I’ve lectured and written in some venues about my concerns about some of the structure of EMS in the United States. The wide disparity of experience and training among EMS providers even in the same county can make it extremely difficult to have low variability high quality care. However EMS providers as a whole are incredibly diligent dedicated personnel who want to do the right thing for patients just like doctors they can let their ego get in the way, and they need to avoid doing that as much as possible.
The main difficulty of EMS operations is that experience with major trauma is lacking in many EMS organizations. In a lecture that I gave at a trial symposium in Cleveland I stated that on average and EMS provider in a 100-200,000 person county will see a major trauma patient maybe once a month whereas these patients are ubiquitous on the trauma service of a level I center. However in the EMS realm trauma is a relatively simple condition to treat. It mainly involves rapidly evaluating and triaging the patient, initiating some basic care which can be either BLS or ALS, activating aeromedical when appropriate, and most important taking the patient to the right hospital. It is been shown in multiple scientific studies that triaging patients to an inappropriate hospital or to a low level trauma center when the difference in time between that transported transport to a level one or two center is minimal puts the patient at a disadvantage and impair survival. It is very difficult for an EMS provider to make a complex transport decision on the spur of the moment without thinking of this previously and without some preplanning. That’s why it is vital for the trauma center to go out into their EMS community and even drawn a map to show where they should take a critical patient first to a nondesignated hospital or level III Trauma Ctr. and where they should contact aeromedical transport and bring the patient directly to the level I or 2 Trauma Ctr. It is vital that they have good systems for activating aeromedical transport that allow the transfer to be put on standby upon the receipt of the call that may involve a critically injured patient, that they launch when the first EMS provider comes on the scene and confirms a critical patient, and that they have a good relationship and preplanned landing zones to allow the helicopter personnel to get to the scene quickly and evacuate the patient rapidly.
There are basically two transport modes or possibly 3-D EMS provider can choose from. They can transport the patient in their own ambulance, they can transport the patient by helicopter, or they could meet in ALS transport ambulance in route and bring a medic into their BLS ambulance to provide advanced life support. When I was coming up and EMS in the 1980s the third option was used very frequently because there was a feeling that ALS possess some magical properties that could save the patient. It was not surprising that further scientific study realize that the 3 to 4 ounces of normal saline that the patient received from the ALS provider did not compensate for the delay in meeting up with that provider. I do feel are some instances where ALS is lifesaving. Those are instances with a difficult airway or when an airway cannot be obtained by the BLS provider. However in those situations the time course is extremely short and delays are often fatal.
The patient arrives in the trauma bay with a king airway in place. Almost immediately an anesthesiologist and emergency medicine resident the head of the bed started preparing to remove the king airway in place and endotracheal tube. The patient’s oxygen saturation’s were above 90% in the patient’s breath sounds were good. At this point the team leader was unsure of whether a king airway was sufficient for the rest of the resuscitation phase, therefore they exceeded to the wishes of anesthesia in emergency medicine and allow them to change the airway. After removing the king airway and, as you can expect, the patient vomited aspirated and it took several attempts to place the endotracheal tube. The patient’s oxygen saturation’s dropped they went into respiratory failure rapidly and had a long hospital course. From this instance we undertook a literature review of King Airways and other supersonic airways and determined that there was no reason to remove the king airway during the resuscitation phase if the patient had good oxygen saturation’s and good breath sounds as well as a chest x-ray that did not show any significant pathology caused by the airway. If it became our policy that if breath sounds were good and oxygen saturation’s were above 90% we believe the king airway in place for the resuscitation and initial diagnostic phases.
We still find it extremely common in the hospital that supraglottic airways are thought to be trash. However some of us who have EMS experience know that these supraglottic it airways can be lifesaving. Therefore we adapted our care to allow them to be used in the hospital. Beyond my trauma center responsibilities, I also think that laryngeal mask airways and King Airways could be lifesaving in those patients in the hospital who have extremely difficult airways and have tried to convince our resuscitation teams to use them and to stock them.
I have found that hospital providers are much less comfortable with respiratory distress then EMS providers. Due to the fact that EMS providers are not used to obtaining definitive airways, and the fact that they do not see the results of long periods of respiratory distress (respiratory failure, tracheostomy, and occasionally death) they can often feel that simply transporting rapidly with lights and sirens is sufficient treatment to someone and who is having respiratory difficulty. I would say in general this is understandable and is in some way safe when the providers have limited airway experience and little or no experience with rapid sequence intubation. However you will find most emergency medicine physicians anesthesiologist and trauma surgeons are far more comfortable having a patient with an endotracheal tube than they are with any other option.
Emergency medical services ability to manage shock is limited. This can be a significant detriment to survival when transport times are long it is why the decision for picking the appropriate transport mode needs to take these factors into account. Basically EMS has crystalloid and Dopamine as their therapies for shock. In general dopamine is not indicated in many EMS protocols for hypovolemic shock and is only indicated for cardiogenic and occasionally septic shock. Most if not all EMS agencies did not have access to blood or plasma transport. This is changing in some sophisticated aeromedical services and the military but as a general rule crystalloid is the only fluid available.
In addition EMS does not possess techniques for advanced vascular access other than large bore IV catheters. While some EMS agencies experimented the central line placement, and several line placement, this is certainly not routine. Comp occasions of these techniques in EMS setting basic etiquette. In addition both the state takes require a fair amount of experience and practice and attempting to put a several line once every six months is likely not going to be successful. I myself have seen cases where the lines have caused fatal complications by the place superior to the inguinal ligament or by infusing large amounts of fluid into the retroperitoneum. Thus the patient with hypertension especially the trauma EMS is limited to placing large IV’s and initiating crystalloid resuscitation. They can be very a compass that the skills it is also extremely helpful to have IV axis with patient survival trumps. However any delay in transport to get IV access or to infuse a limited amount of not optimal. All of these therapy should be undertaken on the patient is moving towards the trauma center. Another problem is the mounting evidence that crystalloid is poison for trauma patients. It has problems as a resuscitation fluid, you can have immunosuppressive properties, and it can also worsen acidosis. Though as long ago as 70 years plasma was able to use the European and Japanese is more still seem unable to be able to provide plasma in the prehospital setting in the US. I’m hopeful that research in the next few years will allow us to find it more useful prehospital resuscitation fluid.
Other adjuncts such as MAST trousers have fallen by the wayside and are almost historical at this point. While the Iraq and Afghanistan wars put increased emphasis on the use of tourniquets there is some evidence presented recently with regards active shooter incidents that may indicate that of the civilian realm tourniquets are less important than they were in the military conflicts. However it is essential that every prehospital vehicle equipped with easy-to-use and effective tourniquets and personnel are well trained in their use. It as an important role of the trauma center to aid with this education and provide opportunities for EMS providers to learn in a simulated setting.
Splinting and immobilization
There is probably no greater moving target in the prehospital realm than in the areas of splinting and immobilization. Both of these areas have undergone tremendous change in just the past five years. When I was trained as an EMT in the early 1980s we were taught extensively in the placement of traction splints and other splints and were taught to try the place limbs in their normal anatomic position in almost all instances. At the present time EMTs are taught to position extremities as they lay unless there is obvious evidence of neurovascular compromise, and simple straightening to anatomic position should be performed. Other than controlling bleeding with pressure dressings there is little else that can be done mangled or injured extremities of the prehospital area. One tool that I would like to mention of Israeli combat dressings and hemostatic dressings I found both of these products to be incredibly useful in the lacerations that are associated with major extremity fractures. The lacerations tend to bleed slowly but extensively over a period of time and and because the bleeding does not appear life-threatening it can often cause significant amounts of blood loss. In several instances I’ve used the Israeli compression hemostatic dressing over open fracture sites to easily control this bleeding and prevent unneeded blood loss. For deep wounds with significant bleeding hemostatic gauze can be packed into the wind can be very effective. Trauma surgeon should stress all the prehospital providers to never place individual pieces of gauze the globe with. When clot forms is very easy to not be able to identify this these individual pieces of gauze and they can remain to dwell in the wounds and cause infection over time. EMTs should be told to you to use one long piece of dressing or to tie a knot between two long pieces addressing to ensure that when you remove the most superficial piece you will be able to the deeper dressing
Regarding spinal mobilization there’s been tremendous change in the last several years. Formerly great effort was spent in the prehospital area to ensure spinal alignment and to minimize movement for victims of blunt and penetrating trauma. However recent studies have demonstrated that spinal immobilization provides very little overall protection for the cervical thoracic of our spines and that in the absence of grossly unstable fractures they do more harm than good. For those of us that work with EMS closely with spent a great deal of time trying to steer a middle road between not immobilizing anyone and staying with our full immobilization schemes. The conclusion many medical directors of come to is that awake patients without spine pain or tenderness, regardless of mechanism, can move themselves to stretchers where a cervical collar can be secured and the patient can be transported to the hospital without a backboard. We still have a great deal of anxiety over the unconscious patient and feel the full immobilization is still required. However in a boon to many EMS agencies, the practice of standing on mobilization work through four EMTs are acquired to take a standing virtually asymptomatic patient and secure them onto a backboard in a highly complex evolution will hopefully become historical. In addition full mobilization for victims of penetrating trauma in the absence of clear neurological deficits has been abandoned.
It is vital that the trauma center maintain situational awareness of the EMS protocols that are being put in place they’re referring agencies. Trauma centers should be diligent about providing transporting agencies with feedback concerning the patient that they bring in, missed injuries, immobilization deficits, and other problems that can improve the care to injured patients. It is also vital that trauma centers listen to complaints and criticism from EMS providers concerning communication, feedback, handoff of care, and resuscitation room practices. EMS providers must always be thought of as team members of the trauma team and must be viewed as such.