Implementation

Regional Emergency Medicine The American experience

Paul Mc Quaid NREMT-P

Implementation

South Shore Hospital Level 3 Trauma Center

• Located on Boston’s South Shore

• 436 bed acute general hospital

• 2nd busiest ER in state of Massachussetts

• 78,000 ER visits per year

• Services a population of 1.2 million

• Approx. 38 trauma cases per month

Implementation

South Shore Hospital Emergency Department

• 72 Beds ED providing services in:– Acute– Semi-acute– Urgent Care– Geriatric ER– Paediatric ER– Emergency Dept. Transitional Care Unit

South Shore HospitalParamedic Services

• Non Transporting ALS

• Services 16 towns

• 400 sq mile coverage area

• 3rd busiest in the state of Massachussetts

• 6,800 ALS calls per year

Implementation

Trauma Centre Designation

• Hospitals receive trauma designation as Level 1 - 4 after thorough application and review process carried out by American College of Surgeons.

• Level 1 Trauma facilities must have in house General Surgery, Neurosurgery, Emergency Services and Anaesthesia 24 hours per day.

• Additional medical and surgical sub specialties available on call and promptly available

• active teaching programmes and trauma research programmes.

Implementation

Trauma Centre Designation

• Level 2: Don’t have same teaching or research requirements

• reduced subspecialties on call

• Level 3: 24 hr ED but in-house surgenry not required at all times.

• Level 4: mostly rural hospitals - stabilisation and transport

Implementation

Trauma Team made up of personnel from:

• Anaesthesiology• Critical care • Internal medicine • Paediatrics • Orthopaedics • Respiratory therapy

• Radiology• Cardiology• Neurology• Obstetrics• ICU services• Chaplaincy

Implementation

Level 1 CriteriaAdult & Paediatric

Physiological

• Adult: Confirmed BP<90 at any time

• Respiratory compromise, obstruction and/or intubation

• Resp rate <10 or > 30 (adult)

• Abnormal resp rate for age

• O2 sats <90%

• CPR in the field

• Transfere from other hospitals who are receiving blood to maintain vital signs

• Hypothermia (<30C or 90F)

• Emergency Physician’s discretion

Implementation

Level 1 CriteriaAdult & Paediatric

Anatomical

• All GSW to neck, Chest or abdomen

• All other penetrating injuries to any body region with large blood loss at scene, exsanguiating haemorrhage or expanding haematoma

• Open or suspected depressed skull fractures

• Pelvic fractures

• Major impalement of any body area

• Burns >15% or involving airyay/face

• Blunt or penetrating injury to:

• Neck:

– Air bubbling from wound

– difficulty with phonation

– saliva in wound

– Signs of cerebral infarction

• Chest:

– massive haemothorax (>1500cc/blood)

– massive open wound

• Abdomen:

– evisceration or large open wound

– rapidly expanding abdomen

Anatomical

• All GSW or penetrating trauma to head,neck, thorax or abdomen.

• Open or suspected depressed skull fracture

• Pelvic Fractures

• Burns >15% or involving face/airway

Anatomical

• All other penetrating injuries to any body region with large blood loss at scene

• Exsanguinating haemorrhage or expanding haematoma

• Multiple long-bone fractures

• Amputations

Anatomical

• Neck:

– Air bubbling from wound

– difficulty with phonation

– saliva in wound

– Signs of cerebral infarction

– Spinal chord injury with neurologic deficit

• Chest:

– Massive haemothorax (>1500cc/blood)

– Massive open injury

– Flail Chest

Anatomical

Anatomical

• Abdomen:– Evisceration or large open

wound

– Rapidly expanding abdomen

– Significant blunt trauma with unstable vital signs

Mechanism

Implementation

Mechanism

• Death at the scene• Ejection from vehicle• Falls > 10 - 15 feet• Destruction of the vehicle • Intrusion into passenger compartment

Implementation

Mechanism

• Motorised vehicle v’s pedestrian @ > 20mph and/or significant impact (windscreen broken, pt. thrown or run over)

• All aeromedical evacuations• Near-drowning with associated trauma

Ground v’s Air Transport

• Air:

• Fast

• Transport to Level 1 facilityAccess to Additional interventions, not available on the ground

• Expensive

• Limited by weather conditions

• Max. 2 patients per flight

Ground v’s Air Transport

• Ground:

• Slow, depending on distance

• Traffic

• Some services reluctant to leave their service area

Case # 1

• 16 yo female

• GSW to head

• GCS 3

• Airway Compromised

• HR 100, BP 166/110, RR 10

POSITIVE

TRAUMA

ALERT

Transport to Closest Appropriate facility

Case # 2

• 21 yo male

• Stab wound to left chest

• Airway patent

• GCS 15

• BS on left

• BP 90/P, HR 130

POSITIVE TRAUMA ALERT

Case # 3• 17 year old male• entrapped for 25 mins• open femur fracture• GCS 6• BP 98/60 -HR 116 - RR 6

POSITIVE TRAUMA ALERT

Transport to Closest Appropriate facility

Pt looses pulse en route to LZ

Implementation

Case # 4

• 8 year old near- drowning in pool

• No signs of trauma• Intubated on scene• Normal brachial

pulse• Responsive to deep

pain.

Near Drowning is NOT considered trauma unless

injury accompanies it!

Implementation

Summary

• EMS providers need to be aware of local hospital’s facilities & capabilities

• All significant trauma must be transported to an appropriate trauma centre

• EMS providers must transport to the closest hospital if there is compromise to: Airway, Breathing or Circulation

• Increased survival rates when trauma patients are transported to Trauma Centres.