The new Morbidity and Mortality Weekly Report is an issue on Guidelines for Field Triage of Injured Patients. Required reading. It describes the changing field triage criteria, which is now more evidenced-based and relies less on mechanism of injury than the previous version.
January 23, 2009 / Vol. 58 / No. RR–1
Guidelines for Field Triage of Injured Patients
Recommendations of the National Expert Panel on Field Triage
In the United States, injury is the leading cause of death for persons aged 1-44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on care of injured persons and on public health. At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called “field triage”. In 1987, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the basis for triage protocols for state and local EMS systems across the United States. Since its initial publication in 1987, the Decision Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began facilitating revision of the Decision Scheme by hosting a series of meetings of the National Expert Panel on Field Triage, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies. The Panel reviewed relevant literature, presented its findings, and reached consensus on necessary revisions. The revised Decision Scheme was published in 2006. This report describes the process and rationale used by the Expert Panel to revise the Decision Scheme.
Download Issue
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Wednesday, January 28, 2009
Saturday, January 24, 2009
Sky
Something really nice happened today.
I was in the supply closet, putting away our latest shipment, when my partner came in and said someone was here to see me.
I walked out through the bay and into the main area and there was a man and a woman in maybe their late forties. The woman held what looked like cookies wrapped up as a gift with a card on it.
It took me but a moment to recognize them.
A week ago we were traveling lights and sirens to the hospital. The man lay on my stretcher, the woman sat up in front. I was on the phone with med control calling in an STEMI alert.
I remember thinking how young the man was and what great shape he looked to be in -- he was in fact in his middle fifties. No medical history or ever a prior episode of chest pain. Now he was clutching at his chest, and the ST elevations on the monitor were not subtle.
He told me today he had a 100% occlusion of the LAD (known as the Widow maker)and a 90% occlusion of another vessel. The doctor said because he called 911 so quickly (after just ten minutes of pain) and he got to the cath lab so quickly, there was minimal damage.
We had a nice talk and shook hands several times.
I think all this new emphasis on cath labs and paramedic activation is the best thing to happen for patients in a long time. For so many years we emphasized trauma and poured resources into it, but it is hard to see the results as clearly as in a case of an MI. Someone crunches a tree with the car, the injuries are done, but with a STEMI, you get the patient to the hospital quickly and the blockage gets cleared, why just six days later, they are out walking on a cold winter day like today when the sky is a gorgeous blue and seems to rise up forever.
I was in the supply closet, putting away our latest shipment, when my partner came in and said someone was here to see me.
I walked out through the bay and into the main area and there was a man and a woman in maybe their late forties. The woman held what looked like cookies wrapped up as a gift with a card on it.
It took me but a moment to recognize them.
A week ago we were traveling lights and sirens to the hospital. The man lay on my stretcher, the woman sat up in front. I was on the phone with med control calling in an STEMI alert.
I remember thinking how young the man was and what great shape he looked to be in -- he was in fact in his middle fifties. No medical history or ever a prior episode of chest pain. Now he was clutching at his chest, and the ST elevations on the monitor were not subtle.
He told me today he had a 100% occlusion of the LAD (known as the Widow maker)and a 90% occlusion of another vessel. The doctor said because he called 911 so quickly (after just ten minutes of pain) and he got to the cath lab so quickly, there was minimal damage.
We had a nice talk and shook hands several times.
I think all this new emphasis on cath labs and paramedic activation is the best thing to happen for patients in a long time. For so many years we emphasized trauma and poured resources into it, but it is hard to see the results as clearly as in a case of an MI. Someone crunches a tree with the car, the injuries are done, but with a STEMI, you get the patient to the hospital quickly and the blockage gets cleared, why just six days later, they are out walking on a cold winter day like today when the sky is a gorgeous blue and seems to rise up forever.
Wednesday, January 14, 2009
LMA
I got to insert an LMA the other day. I had previously done one when I was in the Dominican as part of a surgical medical mission team. The anaesthesiologist let me put one in on a patient who was having a hernia repaired. I slipped it in, and then that was that. I went back to my post in the post-op area.
Here’s how my first field LMA went.
Fifty-year-old obese lady. Witnessed arrest by onlookers, but no shock advised when the first responders got there. Asystole for us. The first time I went in for the tube, I couldn’t see anything. The lady had a significant overbit and I had trouble getting the mouth open wide enough. There wasn’t any emesis in the airway. I was just looking at tongue and throat. No chords, no epiglottis. After bagging some, I put a pillow under her head, and also got out the bougie. The problem with the bougie was to store in our house bag, it gets rolled up, so it was sort of hard to manipulate. I didn’t see anything, but gave it a try passing it. It just kept going down so I knew I wasn’t in.
A couple of years ago, we changed our protocols so that medics were limited to two intubation attempts defined as inserting the blade into the mouth, not attempts to pass the tube. So far I have gotten all my tubes within the two-attempt limit. I wondered what I would do when forced for the first time to not go in a third time. Technically we can go in a third time, but we have to have a pretty good reason for it. I suppose I might have if I had seen the chords and was sure I could get it, but I was lost on this airway, so I put in the LMA.
I had been thinking about doing an LMA on a code -- we can use it as an alternative instead of a backup airway, but the truth is I like intubating and never wanted to give up a tube. I was talking with a medic about LMAs the other day, and while I didn't say it, my reaction was, I'd put one in, but I always get the tube.
It has in fact been quite a number of years since I haven't gotten the tube -- and I have had some tough tubes, including a five hundred pounder -- but maybe he was just an easy tube despite his weight. It has certainly made me a bit cocky. Again, every time someone tells me about a hard tube and how they had to go to a backup airway, I think, I probably would have gotten the tube.
When I was in paramedic school, I zipped in my first 9 tubes in the ER, thinking man this is easy. Then I missed my next three (possibly my next four) and was quite shaken by it. I had some trouble intubating early on in my career, but I had thought now that I was skilled enough that I could intubate anyone, Mallanpotti be damned. And maybe I would have gotten the tube in this lady. Of course it might have taken me a couple more attempts, which wouldn't have been good for her at all to try so many times.
The LMA went in quick and easy, and held in place through a difficult extrication. We maintained excellent capnography throughout so she was getting well ventilated. I did detect a bit of abdominal distension so the seal mustn't have pristine. Still overall I was very impressed. I can tube pretty quickly but the LMA was in in less time than it takes me to open up the ET roll, take out a a sterile tube, stylet and attach a syringe. It was open up the package, attach the syringe, check the inflation, deflate, open the mouth and slide it in. Good to go. Very quick.
But I am finding myself still thinking about not getting the tube. It's like a puzzle I got two attempts to solve, but they won't let me play again. I try to figure out how I could have approached it differently, and wonder where the key to it lay. I guess I'll never know. And I hope my cockiness is not dooming me to a string of difficult airways ahead(maybe all these tubes I have been zipping in have just been a two year strek of easy or lucky tubes). But if a bad streak does come, and it might well, I've got the LMA now watching my back.
I'll keep you posted.
Here’s how my first field LMA went.
Fifty-year-old obese lady. Witnessed arrest by onlookers, but no shock advised when the first responders got there. Asystole for us. The first time I went in for the tube, I couldn’t see anything. The lady had a significant overbit and I had trouble getting the mouth open wide enough. There wasn’t any emesis in the airway. I was just looking at tongue and throat. No chords, no epiglottis. After bagging some, I put a pillow under her head, and also got out the bougie. The problem with the bougie was to store in our house bag, it gets rolled up, so it was sort of hard to manipulate. I didn’t see anything, but gave it a try passing it. It just kept going down so I knew I wasn’t in.
A couple of years ago, we changed our protocols so that medics were limited to two intubation attempts defined as inserting the blade into the mouth, not attempts to pass the tube. So far I have gotten all my tubes within the two-attempt limit. I wondered what I would do when forced for the first time to not go in a third time. Technically we can go in a third time, but we have to have a pretty good reason for it. I suppose I might have if I had seen the chords and was sure I could get it, but I was lost on this airway, so I put in the LMA.
I had been thinking about doing an LMA on a code -- we can use it as an alternative instead of a backup airway, but the truth is I like intubating and never wanted to give up a tube. I was talking with a medic about LMAs the other day, and while I didn't say it, my reaction was, I'd put one in, but I always get the tube.
It has in fact been quite a number of years since I haven't gotten the tube -- and I have had some tough tubes, including a five hundred pounder -- but maybe he was just an easy tube despite his weight. It has certainly made me a bit cocky. Again, every time someone tells me about a hard tube and how they had to go to a backup airway, I think, I probably would have gotten the tube.
When I was in paramedic school, I zipped in my first 9 tubes in the ER, thinking man this is easy. Then I missed my next three (possibly my next four) and was quite shaken by it. I had some trouble intubating early on in my career, but I had thought now that I was skilled enough that I could intubate anyone, Mallanpotti be damned. And maybe I would have gotten the tube in this lady. Of course it might have taken me a couple more attempts, which wouldn't have been good for her at all to try so many times.
The LMA went in quick and easy, and held in place through a difficult extrication. We maintained excellent capnography throughout so she was getting well ventilated. I did detect a bit of abdominal distension so the seal mustn't have pristine. Still overall I was very impressed. I can tube pretty quickly but the LMA was in in less time than it takes me to open up the ET roll, take out a a sterile tube, stylet and attach a syringe. It was open up the package, attach the syringe, check the inflation, deflate, open the mouth and slide it in. Good to go. Very quick.
But I am finding myself still thinking about not getting the tube. It's like a puzzle I got two attempts to solve, but they won't let me play again. I try to figure out how I could have approached it differently, and wonder where the key to it lay. I guess I'll never know. And I hope my cockiness is not dooming me to a string of difficult airways ahead(maybe all these tubes I have been zipping in have just been a two year strek of easy or lucky tubes). But if a bad streak does come, and it might well, I've got the LMA now watching my back.
I'll keep you posted.
Saturday, January 03, 2009
Grandaughters
My father recently had major surgery on his back that required him, at age 75, to spend ten days recovering in a rehab facility. Rehab facility is, of course, the modern code name for a nursing home.
His first night there, still feeling the effects of the anesthesia two days post op, and doped up on way too many meds (They gave him some sleeping pills along with a bendryl (because the morphine was making him itch), he, against orders, got out of bed in the middle of the night looking for sheet music, he says.
My father has always been an independent man and had never previously even spent a night in the hospital. He has also never had any interest at all in sheet music. So he was having some sort of drug and foreign place induced hallucination.
An aide found him on the bathroom floor at four in the morning, sound asleep. She helped him back into bed, but they eventually ended up calling an ambulance to take him back to the hospital to make certain he had done no damage to his back or the steel rods they had put in it. Fortunately, the x-rays were negative and he was back at the home that evening.
It can be disorienting and frightening being old and in a nursing home when you have spend your life being independent. My father was a champion boxer in college. In summers he used to hitchhike across the country and work in oil fields and pea canneries. He was a pilot in the Navy, who gave up that career during the Eisenhower peacetime reductions. He went to work in the financial field and raised three children, and coached little league teams, while caring for my mother who got multiple sclerosis in her thirties, and lived a slowly diminishing life until she died in her early fifties. In his old age he has traveled the world, hiking on several continents and has become an accomplished bird photographer.
When the aide helped him back to bed, they talked and my father showed her pictures of his grandchildren. My younger brother is married to a woman of Trinidadian descent and they have two young daughters. My own daughter, who is a year old today, is half Jamaican. The nurse’s aide, who was also from the islands, as were many of the aides in the nursing home, loved the pictures and told my father he must have done something right to have his sons have such beautiful children of Caribbean descent. Within a day nearly every aide in the home had stopped by to say hello and look at the pictures. The aides made him feel like family and took good care of him during his stay, and protected him.
In the Godfather, Don Vito Coreleone sends his son Michael to Italy where he is kept safe by ancient relatives. Here my father’s granddaughters were my father's seal of protection. Their smiling faces said, “Look out for him, our grandfather is a good man who makes us laugh, and we love him. We are ever grateful for the care you give him.”
***
I have always tried to treat people right, but having a father in a nursing home, even for a brief period, opens my eyes when I go into a nursing home as I do so often. I see the residents as mothers and fathers, I see the families as daughters and sons like myself, and I see the aides as I have never seen them before. Thank you, I say to them. Thank you.
***
Happy Birthday, Zoey!
His first night there, still feeling the effects of the anesthesia two days post op, and doped up on way too many meds (They gave him some sleeping pills along with a bendryl (because the morphine was making him itch), he, against orders, got out of bed in the middle of the night looking for sheet music, he says.
My father has always been an independent man and had never previously even spent a night in the hospital. He has also never had any interest at all in sheet music. So he was having some sort of drug and foreign place induced hallucination.
An aide found him on the bathroom floor at four in the morning, sound asleep. She helped him back into bed, but they eventually ended up calling an ambulance to take him back to the hospital to make certain he had done no damage to his back or the steel rods they had put in it. Fortunately, the x-rays were negative and he was back at the home that evening.
It can be disorienting and frightening being old and in a nursing home when you have spend your life being independent. My father was a champion boxer in college. In summers he used to hitchhike across the country and work in oil fields and pea canneries. He was a pilot in the Navy, who gave up that career during the Eisenhower peacetime reductions. He went to work in the financial field and raised three children, and coached little league teams, while caring for my mother who got multiple sclerosis in her thirties, and lived a slowly diminishing life until she died in her early fifties. In his old age he has traveled the world, hiking on several continents and has become an accomplished bird photographer.
When the aide helped him back to bed, they talked and my father showed her pictures of his grandchildren. My younger brother is married to a woman of Trinidadian descent and they have two young daughters. My own daughter, who is a year old today, is half Jamaican. The nurse’s aide, who was also from the islands, as were many of the aides in the nursing home, loved the pictures and told my father he must have done something right to have his sons have such beautiful children of Caribbean descent. Within a day nearly every aide in the home had stopped by to say hello and look at the pictures. The aides made him feel like family and took good care of him during his stay, and protected him.
In the Godfather, Don Vito Coreleone sends his son Michael to Italy where he is kept safe by ancient relatives. Here my father’s granddaughters were my father's seal of protection. Their smiling faces said, “Look out for him, our grandfather is a good man who makes us laugh, and we love him. We are ever grateful for the care you give him.”
***
I have always tried to treat people right, but having a father in a nursing home, even for a brief period, opens my eyes when I go into a nursing home as I do so often. I see the residents as mothers and fathers, I see the families as daughters and sons like myself, and I see the aides as I have never seen them before. Thank you, I say to them. Thank you.
***
Happy Birthday, Zoey!
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