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
ObjectivesObjectives
Rural Trauma Rural Trauma SystemSystem
Clinical transfer Clinical transfer issuesissues
System transfer System transfer IssuesIssues
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
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
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
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
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
Minor Moderate Severe
Exclusive System
Inclusive System
Scope of a Trauma Care System
Injury Severity
#Pts.
SuttonSutton’’s Five Cs Five C’’s of s of Trauma CareTrauma Care
ComprehensiveComprehensiveCommunicationCommunicationConsistencyConsistencyCostCostCommitmentCommitment
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
Specialty Shortages (Availability)Specialty Shortages (Availability)NeurosurgeryNeurosurgery
OrthopedicsOrthopedics
Trauma SurgeonsTrauma Surgeons
Nursing personnelNursing personnel
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
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
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
Leave Leave ‘‘em in the collar and em in the collar and boardedboarded
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??
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??
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
Case QuestionCase Question
1. What is your 1. What is your diagnosis?diagnosis?
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
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?
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
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)
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
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.
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
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
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 ??
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
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
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.
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
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
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
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
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
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
RETURN TO O.R.:RETURN TO O.R.:
REVASCULARIZATION OF LLEREVASCULARIZATION OF LLE
4 COMPARTMENT 4 COMPARTMENT FASCIOTOMIESFASCIOTOMIES
TRANSFERRED TO ICUTRANSFERRED TO ICU
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
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%
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
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
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
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%
Thunderstorms
Fog
Blizzards
Can’t Fly !
Alternatives ?
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
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
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
38 yo male : Severe liver injury
Procedures:angioembolization of hepatic arteryERCP / Stentangio /StentIVC filterNumerous IR drainage procedures
IssuesIssues
TechnologyTechnology
TechniqueTechnique
Inability to view studiesInability to view studies
Clinically indicatedClinically indicated
Not Necessarily !
Arrggh!
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
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%
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 !
Only State in the Union with no Only State in the Union with no Adult Seat belt Law !Adult Seat belt Law !
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
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
FeedbackFeedback
HIPPA regulationsHIPPA regulations
Difficulty locating Difficulty locating individualsindividuals
Single contact pointSingle contact point
Collector data baseCollector data base
Pressures facing Trauma Pressures facing Trauma SystemsSystems
Personnel ShortagesPersonnel Shortages–– PhysicianPhysician–– NursesNurses
ExpenseExpenseBed capacity/availabilityBed capacity/availabilityDisaster ManagementDisaster Management
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
DiscussionDiscussion