civillian vs military trauma treatments

[Veneficus]

Recently there was talk in a handful of threads which discussed military trauma practices and how they will influence civillian medicine.

Rather than resurrect numerous threads and copy and paste the info, I would just like to share it here.

The topic is surgical treatment of extremity injuries, but I think the epidemiology nicely puts things into perspective of just how applicable military trauma techniques transfer.

"Recent vascular injuries in civillian trauma centers is between 0.2 - 4.0%"

"In modern Iraq and afghanistan conflicts it is 12%."

"35% of all extremity vascular injuries on the battlefield have concominat fractures"

(which increases blood loss)

Just something to consider the next time you are wondering if you need a tk first protocol or some other kind of novel or extreme resuscitation gadget or technique.

 

[Pavehawk]

The techniques transfer very well, it is the need to use said techniques that may not be applicable.

I have no doubt that the timely application of a TK can be useful in civilian practice in some cases, then again so can timely application of gasoline/deisel/Jet A, an option that the military does not always have.

Prehospital care, as you have pointed out many times, can only be made better when we as providers learn to think and use what is needed by the situation.


New skills and techniques are always nice but only when grounded with the knowledge to use them when needed not just because "we can".

 

[Veneficus]

The techniques transfer very well, it is the need to use said techniques that may not be applicable.

I have no doubt that the timely application of a TK can be useful in civilian practice in some cases, then again so can timely application of gasoline/deisel/Jet A, an option that the military does not always have.

Prehospital care, as you have pointed out many times, can only be made better when we as providers learn to think and use what is needed by the situation.


New skills and techniques are always nice but only when grounded with the knowledge to use them when needed not just because "we can".

I agree with what you said here.

The problem to reconcile is that despite EMS education advancing, there is a definitive trend towards more simplified treatment modalities. (one size fits all)

 

[mycrofft]

Hear hear.

 

[Veneficus]

From the same source:

"Primary amputation occurs in 10-15% of military patients and 22% of civillians" (in the case of major extremity injury with vascular complication or other comorbid conditions.)

 

[RocketMedic]

Military trauma is far more likely to involve multiple amputations.

 

[Doczilla]

There's no doubt that vascular injuries in active war zones would exceed civillian data. There's no machine guns, RPG's, or IED's on "the streets". These also produce more vascular injuries because of the protective equipment that we wear that makes the chances of eyeball injuries, TBI's, and blunt thoracic trauma comparatively lower--- hence the increased percentile.

The vascular injuries you DO see in trauma centers comes from a much more diverse breed: MVA's, construction accidents, stabbings, and yes --- shootings; though they be from much, much lower velocity rounds. Though if you add those in to the many other reasons a trauma team can be summoned, and spread it out throughout the country [and consider the ones that DON'Tgo to a state-certified trauma center] , 4% isn't too shabby.

The mentality to use TQ's so hastily in the "Warzone" stems from a few reasons [including but not limited to]:

The probibitive nature of combat to use other means to control hemhorrage or assess the true severity of wounds.

The uncertianty of time to definitive care, making every drop of blood count.

The avdances to "limb profusion therapy" to keep dying extremeties from necrosing in the field.

Training. The military needs to make sure that the highest percentage of people on the ground A: have enough equipment and B: have the skills to implement this equiment effectively. This makes the tourniquet the best, safest bet when judgement/time/resources/safety is lacking.

I've played on both sides of the fence, for years. What this boils down to me is this: Know your operational enviroment. Know where you are in the continuum of care. Know if your actions will definitely make a difference before they reach that facility with PRBC's in the fridge and a trauma team waiting.

 

[Veneficus]

I am not suggesting TKs aren't useful on the civilian side, I just question the thinking it needs to be first line.

With military injuries, I think the TK as the first line is rather undisputed.

 

[RocketMedic]

Its far easier to tourniquet high and manage pain than it is to pack a messy, bleeding hole. Kerlex and hemostatic agents don't repair vessels either, so its not like you're salvaging blood by packing, and with realistic civilian transport capabilities, the limb is very reperfusible after a surgical repair, even from a prehospital tourniquet.

 

[mycrofft]

Don't know about other protections like goggles making for more vascular injuries other than by skewing (fewer of other injury categories by comparison with serious injuries, so the percentage slides), but safety measures (like MRAPS, PPE, working smart, deeper "buddy-care" training) lessen immediate deaths and cases which formerly would have resulted in an on-site fatality now contribute heavily towards the "hurt bad" end of acuity-of-injury figures.

Doczilla: "Know your operational enviroment. Know where you are in the continuum of care. Know if your actions will definitely make a difference before they reach that facility with PRBC's in the fridge and a trauma team waiting". Good for every medic everywhere.

Veneficus: parsing care to what is essential I think is important because of time, distance and support/training constraints.

Knowing more and being able to to something about it is good, but I think we run into the old supply and demand bell curves again, where demand for some level of trained care is high, but the supply of persons with innate ability and desire/confidence to actually do it are limited.

We affect the supply curve for militarily useful candidates by targeted recruiting, pre-screening, then organized steps in training and indoctrination. The same could be done for a better care level: start basic items of medical training earlier in training, identify the nascent medic through testing in Basic Training, offer pay incentives to recruits who already have an EMT or such, offer a higher level of training to lower levels of practitioner, "medical confidence course" (like where you climb walls and ropes and stuff to feel soldierly, but here you would haul casualties, apply dressings, do a short triage rodeo and that sort), so you expand the potential pool of learner/practitioners.

 

[Veneficus]

Its far easier to tourniquet high and manage pain than it is to pack a messy, bleeding hole. Kerlex and hemostatic agents don't repair vessels either, so its not like you're salvaging blood by packing, and with realistic civilian transport capabilities, the limb is very reperfusible after a surgical repair, even from a prehospital tourniquet.

That's just the thing.

There is rarely a messy bleeding hole on an extremity in the civillian world.

There is no need for chemical hemostatic agents.

There is no need for wound packing.

As you can see from the statsitics, there is a considerable difference in the amount of wounds which are subject to primary amputation in the civillian world compared to the military.

Not because of wound severity, but because of the way civillian medicine works. Not every injured person gets transported to a place that provides them with the best medicine money can buy. (especially in civillian trauma where patients often have no money)

There are also the issues of provider avialability, comfort with a treatment, efficency of the facility, etc.

Most surgeons I have met simply will not do a damage control procedure and send somebody on to a higher level of care. Most ED docs are not prepaired or trained for that type care either.
(Please spare me the thoracotomy speech, until you are willing to scrub down a patient, take a vein for autografting out of a healthy limb and create a graft in a non-anatomical flow in order to maintain perfusion to an injured vessle)

It is important for EMS providers to realize a couple of things.

1st, dropping the patient off at a hospital doesn't suddenly make that patient better because there are doctors and surgeons and lights and xrays and the like there.

2nd, only academic facilities can reasonably be expected to provide the latest clinical treatments. (which are often still a decade or more behind the science)

3rd, there are a host of scores and tables which spell out "prudent" treatments, deviating from them can cause a lot of trouble, and few physicians are willing to deviate from them. The ones who do are often criticized for being "reckless."

The system rewards conservative treatment.

Back to bleeding.

Anytime you overtreat a patient you commit a medical error.

In an emergent setting, some overtreatment (some level of error) is inevitable and must be acceptable.

But that doesn't mean overtreat everyone to make things simple or "just in case."

If you need to TK an extremity caught in machinery, that is one thing.

If you slap a TK on every wound that bleeds, that is just outrageous.

It is easy to say "on major bleeding" but I can assure you, major bleeding is entirely defined by the individual provider.

Blanket treatments still need to be reasonable to the injury.

 

[mycrofft]

Would anyone else say that EMS today, coming from it's rough and ready expedient past, tends to address shortfalls in teaching and screening (as evidenced through trends towards poor care outcome due to technique) by lowering standards of care and teaching and blaming the EMS providers/trainees?

In other words, blame the trainee, don't examine the training/trainer. "If 60% of new EMT's are misapplying TK's, then we need to stop telling them to use TK's", versus " 60% are not using them right, we need to get the message across and do that through bulletins to EMSA's and etc.". Or "Medics are persisting in techniques we have proscribed or changed, how have we dropped the ball? How can me motivate them and their employers?". Sounds like centralized control and empowering the Feds, but the AMA and other professional groups might act that way, and JCAHO certainly does, with a vengeance, with some very positive outcomes for patient care.

 

[Veneficus]

Would anyone else say that EMS today, coming from it's rough and ready expedient past, tends to address shortfalls in teaching and screening (as evidenced through trends towards poor care outcome due to technique) by lowering standards of care and teaching and blaming the EMS providers/trainees?

In other words, blame the trainee, don't examine the training/trainer. "If 60% of new EMT's are misapplying TK's, then we need to stop telling them to use TK's", versus " 60% are not using them right, we need to get the message across and do that through bulletins to EMSA's and etc.". Or "Medics are persisting in techniques we have proscribed or changed, how have we dropped the ball? How can me motivate them and their employers?". Sounds like centralized control and empowering the Feds, but the AMA and other professional groups might act that way, and JCAHO certainly does, with a vengeance, with some very positive outcomes for patient care.

I have a whole thread going on blaming (addressing the shortcomings of) instructors

 

[RocketMedic]

That's just the thing.

There is rarely a messy bleeding hole on an extremity in the civillian world.

There is no need for chemical hemostatic agents.

There is no need for wound packing.

As you can see from the statsitics, there is a considerable difference in the amount of wounds which are subject to primary amputation in the civillian world compared to the military.

Not because of wound severity, but because of the way civillian medicine works. Not every injured person gets transported to a place that provides them with the best medicine money can buy. (especially in civillian trauma where patients often have no money)

There are also the issues of provider avialability, comfort with a treatment, efficency of the facility, etc.

Most surgeons I have met simply will not do a damage control procedure and send somebody on to a higher level of care. Most ED docs are not prepaired or trained for that type care either.
(Please spare me the thoracotomy speech, until you are willing to scrub down a patient, take a vein for autografting out of a healthy limb and create a graft in a non-anatomical flow in order to maintain perfusion to an injured vessle)

It is important for EMS providers to realize a couple of things.

1st, dropping the patient off at a hospital doesn't suddenly make that patient better because there are doctors and surgeons and lights and xrays and the like there.

2nd, only academic facilities can reasonably be expected to provide the latest clinical treatments. (which are often still a decade or more behind the science)

3rd, there are a host of scores and tables which spell out "prudent" treatments, deviating from them can cause a lot of trouble, and few physicians are willing to deviate from them. The ones who do are often criticized for being "reckless."

The system rewards conservative treatment.

Back to bleeding.

Anytime you overtreat a patient you commit a medical error.

In an emergent setting, some overtreatment (some level of error) is inevitable and must be acceptable.

But that doesn't mean overtreat everyone to make things simple or "just in case."

If you need to TK an extremity caught in machinery, that is one thing.

If you slap a TK on every wound that bleeds, that is just outrageous.

It is easy to say "on major bleeding" but I can assure you, major bleeding is entirely defined by the individual provider.

Blanket treatments still need to be reasonable to the injury.

However, with the way many EMS systems work, if they're not mandated, they won't be carried on the trucks or allowed at all.

 

[rwik123]

However, with the way many EMS systems work, if they're not mandated, they won't be carried on the trucks or allowed at all.

Do you know of any services that carry a TQ? No one I know of does..it'd have to be cravat and taped tongue depressors if a TQ was to be pursued.

 

[DrankTheKoolaid]

We carry TK's here on our trucks in NorCal

 

[STXmedic]

Down here as well. Along with QuikClot and Celox (one of the two at each service)

 

[zmedic]

How often do you use them? I'm not arguing that we shouldn't carry TKs or quickclot. But when was the last time that you had bleeding you couldn't control with direct pressure. (or a blood pressure cuff inflated just to the point where bleeding stopped.)

 

[STXmedic]

How often do you use them? I'm not arguing that we shouldn't carry TKs or quickclot. But when was the last time that you had bleeding you couldn't control with direct pressure.

I've personally had to use a tourniquet twice. Never had to use one of the hemostatics myself, though I know of them being used (don't know of the appropriateness of their use, however)

(or a blood pressure cuff inflated just to the point where bleeding stopped.)

Which is a tourniquet, is it not?

 

[RocketMedic]

BP cuffs are not good tourniquet replacements.