Prehospital Medical-Legal Issues Amy Gutman MD [email protected].
Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education [email protected].
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Transcript of Amy Gutman MD EMS Medical Director ALS / BLS Continuing Education [email protected].
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Objectives
Historical development of triage
Relationship between triage & development of trauma systems
How changes in triage affect resources
Review Region V Trauma Triage Guidelines
“Those who cannot remember the past are condemned to repeat it.” ~George Santayana
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The “Disease” of Trauma
Leading killer in US of persons <44 yo, however: Life or limb-threats in 10% of all
trauma pts 150,000 deaths annually 44,000 MVC 28,000 GSW
Most expensive “disease” in terms of lost wages, initial care, rehabilitation & lifelong maintenance
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Triage
French: “to sort, cull or select”
Evaluation & classification of casualties initially for evacuation & treatment of battlefield wounded
Greatest good for greatest number
Prior to 1700s rank trumped injury
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Napoleonic Wars Baron Dominique–Jean Larrey was
Napoleon’s Surgeon Major during Rhine Campaign (1792-1798)
Developed “Flying Ambulance” (1797) to transport wounded off battlefield
Goal was treatment within 24 hrs Rescue casualties based on injury not rank Immediate treatment Transport to 1st line hospitals
Baron Pierre Percy developed alternative “Casualty Transport System” to transport surgeons & supplies to patient 1st “Mobile Hospitals”
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American Civil War
1847: Congress authorizes 1st commissions for medical officers
1861: Battle of Bull Run Medical corps dysfunction
○ Too few ambulances○ Minimal organization○ Casualties not evacuated for days
Prompted 1862 appointment of 1st Surgeon General Bill Hammond
1862: 2nd Battle of Bull Run Dr Letterman appointed Medical
Director Army of Potomac Revised ambulance core
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Jonathan Letterman MD
“ Napoleonic” casualty care
Transferred all medical care to Army Medical Corps
Reformed medical supply distribution
Triage by Medical Corps provided 1st prehospital standards of care
3 Tiered Evacuation System Field Dressing / Aid Station Field Hospital / MASH Unit Large Hospitals
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World War I Collecting Zone
Advanced field aid stations
Evacuating Zone Clearing Hospital
Distributing Zone Rest Stations
Transport based upon “self-evacuation” ability
○ “Lyers” vs “Walkers”
“Casualty Clearing Hospitals” MASH “Specialty” Surgeons: Abdominal,
Orthopedics, Plastics Minimum10% operative rate
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World War II
Radio communications
Resuscitation
Antibiotics
1st Air Transport
Development of Echelon System
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WWII Echelon System
1st Echelon: “Physician First” Treat & Street after emergent
procedures No holding capacity but could treat
300-500 wounded simultaneously
2nd Echelon: Secondary triage 72 hour holding OR Capable Supported 3-9 Aid Stations
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WWII Echelon System
3rd Echelon Combat Support Hospitals / MASH
units Advanced care capable of facility rapid
evacuation
4th Echelon Full spectrum of hospitals with
rehabilitation capabilities outside combat zone
Definitive care Limited to no mobility
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Korean War
Increased use of aeromedical transport
Directly transported most seriously injured patients, bypassing “inappropriate” facilities
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Trauma-Related Deaths*
*Includes environmental & post-operative complications
War # / 1000
Mexican 104
Civil 71
Spanish-American 34
WWI 17
WWII 0.6
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Patient Outcomes & Time to Definitive Care
War Time Mortality
WWI 12-18 hrs 8.5%
WWII 6-12 hrs 5.8%
Korea 2-4 hrs 2.4%
Vietnam 65 mins 1.7%
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Civilian Trauma System Evolution
1966 NHTSA “White Paper” Highway Safety Act of 1966 “Accidental Death and Disability: The Neglected Disease of Modern Society”
detailed MVC pts dying from initial trauma & inadequate prehospital care 1st statewide prehospital system in 1969 in Maryland
1971 Illinois Trauma Program Trauma center categorization Advanced communications Safer ambulance designs Improved prehospital training Trauma Registry development / CQI
1973-1976 ACS publishes “Optimal Hospital Resources for Care of the Injured Patient”
resulting in the Emergency Medical Services Act
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Civilian Trauma System Evolution
1990: ACS “Trauma Care Systems Planning & Development
Act” established guidelines, funding & state-level leadership for trauma system development
1992“Model Trauma Care System Plan” introduced concept of
“Inclusive” vs “Exclusive” SystemsAssumes all acute care facilities are part of a larger
integrated systemTiered approach based on known quantity of available &
invariable resources
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“Exclusive” Trauma Systems
Centralizes all injuries regardless of severity to tertiary centers
Excludes acute care facilities with variable capabilities
Over-triage to avoid under-triage
Problems Payer mix Triage based on likelihood of admission
vs tiered resource utilization Non-participation of uncategorized
facilities Lack of MCI training
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Trauma Triage Leads to Trauma Care Systems
CDC / ACS / NHTSA Trauma Triage Guidelines assist providers in triaging pts to the proper facility
Guidelines offer pt-specific destination criteria for definitive treatment
Development of a Trauma Care System integrates prehospital & hospital care to reduce cost, time to OR / ICU, & mortality
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Elements of a Functional Trauma
System Defined Need, Authority & Legislation
Standardized Care with Adaptive Changes Based Upon Resources
Tiered Triage Based on Injury Severity, With Mechanisms to Bypass Lower Echelons
Rapid Transport & Concurrent Treatment Utilizing Standardized Care
Integration of Advanced Technology
Commitment to Training
Outcomes Driven Model
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Triage Tools Problems
“One Size Fits All” No, it doesn’t Populations & resources vary & change
Mature & busy systems have better outcomes
Incident influences outcomes
Changes in triage absolutely affect system resources & patient outcomes
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Triage Tools
START
Trauma Index
Trauma Score / RTS
CRAMS Score Circulation, Respiration, Abdomen, Motor,
Speech
Prehospital Index
Trauma Triage Rule
Kampala Triage
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Anatomically based global severity scoring system that classifies each injury in every body region according to its severity on a 6 point scale: 1 = Minor 2 = Moderate 3 = Serious 4 = Severe 5 = Critical 6 = Maximal (unsurvivable)
9 body regions: Head Face Neck Thorax Abdomen Spine Upper Extremity Lower Extremity External & other
Take highest AIS each of the 3 most severely injured body regions, square each AIS & add the 3 squared numbers together ISS = A2 + B2 + C2
ISS scores ranges from 1 to 75 AIS 0-5 for each category
If any of the 3 scores is a 6, the score is automatically set at 75
Since a score of 6 indicates futility of further medical care in preserving life, this generally means a cessation of further care
Abbreviated Injury Scale (AIS) Injury Severity Score (ISS)
A major trauma requiring a Trauma Center is defined as an ISS > 15
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ACS Field Triage Decision Scheme
Physiologic Criteria
Anatomic Criteria
Mechanism Criteria
Age & Co-morbidities
“When In Doubt Take To A Trauma Center” Criteria
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Physiologic Criteria (Vitals)
1st triage step identifies pts at high risk of suffering from severe injuries: Hypovolemic shock Neurogenic shock Cardiogenic shock Traumatic brain injury
However, critical injuries resulting in “shock” may not be reflected early in vitals due to physiologic compensation
“Do not pass “GO”, Do not collect $100”
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Anatomic Criteria
2nd step evaluates injuries related to anatomical location
Penetrating trauma may cause significant injury dependent on area Proximal long bone fractures, pelvic
fractures & amputations all cause major bleeding
Skull fractures place pt at risk due to bleeding & increased ICP
Paralysis indicative of spinal trauma
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Mechanism of Injury
Significant mechanism of injury often assoc with internal injuries masked by early physiologic compensation
Mechanism alone not enough to determine triage destination
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Special Considerations
Use of anticoagulants (clopidogrel, aspirin, warfarin, NSAIDs)
Bleeding disorder (i.e. hemophiliacs)
Special Popuations Geriatrics (>70) Pediatrics Pregnancy
○ Physiologic changes: increased CO & TBV, hypercoagulability○ High risk of abruption with “minor” trauma
Provider impression Sick vs Not Sick? Not Sick with high potential for Sick?
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Densmore. Outcomes and delivery of care in pediatric injury. J Ped Surg. 2006.
PURPOSESite of care must be correlated with outcomes to design
effective pediatric trauma care systems
Results80,000 injury cases in 27 statesGrouped by age, ISS & site of care89% received care outside of children's hospitals If 0-10 yrs with ISS >15, mortality, LOS & charges all
significantly higher in adult hospitals
CONCLUSIONSYounger & seriously injured children have improved outcomes in
children's hospitals
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Caterino. Modification of Glasgow Coma Scale criteria for injured elders. Acad Emerg Med. 2011
CONCLUSIONS52,412 pts In elders, mortality & TBI increased with GCS decreasing
from 15 to 14 & 14 to 13 In adults, mortality did not increase with the GCS drop-offs
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Trauma & Co-Morbidities
0
10
20
30
40
50
60
None One Two Threeor More
Avg. Age vs. #Medical Problems
0
10
20
30
40
50
60
None One Two Threeor
More
ICU Admit % vs. #Medical Problems
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Trauma & Co-Morbidities
00.5
11.5
22.5
33.5
44.5
5
None One Two Threeor More
Mortality % vs. #Medical Problems
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Appendix J: Air Medical Transport Protocols
Does not require Med Control approval, but does require oversight
Nearest Appropriate Facility: Uncontrolled airways unless ALS can intercept in a more timely
fashion Arrest due to blunt trauma
Air Medical Transport If meets specific criteria & scene arrival time to arrival time at
nearest appropriate hospital, including extrication time > 20 mins Location, weather or road conditions preclude ground ambulance Multiple casualties exceed capabilities of local agencies
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Appendix J: Air Medical Transport Protocols Patient Conditions
Physiologic Criteria Unstable vitals (SBP <90, RR >30 or <10)
Anatomic Criteria Spinal cord injury
Severe Blunt Trauma: ○ Head Injury (GCS <12)○ Severe chest, abdominal or pelvic injuries excluding simple hip fractures
Burns: ○ >20% BSA 2nd or 3rd degree burns○ Airway, facial or circumferential extremity○ Associated with trauma
Penetrating injuries of head, neck, chest, abdomen or groin
Amputations of extremities, excluding digits
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Appendix J: Air Medical Transport Protocols Patient
Conditions Special Conditions considered in
decision to request air medical transport, but not automatic or absolute
MVC Ejected Death in same compartment Pedestrian struck & thrown >15 ft, or
run over
Significant Medical History Age >55 or <10 Significant coexistent illness Pregnancy
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Cudnik. Prehospital factors associated with mortality in injured air medical patients. PEC. 2012
BACKGROUND: Air medical transport provides rapid transport to definitive care. Overtriage & the
expense & transportation risks may offset survival benefits
RESULTS: 557 pts transported by air to a level 1 trauma center. Majority were male (67%),
white (95%) with an injury rurally. Most injuries were blunt (97%), & pts had a median ISS of 9. Overall mortality 4%
Most common reasons for air transport were MVC with high-risk mechanism (18%), MVC speed >20 mph (18%), GCS <14 (15%), & LOC >5 mins (15%)
Factors with high mortality: age >44 yrs, GCS <14, SBP <90 mmHg & flail chest Most common trauma indicators resulting in death, receipt of blood, surgery, ICU
admission included EMS ETI, >2 fractures of humerus/femur, neurovascular injury, cranial crush or penetrating injury, failure to localize to pain on examination, GCS <14
CONCLUSIONS Few prehospital criteria assoc with clinically important outcomes in helicopter-
transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated & developed
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1,200 trauma admits/year
Pts w/ ISS >15 (240 total or 35 pts/surgeon)
Immediate surgical capability available
In-house trauma surgeon
General surgery residency program or trauma fellowship
Research
No minimum patient criteria
Surgical capability available in a “reasonably acceptable time”
General surgeon present at resuscitation
Desirable to have residents
No research minimum
LEVEL I TRAUMA CENTER LEVEL II TRAUMA CENTER
Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation
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Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation
Level III “Community” Trauma Center Specialized ED with majority of
subspecialties on-call
Level IV Rural community hospitals No immediate surgical
interventions available Stabilize & transfer
Uncategorized Essentially a Level IV not
participating in ACS classification “Free-standing” EDs
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Trauma Center DesignationsACS Committee on Trauma / State site verification & accreditation
Specialty Centers Neurocenters Burn Centers Pediatric Trauma Hyperbaric Medicine Microsurgery
Most have “Medical Specialties” certified by Joint Commission MICU CICU / Cath Lab Stroke Centers
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MA State Trauma Centers
Region I Baystate (Level 1 Adult & Pediatric);
Springfield Berkshire Medical Center (Level 2 Adult
& Pediatric); Pittsfield
Region II UMass Memorial (Level 1 Adult Trauma
& Pediatric); Worcester
Region III Anna Jaques Hospital (Level 3 Adult);
Newburyport Beverly Hospital (Level 3 Adult);
Beverly Caritas (Level 3 Adult); Methuen Salem Hospital (Level 3 Adult); Salem Lawrence General Hospital (Level 3
Adult); Lawrence Lowell General Hospital (Level 3 Adult);
Lowell)
Region IV Beth Israel (Level 1 Adult); Boston BMC(Level 1 Adult & Pediatric); Boston Brigham & Women’s (Level 1 Adult);
Boston Boston Children’s (Level 1 Pediatric);
Boston Lahey Clinic (Level 2 Adult); Burlington Massachusetts General (ACS Level 1 Adult &
Pediatric); Boston Tufts / NEMC (Level 1 Adult & Pediatric);
Boston
Region V No verified ACS Trauma Centers
Rhode Island Rhode Island Hospital (Level 1 Adult);
Providence Hasbro Hospital (Level 1 Pediatric); Providence
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Mass ACS Verified Trauma Centers
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Quality Improvement (CQI / QA)
Data & Trauma Registry Data retrieval system for trauma
patient information Used to evaluate & improve the
trauma system as well as provide individual feedback
CQI Examine system performance to
improve outcomes Evaluate calls to determine if
standard of care met Relies upon accurate & complete
documentation
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Transport Decisions
Should be based upon “evidence-based” criteria
Can critical problems be managed en-route
Use Medical Control early & often
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Summary
The lessons of battlefield medicine created civilian trauma systems
Triage tools best understood within the context of the type of system they serve
As field resources change so must trauma systems
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References
Bucher. Does Your Patient Need A Trauma Center? EMS World. 2011
Loftus. Banner Good Samaritan Medical Center. Statewide Trauma Rounds, 2007.
Bledsoe. Essentials of Paramedic Care. 2006. OEMS Prehospital provider Protocols. March 2012. Mosby, Brady, Caroline. Prehospital Care Textbooks.
“Trauma” References cited throughout presentation.