Life and death

[Veneficus]

In one of the other threads there was a lot of talk about using lights and sirens when responding to or transporting "critical" patients.

I realize this is something of a subjective term, but I would really be interested in hearing how many of these patients you actually see.

I incuded a poll, but it would probably be better is you commented on what type of service you work for. Somebody in an ICU is obviously going to see a lot more than somebody who works in a rural EMS agency with 1000 calls a year.

Also, patients who receive life saving treatment in the ED before being discharged home directly from there will not count. (and we will laugh at you)

 

[DesertMedic66]

In my 2 years working as an EMT in an urban system I can only think of 1 call where a fast transport (still safe) actually saved the patients life.

An 82 year old lady was getting her wounds cleaned after a hip surgery when the doctor accident cut the patients femoral artery in the hip area.

The doctor then refused to do anything to help out. Pressure dressings and direct pressure were not working. Transport to the hospital and the doc meets us right at the ER doors with a clamp and clamps the artery before we even get into the trauma room.

 

[Clare]

In the Auckland District there are about 1.3 million people and around 250,000 ambulance call outs per year (and growing!) which means about 380 call outs per day, every day.

On average there is probably one patient a day picked up somewhere in Auckland who is classified as time critical (status one) because they have an immediate threat to their life.

I would say I see one patient per watch that fits this category; i.e. they have some sort of major problem that immediately threatens their life.

A watch cycle here is four 12 hour shifts and I will see an average of probably 30 or 40 patients in that time; so a very, very small percentage.

 

[Veneficus]

In the Auckland District there are about 1.3 million people and around 250,000 ambulance call outs per year (and growing!) which means about 380 call outs per day, every day.

On average there is probably one patient a day picked up somewhere in Auckland who is classified as time critical (status one) because they have an immediate threat to their life.

I would say I see one patient per watch that fits this category; i.e. they have some sort of major problem that immediately threatens their life.

A watch cycle here is four 12 hour shifts and I will see an average of probably 30 or 40 patients in that time; so a very, very small percentage.

So how many fit in the confines of the poll?

And please vote.

 

[Clare]

I don't know what the criteria are for the direct admission to DCCM (ICU) so I can't vote ....

I could ask the Clinical Director; he is an Intensivist.

 

[shfd739]

Private service 911, inter facility and CCT.

Urban to rural depending on where in the county we are. Transport times are 5-45mins.

In the last 6 months that I've been back on a unit I've transported light/sirens 2 or 3 times at the most. Most recent was a STEMI coming from the rural area. ER had plenty of heads up and a transmitted 12 lead. Ideally we would've gone straight to the cath lab. Instead the ER screwed up the STEMI alert so the pt spent 40mins in the ER before going to the cath lab.

Transporting light/siren is something I try to avoid and I hate doing it. If you can wait the 3-6 mins ill save then I won't transport light sirens. Even then I don't always think it's worth it, but in those patients it's still expected that they will go light/sirens to the ER and I get in trouble for not doing it.

 

[ExpatMedic0]

Between the cath lab and traumatic accidents I would be surprised if anyone who works in a very busy system gets less than 1 a week.

 

[Veneficus]

Private service 911, inter facility and CCT.

Urban to rural depending on where in the county we are. Transport times are 5-45mins.

In the last 6 months that I've been back on a unit I've transported light/sirens 2 or 3 times at the most. Most recent was a STEMI coming from the rural area. ER had plenty of heads up and a transmitted 12 lead. Ideally we would've gone straight to the cath lab. Instead the ER screwed up the STEMI alert so the pt spent 40mins in the ER before going to the cath lab.

Transporting light/siren is something I try to avoid and I hate doing it. If you can wait the 3-6 mins ill save then I won't transport light sirens. Even then I don't always think it's worth it, but in those patients it's still expected that they will go light/sirens to the ER and I get in trouble for not doing it.

I was more interested in the medical condition than the types of transport.

Between the cath lab and traumatic accidents I would be surprised if anyone who works in a very busy system gets less than 1 a week.

True, but I have noticed that people who actually see the least amount of critical patients seem to believe they see the most.

I was also interested in personal experience, because saying your service transports dozens is not the same as you transporting dozens.

 

[VFlutter]

I work on a progressive care cardiac floor which also serves as an ICU step down (And one of only 2 non-ICU floors that can take stroke patients). I would say once a day to a few times a week. My patient load is usually 4 with at lest 1 or 2 fairly acute or critical. The majority of my critical patients will be STEMIs and strokes followed by codes, respiratory issues, and then random emergent surgical procedures. I feel like I am pretty competent at assessing who is critical and who is not.

On a related note. I would guess around 5/50 of my critical patients are critical enough that 10 mins will make a significant difference in clinical outcome.

 

[RocketMedic]

Still fairly new, but I've had a total of four in my career.
1. Very rural closed-head injury in New Mexico, 80-mile transport to a helipad, reportedly ended up going straight to OR/PICU and living on a vent for two weeks (discharge with 100% intact neuro and no memory of the incident, got an 'attaboy' for not panic-criking (no RSI in NM)). Not sure how time-critical he was though.
2. Pediatric status asthmaticus (the first time I've ever been really scared). Ended up admitted/pediatric BiPap.
3. On my internship, field ROSC -> cath lab. That was pretty cool.
4. Stab wound to the chest, left ventricular involvement. Cool!

This is in a very busy system, BTW.

 

[cruiseforever]

I work for 2 services Mpls. area. Both would be considered hospital based and operate with almost the same protocols. Most of the light and siren transports that we do are chat. lab or trauma. I checked once a week. Some weeks serveral and other times a couple of weeks with routine transports.

 

[AlphaButch]

Private service 911, inter facility and CCT as well.

Our service does approximately 10-15 direct ICUs a week. Not as many cath labs as I'd expect considering our demographics (95% of our patients >60). Most are respiratory arrests and septic shocks.

 

[medicsb]

When I was working FT hours in NJ, it was variable, but typically more than 1 per week up to 1 per shift on average. Sometimes multiple in a shift.

Most trauma these days don't get rushed to the OR anymore unless there is a large, active knife and gun club active. (I'd be curious as to what the surgery rate is in the first 3 and 24 hours.) After spending the past 3 months on surgery at a level II, I could probably count on one hand how many patients got taken to the OR on the same day (and that is including the ortho cases). There were zero ex-laps, there was one (maybe a second) splenic embolization (which is not done by a surgeon). I think there were maybe 2 craniotomies in patients who came in as the lowest level trauma alert. The volume was averaged maybe 1 "level one" per day, and about 3-5 "level two", and another 3-5 "level three". Of course had they not had surgical residents, they'd probably be reclassified to one level 1 per week and 1 level 2 per day with everything else going to ED with surgical consults as needed.

Working as a medic, severe trauma was relatively rare, occurring every other month, sometime once a quarter. (I did see "trauma" frequently, but they were usually pretty stable.)

 

[Veneficus]

When I was working FT hours in NJ, it was variable, but typically more than 1 per week up to 1 per shift on average. Sometimes multiple in a shift.

Most trauma these days don't get rushed to the OR anymore unless there is a large, active knife and gun club active. (I'd be curious as to what the surgery rate is in the first 3 and 24 hours.) After spending the past 3 months on surgery at a level II, I could probably count on one hand how many patients got taken to the OR on the same day (and that is including the ortho cases). There were zero ex-laps, there was one (maybe a second) splenic embolization (which is not done by a surgeon). I think there were maybe 2 craniotomies in patients who came in as the lowest level trauma alert. The volume was averaged maybe 1 "level one" per day, and about 3-5 "level two", and another 3-5 "level three". Of course had they not had surgical residents, they'd probably be reclassified to one level 1 per week and 1 level 2 per day with everything else going to ED with surgical consults as needed.

Working as a medic, severe trauma was relatively rare, occurring every other month, sometime once a quarter. (I did see "trauma" frequently, but they were usually pretty stable.)

I would include all of the surgical procedures or disciplines, open surgery is not the only kind anymore and getting more rare.

I think it would be harder to include OB because most of the time there are not any complications.

 

[medicsb]

I would include all of the surgical procedures or disciplines, open surgery is not the only kind anymore and getting more rare.

Yeah, I agree. For every open case I saw there were about 5-10 laparoscopic cases and there were many patients on the surgical services who were treated by IR. But, I personally tend to think of interventional radiology as quasi-surgery and I definitely would not think of interventional radiologists as surgeons, same for interventional cardiologists or neurologists.

Regardless, where I was at, IR + lap + open cases for trauma within the first 24 hours of admission was quite rare even in some of the sickest patients. The conservative management of trauma is good and bad. I wonder how M&M of severe trauma will change as the old surgeons retire (or die), considering that most new residents get little experience with opening a belly and considering that many trauma centers do not have dedicated or fellowship trained trauma surgeons.

 

[Mariemt]

I would say we respond to a page with them more than we transport with them.

Choking, unresponsive / not breathing, drownings, and cpr in progress.(we have 2 medics and will provide als intercept or go to a scene of another town).

If im driving my medic somewhere for ALS we usually need to be there right now as they don't call us to another town often.
I chose 1 time per month. That's transporting.

Dispatched, about 10% . That includes our ALS intercept.

 

[Veneficus]

Yeah, I agree. For every open case I saw there were about 5-10 laparoscopic cases and there were many patients on the surgical services who were treated by IR. But, I personally tend to think of interventional radiology as quasi-surgery and I definitely would not think of interventional radiologists as surgeons, same for interventional cardiologists or neurologists.

It is interesting that you say this. Many procedures from interventional medicine types is basically a combination of medicine and surgery, which in my personal philosophy isthe optimal way to treat patients.

I also think that intravascular procedures are really the future of surgery, with laproscopic/minimally invasive techniques a distant second, and open surgery becoming something of a exceptional circumstance.

I think the reason that these disciplines exist is because of an overall reluctance to embrace these procedures by surgeons, but I suspect in the next few generations that will change for the reasons you cite below.

Regardless, where I was at, IR + lap + open cases for trauma within the first 24 hours of admission was quite rare even in some of the sickest patients. The conservative management of trauma is good and bad.

As much as I love trauma surgery, I have to admit that most life-threatening trauma is really vascular in nature. For a number of serious wounds, intravascular and conservative treatment I think is going to be the rule rather than the exception as medicine advances in the forseeable future.

The downside I see is people will be less likely to take a more aggresive approach when the situation calls for it.

I wonder how M&M of severe trauma will change as the old surgeons retire (or die), considering that most new residents get little experience with opening a belly and considering that many trauma centers do not have dedicated or fellowship trained trauma surgeons.

I don't think that it will really change much in the sort term as the amount of trauma surgeons world wide is very small. There are nations where trauma is the exclusive realm of either ortho or vascular surg.

Many of the surgeons I know think that open surgery in the future will be a specialty or fellowship unto itself.

If I was forced to make a decsion on it, I would give the whole thing over to cardio/thoracic surgery. Despite the advancement of intravascular procedures, it is postulated that cardiac surgery will decline some, but hit a steady state in the next 10 years. All of their surgery is open and by virtue of the most experience, especially with complicated life support systems and techniques in place for it, I see it as the logical group to take over trauma.

Surgical intensivists have made a go at it and are very successful, as the treatment of life-threatening pathways are common, but unless somebody finds a way to make it feasable in 5-7 years post grad instead of 7-10, I cannot think of any way to stop the numbers of providers from declining.

It has been my experience that the very personality and values of the modern surgeon is diametrically opposed to what is required for trauma. I don't expect a change in that in my lifetime.

 

[Bullets]

Municipal PD-based 911, 30k pop, 5k calls a year

The hospital is in our town and is a Level II trauma center, comprehensive stroke center, STEMI center so all of our patients pretty much go there. If you average it out we probably get 1 call a week that gets sent upstairs to the OR or ICU. We had our second STEMI this week today, and we had a deep laceration that severed the ulnar and radial arteries and required surgery.

Because we have the hopsital in town, much of the towns businesses are supporting medical facilities: dialysis centers, doctors offices, rehab and SNFs, ect. So we get a lot of our calls from these places which puts us behind the 8 Ball from dispatch since most have histories

 

[abckidsmom]

Rural, municipal fire-based system with 6k calls/year.

I probably see 2 or so critically ill patients each month. Of those, maybe 1 in 10 is time-critical, minutes matter kind of situation. An extensive discussion with my husband ended up with us agreeing that is average for both of us, he's in a suburban fire-based system.

Since he runs 2-3 times the calls as I do we postulate that rural patients are sicker. At least this has been our experience.

ETA: but his particular suburban system is upper socioeconomic people, and my rural system is lower.

 

[Brandon O]

Private system, EMD'd, 911 and routine transfer.

Probably one every few months -- 6 is your closest poll option. The "maybes" who need quick eval to rule out potential badness are much more common, but of course most of the time the answer is "nope."