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Rural Trauma Transfer Rural Trauma Transfer Issues: CREST Symposium Issues: CREST Symposium John E. Sutton, Jr. MD, FACS John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Chief, Division of Trauma and Acute Surgical Illness Acute Surgical Illness Dartmouth Dartmouth - - Hitchcock Medical Center Hitchcock Medical Center
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Page 1: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Rural Trauma Transfer Rural Trauma Transfer Issues: CREST SymposiumIssues: CREST Symposium

John E. Sutton, Jr. MD, FACSJohn E. Sutton, Jr. MD, FACSChief, Division of Trauma and Chief, Division of Trauma and

Acute Surgical IllnessAcute Surgical IllnessDartmouthDartmouth--Hitchcock Medical CenterHitchcock Medical Center

Page 2: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

ObjectivesObjectives

Rural Trauma Rural Trauma SystemSystem

Clinical transfer Clinical transfer issuesissues

System transfer System transfer IssuesIssues

Page 3: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

What Is Rural Trauma?What Is Rural Trauma?

•• When optimal care of injured patients is delayed When optimal care of injured patients is delayed or limited by geography, weather, distance, or or limited by geography, weather, distance, or resourcesresources

•• Often a low volume experience that demands Often a low volume experience that demands continuous evaluation and education to continuous evaluation and education to maintain optimal skillsmaintain optimal skills

ACS Committee on Trauma, 2006ACS Committee on Trauma, 2006

Page 4: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

What is Rural Trauma?What is Rural Trauma?

…… 84% of U.S. residents can 84% of U.S. residents can reach a Level I or Level II trauma reach a Level I or Level II trauma

center within an hour, but only center within an hour, but only 24% of residents in rural areas 24% of residents in rural areas have access within one hour have access within one hour ……

Branas et al. Health Services Research 2000

Presenter
Presentation Notes
FACT – Read – we are doing the job for some of our citizens but not for all….
Page 5: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

What is Rural Trauma? What is Rural Trauma?

…… death rate in rural area is death rate in rural area is inversely related to the inversely related to the population density population density ……

Baker et al, Baker et al, NEJM NEJM 19871987

Presenter
Presentation Notes
FACT – Read -
Page 6: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

What is Rural Trauma?What is Rural Trauma?

…… nearly 60% of all trauma nearly 60% of all trauma deaths occur in rural areas deaths occur in rural areas

despite the fact that only 20% despite the fact that only 20% of the nationof the nation’’s population live s population live

in these areas in these areas ……

Report on Injuries in AmericaReport on Injuries in AmericaNational Safety Council National Safety Council -- 20032003

Presenter
Presentation Notes
FACT – read – first identified in the late 1980s – affirmed recently by the National Safety Council
Page 7: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Trauma SystemsTrauma Systems

Increased time to definitive care Increased time to definitive care associated with higher mortality ratesassociated with higher mortality ratesTrauma system development reduces Trauma system development reduces risk of death from injuryrisk of death from injury

Sampalis JS et al. Journal of Trauma, 1999Sampalis JS et al. Journal of Trauma, 1999Nathens AB. J Trauma, 2000Nathens AB. J Trauma, 2000

Page 8: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Minor Moderate Severe

Exclusive System

Inclusive System

Scope of a Trauma Care System

Injury Severity

#Pts.

Page 9: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

SuttonSutton’’s Five Cs Five C’’s of s of Trauma CareTrauma Care

ComprehensiveComprehensiveCommunicationCommunicationConsistencyConsistencyCostCostCommitmentCommitment

Page 10: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

CHALLENGES OF RURAL CHALLENGES OF RURAL PRACTICE SETTINGPRACTICE SETTING

Geographic Geographic distancesdistancesHealth delivery Health delivery system under stresssystem under stressSupporting Supporting programs lackingprograms lackingRural practitioners Rural practitioners isolated isolated

Page 11: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Specialty Shortages (Availability)Specialty Shortages (Availability)NeurosurgeryNeurosurgery

OrthopedicsOrthopedics

Trauma SurgeonsTrauma Surgeons

Nursing personnelNursing personnel

Page 12: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Consequences of ShortagesConsequences of Shortages

Lack of experience with trauma careLack of experience with trauma care

Shifting of patients for definitive careShifting of patients for definitive care

Overloading Tertiary ResourcesOverloading Tertiary Resources

Delay in definitive treatmentDelay in definitive treatment

Page 13: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock
Page 14: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Clinical Transfer IssuesClinical Transfer Issues

Spinal immobilizationSpinal immobilization

Unstable trauma transfersUnstable trauma transfers

Transfers for technologyTransfers for technology

““MinimalMinimal”” Brain traumaBrain trauma

Delays in transferDelays in transfer

Page 15: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock
Page 16: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Unconscious Patient With No Neurologic Deficit

Spiral Screening CT Scan of the Entire Neck (1.3 mm cuts with reconstruction)

Normal CT scan

Abnormal/Questionable CT scan

Keep in Collar

Official Staff Film Interpretation = NL

Tertiary survey in a.m.Able to participate with P.E.

DoneRemove collar

Obtunded

Spine Consult

MRI

Abnormal

Page 17: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Leave Leave ‘‘em in the collar and em in the collar and boardedboarded

Page 18: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Unstable Trauma TransfersUnstable Trauma Transfers

Case Hx:Case Hx:72 yo male crashed into a tree. ? Pulse at the 72 yo male crashed into a tree. ? Pulse at the

scene. CPR startedscene. CPR startedArrived at ED, no pulse, V FibArrived at ED, no pulse, V FibDefibrillated x1, Sinus tachycardia. BP 70/Defibrillated x1, Sinus tachycardia. BP 70/Pupils mid positioned and fixedPupils mid positioned and fixedCXR = normal;CXR = normal; FAST negative; abdomen softFAST negative; abdomen soft

Call for Transfer?? DHART??Call for Transfer?? DHART??

Page 19: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

OutcomeOutcome

DHART calledDHART calledIn flight pt. develops V fibIn flight pt. develops V fibDefibrillation x5, ACLS protocolsDefibrillation x5, ACLS protocolsArrives DHMC, full CPRArrives DHMC, full CPRPronounced after 5 minutesPronounced after 5 minutes

Appropriate transfer??Appropriate transfer??

Page 20: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Case History 1.Case History 1.31 yo man in ATV 31 yo man in ATV accident, accident, transported from a transported from a rural hospitalrural hospitalHistory of von History of von WillebrandWillebrand’’s s DiseaseDiseaseBlood pressure Blood pressure stable, but stable, but hematocrit has hematocrit has decreased over the decreased over the last four hourslast four hoursFAST scan positive FAST scan positive for intrabdominal for intrabdominal fluidfluid

Page 21: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Case QuestionCase Question

1. What is your 1. What is your diagnosis?diagnosis?

Page 22: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Case QuestionCase QuestionDiagnosis: Diagnosis: Splenic Splenic Laceration from Laceration from Blunt TraumaBlunt TraumaWhat is your What is your next step in next step in treatment?treatment?A. SurgeryA. SurgeryB. EmbolizationB. EmbolizationC. Close C. Close

ObservationObservation

Page 23: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Case QuestionCase Question

Splenic Splenic Arteriogram Arteriogram performedperformedLower pole of Lower pole of spleen shows spleen shows abnormal abnormal blush but no blush but no active bleedingactive bleedingWhat Now?What Now?

Page 24: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Case QuestionCase Question

Proximal Proximal embolization of embolization of splenic artery splenic artery performedperformedPatient required Patient required no further no further treatment for treatment for internal bleedinginternal bleeding

Page 25: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

CASE HISTORY 2.CASE HISTORY 2.

58 yo male fell 8 feet onto a basement 58 yo male fell 8 feet onto a basement crushed stone floorcrushed stone floor–– P.E. P.E. –– Chest = left chest wall tenderness; Chest = left chest wall tenderness;

decreased B.S.decreased B.S.–– Abd. = soft with no guarding. Left upper Abd. = soft with no guarding. Left upper

quadrent quadrent Tenderness (? Chest wall tenderness)Tenderness (? Chest wall tenderness)

Page 26: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

OSH Evaluation:OSH Evaluation:

CT abdomen = no evidence of free fluid or CT abdomen = no evidence of free fluid or visceral injury.visceral injury.

H/H = 12.2/ 36H/H = 12.2/ 36

CXR = CXR = ““poorpoor””

quality portable film. No quality portable film. No obvious hemopneumothoraxobvious hemopneumothorax

Admit to ICUAdmit to ICU

Page 27: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

48 hours later:48 hours later:

Increased SOBIncreased SOB

HR= 130HR= 130--140140

Full CT scan of chest = widened Full CT scan of chest = widened mediastinum mediastinum

Transferred to DHMC.Transferred to DHMC.

Page 28: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

DHMC Arrival: What diagnostic tool DHMC Arrival: What diagnostic tool to use?to use?

Ultrasound ( Transesophageal echo)Ultrasound ( Transesophageal echo)

Fine cut dynamic CT scanFine cut dynamic CT scan

AngiographyAngiography

Page 29: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Outcome:Outcome:Fine cut dynamic CT scan = confirmed Fine cut dynamic CT scan = confirmed evidence of ruptureevidence of rupture

Subsequent arteriogram in OR Subsequent arteriogram in OR facilitated placement of endovascular facilitated placement of endovascular stentstent

Position of stent was confirmed and Position of stent was confirmed and visualized by TEE (Echo)visualized by TEE (Echo)

Pt discharged the next dayPt discharged the next day

Page 30: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Minimal Brain InjuryMinimal Brain Injury

Hx of amnesia (canHx of amnesia (can’’t remember t remember the accident)the accident)

HeadacheHeadache

DizzinessDizziness

GCS = 13GCS = 13--1515

Transfer ??Transfer ??

Page 31: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Minimal Brain InjuryMinimal Brain InjuryWestern Trauma Assoc. Western Trauma Assoc. –– 2766 pts. GCS 132766 pts. GCS 13--15 15 –– None of 1170 with normal CT deterioratedNone of 1170 with normal CT deteriorated

Stein and RossStein and Ross–– 658 pts. GCS 13658 pts. GCS 13--1515–– 542 normal CT = no deterioration542 normal CT = no deterioration

Dacey et. al.Dacey et. al.–– 610 pts GCS 13610 pts GCS 13--1515–– Discharge if CT normalDischarge if CT normal

East GuidelinesEast Guidelines–– Pts. With normal CT have a 0Pts. With normal CT have a 0--3% chance of deterioration 3% chance of deterioration

usually with GCS 13usually with GCS 13--1414

Page 32: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Time to definitive careTime to definitive careInjury to final hospitalInjury to final hospital

Rural environmentRural environmentInterfacility transferInterfacility transfer

Injury Arrive Initial

Hospital

Depart Initial

Hospital

Arrive TraumaCenter

Decision to Transfer

Page 33: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

CASE HISTORY 3.CASE HISTORY 3.

37 Y.O. MALE PEDESTRIAN 37 Y.O. MALE PEDESTRIAN STRUCK BY CAR STRUCK BY CAR

TRAVELLING 40TRAVELLING 40--50 MPH ; 50 MPH ; LANDED IN A LANDED IN A

SNOWBANK.TRANSPORTED SNOWBANK.TRANSPORTED BY CAR TO LOCAL BY CAR TO LOCAL

HOSPITAL.HOSPITAL.

Page 34: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

V.S.V.S. BP 70/50BP 70/50 P= 60P= 60 R= 22R= 22

GEN: NON RESPONSIVE , + ETOHGEN: NON RESPONSIVE , + ETOHCHEST: CLEAR AND SYMETRIC CHEST: CLEAR AND SYMETRIC BSBSABD: TENDER LOWER ABD: TENDER LOWER ABDOMENABDOMENPELVIS: TENDER ; LARGE PELVIS: TENDER ; LARGE SCROTAL HEMATOMASCROTAL HEMATOMARECTAL: NORMAL , HEME NEGRECTAL: NORMAL , HEME NEGEXTREM.: SYMETRIC BUT COLDEXTREM.: SYMETRIC BUT COLD

Page 35: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

RESUSITATION / RESUSITATION / EVALUATIONEVALUATION

6 LITERS CRYSTALLOID; 2UNITS 6 LITERS CRYSTALLOID; 2UNITS PCPCH/H 14/41; ONE HOUR LATER 8.6/25H/H 14/41; ONE HOUR LATER 8.6/25CXR = NEG CXR = NEG PELVIS = SPELVIS = S--I I DISRUPTION , WIDENED DISRUPTION , WIDENED SYMPHYSISSYMPHYSIS26 MGS. OF MSO4 GIVEN FOR PAIN26 MGS. OF MSO4 GIVEN FOR PAINTRANSFERRED TO DHMC 3 HRS TRANSFERRED TO DHMC 3 HRS AFTER INITIAL ARRIVALAFTER INITIAL ARRIVAL

Page 36: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

ARRIVAL DHMC:ARRIVAL DHMC:

BP = 80/ RAPIDLY TO ZEROBP = 80/ RAPIDLY TO ZEROP = 115 RR = 12 P = 115 RR = 12 CARDIOPULMONARY ARRESTCARDIOPULMONARY ARRESTASYSTOLIC , NO ASYSTOLIC , NO RESPIRATIONSRESPIRATIONSCODE: INTUBATED ; CODE: INTUBATED ; RESUSITATEDRESUSITATEDABG = 6.72/60/565ABG = 6.72/60/565

Page 37: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

RESUSITATION / RESUSITATION / EVALUATION in EDEVALUATION in ED

8.5 LITERS CRYSTALLOID; 6 8.5 LITERS CRYSTALLOID; 6 UNITS OUNITS O--NEG , 4 UNITS FFPNEG , 4 UNITS FFPHGB = 8.2HGB = 8.2 K+ = 4.5 K+ = 4.5

BUN/CR =12/2.1BUN/CR =12/2.1PT/PTT = 19/66 PT/PTT = 19/66 ABG = 7.07/38/556ABG = 7.07/38/556CXR, CCXR, C--SPINE, PELVIS SPINE, PELVIS CYSTOGRAM, RUQ FAST = NEGCYSTOGRAM, RUQ FAST = NEGCT HEAD = NEGATIVECT HEAD = NEGATIVE

Page 38: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

DEFINITIVE TREATMENTDEFINITIVE TREATMENT

O.R. :O.R. :PROCTOSCOPY NEGATIVEPROCTOSCOPY NEGATIVEEXTERNAL FIXATOR APPLIEDEXTERNAL FIXATOR APPLIEDCOMPARTMENT PRESSURES COMPARTMENT PRESSURES LLELLE

S Post = 8S Post = 8--10 D Post = 810 D Post = 8--1010 ANT= 15ANT= 15--2020 LAT = 15LAT = 15--2020

Page 39: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

DEFINITIVE TREATMENT: DEFINITIVE TREATMENT: Continued hemorrhageContinued hemorrhage

ANGIOGRAM SUITE: ANGIOGRAM SUITE: BLEEDING FROM THE LEFT BLEEDING FROM THE LEFT

HYPOGASTRIC ARTERY BRANCHESHYPOGASTRIC ARTERY BRANCHES

EMBOLIZATIONEMBOLIZATION

THROMBOSED LEFT POPLITEAL THROMBOSED LEFT POPLITEAL ARTERYARTERY

Page 40: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

RETURN TO O.R.:RETURN TO O.R.:

REVASCULARIZATION OF LLEREVASCULARIZATION OF LLE

4 COMPARTMENT 4 COMPARTMENT FASCIOTOMIESFASCIOTOMIES

TRANSFERRED TO ICUTRANSFERRED TO ICU

Page 41: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Delays in Interfacility TransportsDelays in Interfacility Transports

DHART transfers 1/1/04DHART transfers 1/1/04--12/31/04 n = 23812/31/04 n = 238–– Request PTA :Request PTA : 19.3% ( n = 46 )19.3% ( n = 46 )–– 00--59 min:59 min: 32.5% ( n = 77 )32.5% ( n = 77 )–– 6060--119 min:119 min: 23.1% ( n = 55 )23.1% ( n = 55 )–– 120120--179 min:179 min: 17.6% ( n = 42 )17.6% ( n = 42 )–– > 179 min:> 179 min: 7.5% ( n = 18 )7.5% ( n = 18 )

No statistical correlation between frequency of CT scanning or ISS and delayed request for transfer

Page 42: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Hospital Size and Time to Initiate Hospital Size and Time to Initiate TransferTransfer

<25 <25 (n=59)(n=59)

2525--50 50 (n=41)(n=41)

5151--100100(n=63)(n=63)

>100>100(n=75)(n=75)

PTAPTA 27%27% 32%32% 14%14% 13%13%

< 1 hour< 1 hour 36%36% 41%41% 24%24% 29%29%

11--2 2 hourshours 17%17% 19%19% 25%25% 27%27%

>2 hours>2 hours 20%20% 7%7% 37%37% 31%31%

Page 43: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Time to Initiation (ISS 15 vs >15)

0

5

10

15

20

25

30

35

PTA < 1 hour 1-2 hours > 2 hours

% o

f Pat

ient

s

Series1Series2ISS <15

ISS ≥15

Page 44: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock
Page 45: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

System Transfer IssuesSystem Transfer IssuesAccessing entry into the Level I centerAccessing entry into the Level I center

Available resources for transportAvailable resources for transport

Technology changes Technology changes –– CDs of CTsCDs of CTs

Lack of State Safety Support Lack of State Safety Support (e.g. no seat belt law)(e.g. no seat belt law)

FollowFollow--up / Feedbackup / Feedback

Page 46: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Whom do you call ?Whom do you call ?DHART Comm.DHART Comm.–– PatientPatient’’s name / DOBs name / DOB–– Referring physicianReferring physician–– Hospital call back numberHospital call back number

Connect with the Trauma Connect with the Trauma Surgeon on callSurgeon on call

Arrange transportation if Arrange transportation if desireddesired

1-800-650-3222

Page 47: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

DHARTDHART--Dartmouth Hitchcock Dartmouth Hitchcock Advanced Response TeamAdvanced Response Team

Air Transports 850+Air Transports 850+Ground 970+Ground 970+1800+ Annual Transports1800+ Annual TransportsInterhospital TransportsInterhospital Transports–– Trauma ~ 80%Trauma ~ 80%–– CardiacCardiac–– Critical Care Critical Care –– High Risk ObstetricsHigh Risk Obstetrics–– NeonatalNeonatal–– PediatricPediatric

Scene Calls 10%Scene Calls 10%

Page 48: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Thunderstorms

Fog

Blizzards

Can’t Fly !

Page 49: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Alternatives ?

Page 50: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Ambulance ServiceAmbulance ServiceAvailabilityAvailability

Level of trainingLevel of training

Leaving the community Leaving the community ““uncovereduncovered””

Undue delay waiting for DHART Undue delay waiting for DHART groundground

Page 51: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Technology ChangesTechnology Changes

CT scan details the CT scan details the injuryinjuryCT ReconstructionsCT ReconstructionsCT Available in all CT Available in all hospitalshospitalsNewer generations Newer generations with increased detail with increased detail and speedand speedDigital ImagingDigital Imaging

Page 52: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Technology Changes:Technology Changes:

Splenic TraumaSplenic Trauma–– Angiography for embolizationAngiography for embolizationThoracic arterial injuryThoracic arterial injury–– Angio with endovascular stentAngio with endovascular stentHepatic injuryHepatic injury–– Interventional radiology: drains, angio, stentsInterventional radiology: drains, angio, stentsSpinal Cord injurySpinal Cord injury–– MRIMRI

Page 53: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

38 yo male : Severe liver injury

Procedures:angioembolization of hepatic arteryERCP / Stentangio /StentIVC filterNumerous IR drainage procedures

Page 54: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

IssuesIssues

TechnologyTechnology

TechniqueTechnique

Inability to view studiesInability to view studies

Clinically indicatedClinically indicated

Page 55: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Not Necessarily !

Arrggh!

Page 56: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Potential ImpactPotential Impact

Delays in secondary triageDelays in secondary triagePatient safetyPatient safety–– Increased radiation exposureIncreased radiation exposure–– Delays in emergent careDelays in emergent careCostCost–– Patients billed twicePatients billed twice–– Burden to entire trauma systemBurden to entire trauma system

Page 57: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Transferring Facility CT Scans DHMC ED Repeat CT Scans

Exam Number Performed Number Performed Repeat Rate

Head 259 132 51%

Chest 108 34 31%

Abdomen 130 38 29%

Pelvis 127 45 35%Cervical Spine 173 86 50%Thoracic Spine 23 14 61%Lumbar Spine 18 14 78%

Face 27 11 41%

Page 58: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Necessary Workup prior to Necessary Workup prior to TransferTransfer

Hx and PE.Hx and PE.IV AccessIV AccessGCS < 8GCS < 8 = Intubate pt= Intubate ptXX--rays ???rays ???

Do not delay transfer for Do not delay transfer for extensive (complete) xextensive (complete) x--ray ray evaluation !evaluation !

Page 59: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Only State in the Union with no Only State in the Union with no Adult Seat belt Law !Adult Seat belt Law !

Page 60: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

VariableVariable Restrained Restrained (n =469)(n =469)

Unrestrained Unrestrained (n=225)(n=225)

DifferenceDifference

Location of Location of CollisionCollision

NH 43%NH 43%VT 57%VT 57%

NH 57%NH 57%VT 43%VT 43%

33% higher restraint use by 33% higher restraint use by VT patientsVT patients

Mean Injury Mean Injury Severity Severity ScoreScore

12.412.4 14.014.0 13% higher ISS for 13% higher ISS for unrestrained unrestrained

MortalityMortality 4%4% 11%11% 175% higher mortality for 175% higher mortality for unrestrained unrestrained

Mean ICU Mean ICU DaysDays 1.81.8 3.73.7 105% longer ICU stay for 105% longer ICU stay for

unrestrained unrestrained

Mean Mean Hospital Hospital DaysDays

7.87.8 11.111.1 42% longer hospital stay for 42% longer hospital stay for unrestrainedunrestrained

Known restraint use or non-use: n = 694

Presenter
Presentation Notes
Looking at all cases where the use of restraints was known, demonstrated a 33% higher rate of restraint use by Vt. Pts. Moreover, unrestrained drivers suffered more serious injuries, with higher mortalities and had longer ICU and hospital stays.
Page 61: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Conclusions:Conclusions:Mandatory seat belt laws Mandatory seat belt laws seem to result in higher seem to result in higher utilization of seat belt use in utilization of seat belt use in Vermont compared to NHVermont compared to NHRestrained pts. are less Restrained pts. are less severely injured and severely injured and consume less hospital consume less hospital resourcesresourcesNH legislators should reNH legislators should re-- consider a mandatory seat consider a mandatory seat belt law for societal benefitbelt law for societal benefit

Presenter
Presentation Notes
In conclusion, it appears that there is a higher use of seat belt use by Vermont residents that result in less injury and hospital stays. These facts should be considered by NH lawmakers when considering a mandatory seat belt law. Thank You.
Page 62: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

FeedbackFeedback

HIPPA regulationsHIPPA regulations

Difficulty locating Difficulty locating individualsindividuals

Single contact pointSingle contact point

Collector data baseCollector data base

Page 63: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Pressures facing Trauma Pressures facing Trauma SystemsSystems

Personnel ShortagesPersonnel Shortages–– PhysicianPhysician–– NursesNurses

ExpenseExpenseBed capacity/availabilityBed capacity/availabilityDisaster ManagementDisaster Management

Page 64: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

Opportunities for improvement:Opportunities for improvement: CREST?CREST?

Educational outreachEducational outreachFacilitate referral processFacilitate referral processStandardized protocolsStandardized protocolsTelemedicine consultationsTelemedicine consultationsTelemedicine remote surgery ?Telemedicine remote surgery ?Improve communicationImprove communication

Page 65: Rural Trauma Transfer Issues: CREST Symposium Trauma Transfer Issues: CREST Symposium John E. Sutton, Jr. MD, FACS Chief, Division of Trauma and Acute Surgical Illness Dartmouth-Hitchcock

DiscussionDiscussion


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