, etc) will survive...they may need timely interventions in the

hospital...but the time factor really isn't an issue (not meant to be read that

we can hang on scene for ever...just that we need to be efficient, not

reckless).

Dudley

Re: Benefit for Trauma Patients

Kenny, you know more than you think. The interventions you mention are now

all now subject to serious scrutiny. There is now evidence that (1)

aggressive fluid resuscitation does more harm than good (that's OLD stuff), (2)

HEMS

makes no difference in patient outcomes at all, and (3) spinal " immobilization "

is not only a misnomer but makes no difference in outcomes in the long run.

Further, intubation is not the standard, ventilation is. And, as Dr.

Bledsoe has pointed out, recent research has shown that time on scene has no

effect

upon patient outcomes.

So where does this leave us? Are there any interventions that do make a

difference? Yes, but not those. When we can correct an immediate threat to

life, such as clearing an obstructed airway and ventilating the patient, reverse

a severe asthma attack and ventilate our patient, stop uncontrolled external

bleeding, reverse pulmonary edema, reverse an anaphylactic reaction, reverse

severe hypoglycemia, defibrillate and stop ventricular fibrillation, cardiovert

V-tach, SVT, stop seizures, and so forth, we do make a difference. And we

generally need to do those things immediately, and on scene.

None of those conditions benefit from helicopter transport. None of them

benefit from Code 3 transport.

What MAY benefit? Uncontrolled internal bleeding that must be fixed in the

OR. Fulminating increase in ICP that needs the services of a neurosurgeon.

Treatment for STEMI and strokes are dependent upon getting the patient to the

right place within certain time windows. That might involve HEMS or fixed

wing transport when long distances to hospitals with cathlab capabilities are

far away. But in urban areas, HEMS is not needed, doesn't help, and can have

a catastrophic outcome.

It is difficult not to become mesmerized by toys. We all love our toys.

The grander the toy, the more we like it. But most of the time, big toys do

not save lives.

Take a look at what EMS does in other countries, and the first thing you'll

notice is that their toys are smaller and fewer than ours; yet, in some ways

they do a better job than we do.

I submit that we should be taking a hard look at what we do and how we do it

and concentrate on those things that actually do improve patient outcomes

rather than things that make a lot of noise and create excitement.

We must stop the abuse of our systems by taking every patient involved in a

MVC at 40 mph or better, every patient in a rollover, one involved in a MVC in

which another person was killed, one who fell a certain number of feet, and

those who meet other artificial criteria to the Level I. The folks at the

Level 1 need to get a grip and stop telling us to do those things.

Instead, we need to learn to assess our patients better and make better

transport decisions. When we risk life and limb to rush a patient to a trauma

center only to have the patient walk out two hours later, we have not done

anything heroic.

Gene G.

Gene G.

In a message dated 10/22/08 3:10:43 PM, kenneth.navarro@...

writes:

>

> " spenair " wrote:

>

> >>> If you have the ability under your guidelines to perform an

> intervention that benefits your patient, a few more seconds or

> minutes on scene will not cause more harm IMHO. <<<

>

> I reached into my pocket and found two cents, so I though I would

> throw them in.

>

> This above quoted statement is very interesting and begs an important

> question. What field intervention( question. What field interventi

> patients? (I'm assuming " benefit " refers to an improvemnt in long

> term outcome.)

>

> Intuitively, we can all think of things we believe are beneficial,

> but are they really?

>

> Intubation may not be a benefit, aggressive fluid replacement may not

> be a benefit, helicopters may not be a benefit, spinal motion

> restrictions may not be a benefit (even in serious trauma patients).

>

> The more I learn, the more I realize how little I actually know.

>

> Kenny Navarro

>

>

>

**************

Play online games for FREE at Games.com! All of your favorites,

no registration required and great graphics – check it out!

(http://pr.atwola.com/promoclk/100000075x1211202682x1200689022/aol?redir=

http://www.games.com?ncid=emlcntusgame00000001)