Regional Emergency Medicine The American experience Paul Mc Quaid NREMT-P

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

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 Hospital Paramedic 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

Trauma Centre Designation Hospitals receive trauma designation as Level 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.

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

Trauma Team made up of personnel from: Anaesthesiology Critical care Internal medicine Paediatrics Orthopaedics Respiratory therapy Radiology Cardiology Neurology Obstetrics ICU services Chaplaincy

Level 1 Criteria Adult & Paediatric Physiological Adult: Confirmed BP<90 at any time Respiratory compromise, obstruction and/or intubation Resp rate 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

Level 1 Criteria Adult & 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

Abdomen: –Evisceration or large open wound –Rapidly expanding abdomen –Significant blunt trauma with unstable vital signs

Mechanism

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

Mechanism Motorised vehicle v’s > 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 RR 6     POSITIVE TRAUMA ALERT Transport to Closest Appropriate facility Pt looses pulse en route to LZ

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!

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.