In my state, "treat and release" is not in the paramedic scope of practice. While we regularly “treat and release,” this occurs only through the refusal process, after first offering/advising transport X 3 to the patient.
This morning I responded to a dispatch for “altered mental status” and on arrival, found a babbling middle-aged woman sitting on the toilet playing with her underwear. The first responders offered to get our stretcher for us (which we had left in the ambulance due to the pouring rain). Seeing my glucometer reading popping up at 34 after doing a finger stick, I told the responders to wait to see if we would be transporting or not.
An amp of D50 later, the woman was apologizing for bothering us, and refusing our advice of transport to the hospital. She forgot to eat last night, she said, after having spent the previous day hiking. She said she was back to normal now and did not want to go to the hospital. She promised to check her sugar regularly, and to follow up with her doctor. Her boyfriend was already cooking her toast, eggs and bacon. They both assured us they would call us back if there was any change in her condition.
Still we made the dutiful effort of offering transport X 3 before accepting her refusal, witnessed by her boyfriend and the police officer.
In the last week, these are some of the refusals I have taken:
A woman who called 911 because she thought the medicine the ED had just given her for her nausea was an "antipsychotic" instead of an "antiemetic." Somehow she had looked Prochloroperazine up on the internet and had determined it was the same as Thorazine, which quite upset her. Once I showed her prochloroperazine was, in fact, compazine, she said "never mind."
A woman whose lengthy oxygen cannula was tangled around her so badly that she could not walk without fear of tripping. She wasn't hurt, she just wanted to be untangled.
And two calls at the jail to check prisoners for scratches received during the altercations that led to their arrests.
On each of these calls, I dutifully offered transport at least three times. Each patient refused. I collected their signatures on the dotted line and thoroughly documented each encounter.
I feel rather silly sometims advising people to be seen at the ED when I didn't think they need to go.
Perhaps there is no more uncomfortable area for recommending transports than when we are called for the "prisoner evaluation." Aside from the scratches and bruises from fights, we often get called to the local jail on a Friday evening of a holiday weekend to evaluate a prisoner who says he is not feeling well -- a classic case of "jailitis." Again, while we are called to the jail for an "evaluation," since treat and release is not in our scope of practice, we have to evaluate and then recommend transport. Law enforcement, of course, often believes the patient is faking and they have no intention of sending the prisoner with the required officer/chaperone to the hospital. The cops look to us to tell them the patient is fine. They are covering themselves by passing the liability to us. We have a fine line to walk in dealing with these patients – hold true to our medical policies while not jamming up the police department unneccessarily.
Let me be clear, I am not talking about the prisoners who I believe actually do need to go to the hospital, and who I will fight vigorously to see get the care they need. I’m speaking of the malingerers.
Now certainly there is something called the art of the refusal. There is a way that your advice is prefaced and phrased that varies to the degree of the urgency of the patient.
I did not speak to the woman who had mistaken compazine for Thorazine in the same way that I would address a man with crushing chest pain and an ST elevation who is refusing to go to the hospital. Nor do I address the prisoner punched in the face without loss of consciousness or complaint in the same way I speak to the man who made a face impression in the windshield of his car at 55 miles an hour. Tone and body language certainly come into play. If they need to go, I am quite earnest and animated about it. If not, I simply cover the legal bases.
"If you are not transported, you might die."
versus
"You were punched in the face. There is nothing I can do to have you unpunched. I don't feel any broken bones. You did not lose conciousness. Your vitals are normal. You appear to have a completely intact and normal nuerological function. I am however, legally required (3 times!) to advise and offer you treatment and transport to the hospital. I cannot however take you against your will. If you do not wish to go, sign here (hand them pen and point to signature line), but you can always change your mind and call us back five minutes from now, an hour from now or whenever you feel there is a change in your condition, and we will be happy to return and take you to the hospital. It is your choice. (Again hand pen to patient if they have not already taken it)."
I write this because of the swine flu. I am hearing that some states are instituting measures whereby if an EMS crew arrives at a scene and finds an otherwise healthy person at home, feeling yucky with a fever and vomiting, the paramedic or EMT would call a medical hotline and speak with a nurse who, if she believes the patient merely has the flu, might tell the patient to stay hydrated and stay at home, and EMS would clear.
Should such a measure be implemented in our state, it would mark a change in the way we do business -- a welcome change in my opinion. Maybe such an experience with the swine flu could lead to a general purpose hotline with either a nurse or physician on the end of the line who could make some of these transport/no-transport necessary decisions, so we don't have to go through the recommend X 3 charade we do everyday. (Like some of my fellow bloggers lately, I do not advocate EMS making these decisions without at the minimum, a medical control consult.)
A problem with the nontransports is the ambulance companies don't get paid if they don't transport. Creating a reimbursement mechanism certainly involves a lot of work at a lot of levels.
Maybe the President's Health Reform can focus on this. I'm an optimist.
***
As an FYI, attached is our state's new policy on how EMS should deal with the many situations that arise when called to a jail or detention center:
EMS RESPONSE TO DETENTION/HOLDING FACILITIES
EMS providers are often called to detention or holding facilities to assess, treat and transport
detainees. It is important to keep in mind that detainees have the same rights to medical treatment as does the lay public.
Request for Evaluation Only
While it is beyond the practice for paramedics or EMTs to provide intentional treat and release
services, EMS responders often encounter situations where a patient (or law enforcement) desires evaluation, but does not want transportation. When in such a situation, EMS responders must treat the scenario the same as they would a patient in a home or at an accident scene who requests evaluation only. The EMS responder should follow good medical judgment in these situations, including doing a full history and assessment. Vitals signs should be assessed, including checking blood sugar if relevant.
Patient/detainee Refusal of Transport
If in the judgment of the EMS provider the patient/detainee should be medically evaluated at the hospital, every attempt should be made to convince the patient/detainee (and law enforcement) to allow ambulance transportation to a local medical facility. EMS responders should offer transportation several times; fully explain the potential medical consequences of refusing care to the patient/detainee and make every effort to ensure all parties understand the risks, and advise the patient/detainee to ask the law enforcement officer to recall 911
if necessary. Should the patient/detainee refuse this offer of transport, a full refusal PCR should be completed. The law officer should witness it. In the event the patient/detainee refuses care and refuses to sign the PCR, document this fact and have the law officer attest to the patient’s refusal to sign.
Police Officer Ordered Transport
In the event the patient/detainee refuses treatment and transportation, but law enforcement orders it, EMS should transport the patient/detainee and document all circumstances in the PCR. In all cases a law enforcement officer should accompany a detainee in the ambulance.
Law Enforcement Refused Transport
In the event the patient/detainee requests transport, but the law enforcement officer refuses to allow the patient/detainee to be transported, document this fact, including the name of the officer in your report. The officer can legally sign a refusal for a patient/detainee who requests transportation (however in practice this is not done – normally the patient/detainee will sign). Documentation should also include the EMS responder’s cautions to the law enforcement officer on the consequences of withholding necessary evaluation and or treatment. The EMS responder should request that the law enforcement officer sign under this documentation. Medical Direction must be contacted (see section below).
Medical Control
EMS responders are always encouraged to contact Medical Direction to allow the on-line physician to speak directly with the patient/detainee or law enforcement officer in an effort to convince them of the need for further medical evaluation. In all circumstances in which a patient/detainee is given an approved EMS medication such as a breathing treatment or dextrose, and then refuses transport or has transport denied by the law enforcement officer, the EMS responder must contact Medical Direction.
Scope of Practice
At no time should an EMS responder perform any treatments or evaluation methods beyond their scope of practice such as administering insulin, dispensing or verifying medications.
Transport Destination
The law enforcement officer may determine the hospital of choice unless it conflicts with
patient/detainee need as determined by regional guideline or state regulation. Medical Direction should be contacted with any questions.
Thursday, October 29, 2009
Saturday, October 24, 2009
Changes
I haven't been posting as much as I would like to. That should change soon. I just finished a major class I was taking (which I will write about shortly) so I will have more free time.
I also am making some changes to the blog. I have been invited to join the JEMS blog network, and am currently working on the look of the new blog, which will have a new address. People coming to this site will be redirected to the new blog site.
I have enjoyed being on Blogger, but felt it was time for a change.
I hope to be up and running on the site this week.
www.medicscribe.com
I also am making some changes to the blog. I have been invited to join the JEMS blog network, and am currently working on the look of the new blog, which will have a new address. People coming to this site will be redirected to the new blog site.
I have enjoyed being on Blogger, but felt it was time for a change.
I hope to be up and running on the site this week.
www.medicscribe.com
Sunday, October 11, 2009
Running the Streets
I finished my half marathon on Saturday, limping across the finish line in 2:34:14. Part of the run went through streets and neighborhoods in Hartford where I have responded over the years to motor vehicles, drunks, cardiacs, asthmas, shootings, diabetics and general illness. When I started as a paramedic in Hartford, I did most of my calls within the city limits. I liked that. I felt I knew the streets, knew the people, many by my patients I knew by their first names. I felt a part of the neighborhoods. Hartford was "my town."
Over the years as ambulance companies consolidated, and territories changed, my response area became much larger, and fewer and fewer of my calls were in common neighborhoods. I also then became assigned to a contract town north of the city. Still until a year ago when I got my clinical coordinator job, I managed to worked 20-30 hours a week in “the city,” which basically now means a combination of towns as well as a fair number of transfers.
I’ve worked in the suburban town now for ten years or so. While I have been losing touch with my Hartford, the suburban town is now my true town. And one of the good things about this town is there are not as many carry downs as there are in the city, and that is my primary concern today as I head into work, stiff and sore from my race and barely able to lift my legs off the ground. No carry downs, please. I don’t even want to have to walk up a set of stairs as each step is a source of pain. Even worse, going down stairs. I am hoping for a quiet day, a day to rest my weary body. After checking my gear, I head to the bunkroom, where I am soon fast asleep, my cheek against the pillow.
Baaaaaaaehhh!
The tone sounds.
It turns out to be double good news. A first floor apartment and a patient who insists on going to the hospital in her daughter's car. The patient, who lives on the first floor, says she called 911 only because her she was unable to shout loud enough to wake her daughter, who was sleeping upstairs. She has a chronic illness, and apologizes for bothering us, and refuses our earnest offers of transport.
Our second call (after a nice two hour nap) is for a disoriented man with slurred speech found wandering along the road. The officer on scene is one of the newer recruits and he is concerned about the man's orientation and speech. The man is in his seventies, but impeccably dressed in his Sunday best. According to the officer the man claims he was walking to a church far on the other side of town -- well beyond his means to walk.
As I begin to question the man, something about him strikes me as familiar. I seem to recall him being in a minor motor vehicle accident and the officer at that scene, also concerned about the man’s speech, called us to access the man. The more I think the clearer it becomes. That call was outside a church, and some of the church members came out and said that he had had a stroke a year before and they vouched that this was indeed the man’s normal speech and behavior. That church was on the other side of town from where we are now. While the man denies ever being in our ambulance, he tells us the name of his church, and it is the one we responded to before. My partner speaks up then, and says he remembers that call as well.
We now do our run forms electronically and the laptop we carry has the ability for me to access any calls I have done. I enter the man’s name in the computer and it comes back with a hit. He is in fact the same man from that accident.
With that knowledge we are able to assure the officer that there is no medical issue here, just a man who likes to go to church on Sunday, and with the loss of his license following his inability to drive safely, it seems he still makes his effort to attend the Sunday service.
We get a refusal and the officer takes the man on to church.
After ten years in a town with a large elderly population it is quite common to have repeat customers. I like walking into a house or apartment and recognizing a familiar face and calling someone by their name without having to be introduced. I like that all the officers know me and that we have such a good working relationship. Community policing has been advocated as a solution to crime. I really believe in community EMS, and am glad that I can work in a town where that seems like it will always be possible. Patients in this town may have their own doctors and they largely have their own paramedics -- the four of us who cover the town between us 24/7. All four of us have been responding in this town for more than ten years.
There are no half marathons in the suburban town. If I do want to run these streets like I ran Hartford's, they do have an annual 5K road race. It, however, falls on Memorial Day – always a Monday, one of my regularly scheduled days. I could take off to run the streets of my now adopted town, and that would be great fun -- to run on sneakers instead of ambulance tires -- but that would mean losing my holiday pay. As much as I love running, I love triple time holiday pay more.
Here’s a link with an account of my run and some photos:
Hartford Half Marathon
Over the years as ambulance companies consolidated, and territories changed, my response area became much larger, and fewer and fewer of my calls were in common neighborhoods. I also then became assigned to a contract town north of the city. Still until a year ago when I got my clinical coordinator job, I managed to worked 20-30 hours a week in “the city,” which basically now means a combination of towns as well as a fair number of transfers.
I’ve worked in the suburban town now for ten years or so. While I have been losing touch with my Hartford, the suburban town is now my true town. And one of the good things about this town is there are not as many carry downs as there are in the city, and that is my primary concern today as I head into work, stiff and sore from my race and barely able to lift my legs off the ground. No carry downs, please. I don’t even want to have to walk up a set of stairs as each step is a source of pain. Even worse, going down stairs. I am hoping for a quiet day, a day to rest my weary body. After checking my gear, I head to the bunkroom, where I am soon fast asleep, my cheek against the pillow.
Baaaaaaaehhh!
The tone sounds.
It turns out to be double good news. A first floor apartment and a patient who insists on going to the hospital in her daughter's car. The patient, who lives on the first floor, says she called 911 only because her she was unable to shout loud enough to wake her daughter, who was sleeping upstairs. She has a chronic illness, and apologizes for bothering us, and refuses our earnest offers of transport.
Our second call (after a nice two hour nap) is for a disoriented man with slurred speech found wandering along the road. The officer on scene is one of the newer recruits and he is concerned about the man's orientation and speech. The man is in his seventies, but impeccably dressed in his Sunday best. According to the officer the man claims he was walking to a church far on the other side of town -- well beyond his means to walk.
As I begin to question the man, something about him strikes me as familiar. I seem to recall him being in a minor motor vehicle accident and the officer at that scene, also concerned about the man’s speech, called us to access the man. The more I think the clearer it becomes. That call was outside a church, and some of the church members came out and said that he had had a stroke a year before and they vouched that this was indeed the man’s normal speech and behavior. That church was on the other side of town from where we are now. While the man denies ever being in our ambulance, he tells us the name of his church, and it is the one we responded to before. My partner speaks up then, and says he remembers that call as well.
We now do our run forms electronically and the laptop we carry has the ability for me to access any calls I have done. I enter the man’s name in the computer and it comes back with a hit. He is in fact the same man from that accident.
With that knowledge we are able to assure the officer that there is no medical issue here, just a man who likes to go to church on Sunday, and with the loss of his license following his inability to drive safely, it seems he still makes his effort to attend the Sunday service.
We get a refusal and the officer takes the man on to church.
After ten years in a town with a large elderly population it is quite common to have repeat customers. I like walking into a house or apartment and recognizing a familiar face and calling someone by their name without having to be introduced. I like that all the officers know me and that we have such a good working relationship. Community policing has been advocated as a solution to crime. I really believe in community EMS, and am glad that I can work in a town where that seems like it will always be possible. Patients in this town may have their own doctors and they largely have their own paramedics -- the four of us who cover the town between us 24/7. All four of us have been responding in this town for more than ten years.
There are no half marathons in the suburban town. If I do want to run these streets like I ran Hartford's, they do have an annual 5K road race. It, however, falls on Memorial Day – always a Monday, one of my regularly scheduled days. I could take off to run the streets of my now adopted town, and that would be great fun -- to run on sneakers instead of ambulance tires -- but that would mean losing my holiday pay. As much as I love running, I love triple time holiday pay more.
Here’s a link with an account of my run and some photos:
Hartford Half Marathon
Monday, October 05, 2009
Flu Shots
Flu season is rapidly upon us. I woke up this morning with a slight case of the sniffles that as the day has gone on has proved to be (hopefully) somewhat of a false alarm. I am hoping to get through the week unaffected as next Saturday I hope to run* in my first half-marathon. I have already paid the registration fee as well as completed my last long run -- a 10.5 mile trek a week ago. The race is 13.1 miles. After 10.5, I knew I could make 13.1 so I stopped to conserve my body and prevent overtraining, which can and has for me in the past led to a lowered immune system and consequently the flu, which wiped me out from participating last year, although I never went so far as to preregister as I have this year.
With flu season comes flu shots. Everyone Hospitals, medical offices, ambulance services, senior centers, and pharmacies are all giving them out. It is hard to avoid mention of them. There is a sign on our ambulance service’s bulletin board about where and when to go to get your flu shot.
I get my flu shot every year. I will get the swine flu shot too. I believe in science. I believe in benefit versus risk analysis. Sure I might die from the shot in a rare occurrence, but I am much more likely to avoid the flu or get it much less severely than I otherwise would have had I not gotten the shot. I hate getting the flu. I haven’t died from it, but sometimes I feel like I will never be well again, and I hate that. Not for me.
I know quite a number of health care workers who are refusing to get flu shots and/or swine flu shots. I recall seeing some controversy on TV where the health care workers were rallying and holding up signs and an off-camera hospital spokesman was saying they didn’t have to get flu shots as required by the hospital, but the hospital also didn’t have to keep them employed. Something to that effect.
One side is advancing the argument that health care workers need to get the shot so they won’t get sick from sick patients and then pass it along to other vulnerable patients who will get sicker. Makes sense to me.
The other side is advancing the we have a right to what goes in our bodies argument, which I generally believe in as a proponent of freedom and the American way.
When these two clash, it does raise interesting issues. Let me just answer it this way. If I have a choice of going to two hospitals -- one hospital where all the staff have gotten their shots and one where none of them have, I’ll go to the hospital where they have all gotten their shots.
The dear mother of my darling twenty-one-month-old also works in health care and she never gets the flu shot. She won't let them come near here with that needle even though she herself gives the same shot to others countless times. We don't even argue about it anymore. I'm not going to change her mind, she isn't going to change mine.
I had a patient this morning with some mild difficulty breathing on exertion. I asked him when it started. “Right after I got my flu shot on Monday,” he said. Similar words to what a patient told me yesterday, and similar words to what I have seen written on quite a number of run forms I have read in my job as a clinical coordinator. “Patient states it all started when they got their flu shot….”
Cause and effect. You get a shot, you get sick. It didn’t matter that this guy had a multiple pneumonia history, his blood sugar was 500 and he weighed 300 pounds and had four by-passes and for the last two years he has slept upright every night in a chair and his apartment smelled of cat urine. He’d be perfectly healthy if not for that flu shot. He even handed me the literature they gave him about the shot and all its possible side effects. I set it back on the table and asked again for his med list.
You get a shot, you get sick. Cause and effect. One of the patients on the run forms I read blamed his syncope on the flu shot. I saw his diagnosis -- AAA -- aortic abdominal aneurysm. If they are linked we are in more trouble than we thought.
You get a shot, bad things may happen. It is the way people think. But the shots don’t guarantee you won’t have to call 911 in the ensuing week. If they came with that guarantee, we’d go door to door inoculating everyone. Then we could close up shop for a week and all of us go to the upcoming EMS Expo in Atlanta. No need to cover the town.
Anyway, I can get my shot as early as this Thursday. But I think I am going to wait until next week. I don’t want to risk getting sick and missing my race.
Vaccine is on its way, but public still wary
***
*I am actually planning a 4-1 run/walk. I’ll run four minutes, walk one minute and then start running again, repeating until I cross the finish line. I have run as much as 7.5 miles without walking but by the end I am not running too fast. Running experts say at my age I will likely have a faster finishing time with the walk breaks. My goal is to complete the race not necessarily compete.
With flu season comes flu shots. Everyone Hospitals, medical offices, ambulance services, senior centers, and pharmacies are all giving them out. It is hard to avoid mention of them. There is a sign on our ambulance service’s bulletin board about where and when to go to get your flu shot.
I get my flu shot every year. I will get the swine flu shot too. I believe in science. I believe in benefit versus risk analysis. Sure I might die from the shot in a rare occurrence, but I am much more likely to avoid the flu or get it much less severely than I otherwise would have had I not gotten the shot. I hate getting the flu. I haven’t died from it, but sometimes I feel like I will never be well again, and I hate that. Not for me.
I know quite a number of health care workers who are refusing to get flu shots and/or swine flu shots. I recall seeing some controversy on TV where the health care workers were rallying and holding up signs and an off-camera hospital spokesman was saying they didn’t have to get flu shots as required by the hospital, but the hospital also didn’t have to keep them employed. Something to that effect.
One side is advancing the argument that health care workers need to get the shot so they won’t get sick from sick patients and then pass it along to other vulnerable patients who will get sicker. Makes sense to me.
The other side is advancing the we have a right to what goes in our bodies argument, which I generally believe in as a proponent of freedom and the American way.
When these two clash, it does raise interesting issues. Let me just answer it this way. If I have a choice of going to two hospitals -- one hospital where all the staff have gotten their shots and one where none of them have, I’ll go to the hospital where they have all gotten their shots.
The dear mother of my darling twenty-one-month-old also works in health care and she never gets the flu shot. She won't let them come near here with that needle even though she herself gives the same shot to others countless times. We don't even argue about it anymore. I'm not going to change her mind, she isn't going to change mine.
I had a patient this morning with some mild difficulty breathing on exertion. I asked him when it started. “Right after I got my flu shot on Monday,” he said. Similar words to what a patient told me yesterday, and similar words to what I have seen written on quite a number of run forms I have read in my job as a clinical coordinator. “Patient states it all started when they got their flu shot….”
Cause and effect. You get a shot, you get sick. It didn’t matter that this guy had a multiple pneumonia history, his blood sugar was 500 and he weighed 300 pounds and had four by-passes and for the last two years he has slept upright every night in a chair and his apartment smelled of cat urine. He’d be perfectly healthy if not for that flu shot. He even handed me the literature they gave him about the shot and all its possible side effects. I set it back on the table and asked again for his med list.
You get a shot, you get sick. Cause and effect. One of the patients on the run forms I read blamed his syncope on the flu shot. I saw his diagnosis -- AAA -- aortic abdominal aneurysm. If they are linked we are in more trouble than we thought.
You get a shot, bad things may happen. It is the way people think. But the shots don’t guarantee you won’t have to call 911 in the ensuing week. If they came with that guarantee, we’d go door to door inoculating everyone. Then we could close up shop for a week and all of us go to the upcoming EMS Expo in Atlanta. No need to cover the town.
Anyway, I can get my shot as early as this Thursday. But I think I am going to wait until next week. I don’t want to risk getting sick and missing my race.
Vaccine is on its way, but public still wary
***
*I am actually planning a 4-1 run/walk. I’ll run four minutes, walk one minute and then start running again, repeating until I cross the finish line. I have run as much as 7.5 miles without walking but by the end I am not running too fast. Running experts say at my age I will likely have a faster finishing time with the walk breaks. My goal is to complete the race not necessarily compete.
Friday, October 02, 2009
The Golden Hour
R. Adams Cowley, the founder of Maryland's well-known Shock Trauma hospital in downtown Baltimore, famously said:
"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."
The Merriam-Webster On-Line dictionary defines "golden hour" as "the hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective."
“Give us an hour…We will give you a lifetime” is the motto of Vanderbilt Life Flight, and perhaps, other helicopter services. Again from the Vanderbilt Life Flight web site: "Within one hour of the trauma, irreparable organ damage occurs but superior care before that one hour makes all the difference."
The 2nd edition of the Prehospital Trauma Life Support said "The critical trauma patient has only 60 minutes to reach definitive surgical care or the odds of a successful recovery diminish dramatically."
(It is my guess that this is no longer in the current edition.)
The following quotes are from a 2001 Academic Emergency Medicine journal article:
"The Golden Hour: Scientific Fact or Medical Urban Legend?"
“The golden hour justifies much of our current trauma system...scoop and run, aeromedical transport, and trauma center designations with trauma teams in place are, in part, predicated on the idea that time is a critical factor in the management of injured patients....While it seems intuitive that less time is better for trauma patients, there are risks and costs involved in attempting to deliver patients to trauma centers within an hour...These may be justified if there is a benefit, but may not be if there is no proven benefit or if the benefit applies only to certain circumstances.”
In the article they researched Cowley and any mention of the golden hour. What they found was articles referencing articles that referenced articles that had no reference.
A text on trauma edited by Cowley contains a chapter authored by Shakar, which discusses “Cowley’s Golden Hour,” referencing a 1976 Cowley article.
“The 1976 article …describes Maryland’s trauma system and states that the first 60 minutes after an injury determines a patient’s resulting mortality.” It references a Cowley paper of 1975.
“1975 Cowley article states ‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’ but no data or reference is provided.”
They they looked at the scientific evidence about time and trauma. They found research studies both supporting a link and not supporting a link. As a rule the articles had poor quality, selection bias, small samples, and uncontrolled variables.
These were their conclusions:
“Our search into the background of this term yielded little scientific evidence to support it.”
“There are no large, well-controlled studies in the civilian population that either strongly support or refute the idea that faster is universally better in trauma care.”
“The intuitive nature of the concept and the prestige of those who originally expressed it resulted in its widespread application and acceptance.”
Which leads me back to a story I heard many years ago about the origins of the golden hour. Cowley, trying to win support for a the shock trauma hospital and what would become Maryland's elite helicopter program that would fly trauma victims from all over the state to the Baltimore hospital, determined with a helicopter any trauma victim in the state could reach the hospital in 60 minutes, thus "the Golden Hour."
Whether that story is true or not, I don't know. I do know there is nothing magic about 60 minutes. True some few may only have sixty minutes, but some have only forty, some five, and some none at all, while others may have two hours, two days or a lifetime.
Prehospital people need to look at each patient individually, weigh the risks (lights and sirens versus with traffic, helicopter versus ground), use their best judgment and common sense on a case by case basis. Err on the side of the patient. When in doubt contact medical control.
Clearly the more critical a patient the less time they have. Some patients truly need scoop and run. Ten minutes scene time won't cut it for them, many others may benefit by a slower, safer pace.
Promoting a definite time, not supported by evidence, serves no one.
***
Today as I was getting ready to post this, I came across the following "Article in Press" from the Annals of Emergency Medicine:
Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a North American Prospective Cohort.
Here's the conclusion:
"In this North American sample (Level I and Level II trauma centers in 10 cities, over 3500 patients among whom 20% died), there was no association between EMS intervals* and mortality among injured patients with physiologic abnormality in the field."
* Intervals include activation, response, scene-time, transport, or total EMS time.
The Editor's capsule summary offers the following: "This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights and sirens transport for trauma patients, with its inherent risks may not be warranted."
The article does state that their research adds further support to the concept that where a patient is transported is more important than how fast they are taken to the hospital.
"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."
The Merriam-Webster On-Line dictionary defines "golden hour" as "the hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective."
“Give us an hour…We will give you a lifetime” is the motto of Vanderbilt Life Flight, and perhaps, other helicopter services. Again from the Vanderbilt Life Flight web site: "Within one hour of the trauma, irreparable organ damage occurs but superior care before that one hour makes all the difference."
The 2nd edition of the Prehospital Trauma Life Support said "The critical trauma patient has only 60 minutes to reach definitive surgical care or the odds of a successful recovery diminish dramatically."
(It is my guess that this is no longer in the current edition.)
The following quotes are from a 2001 Academic Emergency Medicine journal article:
"The Golden Hour: Scientific Fact or Medical Urban Legend?"
“The golden hour justifies much of our current trauma system...scoop and run, aeromedical transport, and trauma center designations with trauma teams in place are, in part, predicated on the idea that time is a critical factor in the management of injured patients....While it seems intuitive that less time is better for trauma patients, there are risks and costs involved in attempting to deliver patients to trauma centers within an hour...These may be justified if there is a benefit, but may not be if there is no proven benefit or if the benefit applies only to certain circumstances.”
In the article they researched Cowley and any mention of the golden hour. What they found was articles referencing articles that referenced articles that had no reference.
A text on trauma edited by Cowley contains a chapter authored by Shakar, which discusses “Cowley’s Golden Hour,” referencing a 1976 Cowley article.
“The 1976 article …describes Maryland’s trauma system and states that the first 60 minutes after an injury determines a patient’s resulting mortality.” It references a Cowley paper of 1975.
“1975 Cowley article states ‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’ but no data or reference is provided.”
They they looked at the scientific evidence about time and trauma. They found research studies both supporting a link and not supporting a link. As a rule the articles had poor quality, selection bias, small samples, and uncontrolled variables.
These were their conclusions:
“Our search into the background of this term yielded little scientific evidence to support it.”
“There are no large, well-controlled studies in the civilian population that either strongly support or refute the idea that faster is universally better in trauma care.”
“The intuitive nature of the concept and the prestige of those who originally expressed it resulted in its widespread application and acceptance.”
Which leads me back to a story I heard many years ago about the origins of the golden hour. Cowley, trying to win support for a the shock trauma hospital and what would become Maryland's elite helicopter program that would fly trauma victims from all over the state to the Baltimore hospital, determined with a helicopter any trauma victim in the state could reach the hospital in 60 minutes, thus "the Golden Hour."
Whether that story is true or not, I don't know. I do know there is nothing magic about 60 minutes. True some few may only have sixty minutes, but some have only forty, some five, and some none at all, while others may have two hours, two days or a lifetime.
Prehospital people need to look at each patient individually, weigh the risks (lights and sirens versus with traffic, helicopter versus ground), use their best judgment and common sense on a case by case basis. Err on the side of the patient. When in doubt contact medical control.
Clearly the more critical a patient the less time they have. Some patients truly need scoop and run. Ten minutes scene time won't cut it for them, many others may benefit by a slower, safer pace.
Promoting a definite time, not supported by evidence, serves no one.
***
Today as I was getting ready to post this, I came across the following "Article in Press" from the Annals of Emergency Medicine:
Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a North American Prospective Cohort.
Here's the conclusion:
"In this North American sample (Level I and Level II trauma centers in 10 cities, over 3500 patients among whom 20% died), there was no association between EMS intervals* and mortality among injured patients with physiologic abnormality in the field."
* Intervals include activation, response, scene-time, transport, or total EMS time.
The Editor's capsule summary offers the following: "This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights and sirens transport for trauma patients, with its inherent risks may not be warranted."
The article does state that their research adds further support to the concept that where a patient is transported is more important than how fast they are taken to the hospital.
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