Latest / The JEMS Report / How to Save Trapped Trauma Patients
Transcript
- speaker-0: Everybody, welcome back to the Gems Podcast. I'm joined again by Dr. Tim Nutbeam. So if you don't remember, he and I connected on ⁓ LinkedIn, had a great chat ⁓ not too long ago about ⁓ some extrication considerations. There were a lot of messages that came back and forth. So I wanted to get him back and ⁓ kind of unpack things a little bit more. So Doc, I'll ⁓ pass it over to you, let you introduce yourself and we'll have a have a little chat. speaker-1: ⁓ good morning, good afternoon. Whenever you're listening to this, ⁓ it's ⁓ really nice to be back. Many thanks for the invite. ⁓ my name's Tim Nuttbeam. I'm a a consultant, so an attending in US speak in emergency medicine and in pre-hospital emergency medicine, so that's EMS. ⁓ and I work ⁓ part-time at a major trauma centre in Plymouth in the southwest of the UK, ⁓ with responsibility for major trauma in the emergency department. And then I work part time for our local air ambulance, so doing clinical shifts ⁓ out and about. And I run a research group called Impact, which focuses particularly on post collision care and kind of what happens after an impact and ⁓ does research and systems improvement in that area. speaker-0: Yeah, and and thank you so much for that work that you're doing. ⁓ the ⁓ the exit study that you did, I thought was was amazing. We've since posted it on Gem. So I'll get a link back to it ⁓ for this podcast if anybody hasn't caught it, but it's some great work. And ⁓ you know, we started to have a little bit of the discussion ⁓ last time ⁓ that not every intervention belongs inside the vehicle, right? ⁓ so as we look at post ⁓ post-collision care and resuscitation of those complex trauma victims. How do we how do we decide what what has to happen there and what's better deferred for outside of that vehicle? I know some of that is dependent on how quickly we can get them out, but ⁓ what's what's kind of your your thought process? speaker-1: So it's a it's a really complex area. ⁓ and one of the ⁓ attractions to me of pre hospital medicine is that level of complexity. ⁓ and in order to understand that complexity, you need to understand the interaction between the rescue environments, the patients, and the utility of the clinical interventions that we can offer. And some of that is about understanding rescue well. ⁓ some of that is about understanding things like the crash pulse and injury and what that means to our patients. Some of that's about accepting the limitations. So, what are the limitations of clinical examination in the trapped environment? How do I choose the right patients to offer some of the more difficult interventions, like for example, decompression of attention, pneumothorax? ⁓ yeah, and some of that I think is being very humbling for me, realizing that We're we're probably not as good as we think we are in terms of identifying time dependent injury. and that if we get it wrong, harms come with that. I think it's probably worth just my absolute priority if someone is trapped is to relieve that entrapment as soon as possible. And I think it's really difficult to have a look at these interventions as a as a single item. So you could say. You know, should I give a whole blood transfusion? Should I give tranexamic acid? Should I give ⁓ you know, should I put on a blood pressure cuff and monitor their heart rate and do their oxygen saturations? And of course, as independent interventions, they probably, if you're selecting the right patients, all make perfect sense and that's great. But you need to think about the impact you're having on the operational environment, the rescue environment, and and the patient in that context as well. And And it's that interaction, I think, where things get get really, really difficult. So I think the first thing to be aware of is that when we look at patients who are injured and appear entrapped, only about ⁓ substantially less than ten percent of them have got genuine physical entrapment. And most of those that have genuine physical entrapment, it's not what the Australians would call entombing. or ⁓ what s some people would call ⁓ anatomical entrapments, but it can be relatively easily relieved by opening a door or moving the car away from road furniture or whatever it might be. Very few people, particularly in vehicles which have been kind of on the roads in the last 10 to 15 years, are have genuine anatomical entrapments. And those that do, apart from the really rare occasions that we talk about, you know, the the the the once in a lifetime really odd cases. ⁓ it it can normally re- be relieved either by opening a door, a dash roll, or something relatively s it's simple's not fair, because obviously environment can be very difficult, but you know, something that can be delivered in a handful of minutes. What I'm very conscious of is a mistake we've made previously, which is that Because of our concern for particularly injuries expect affecting the spine, we've taken a very steady, and it's turned out to be slow and steady approach to relieving entrapments. And that has meant that we've had to deliver interventions in the car to keep our patients alive, rather than it's necessary to deliver those interventions during the entrapment phase, because that's the right thing to do regardless. So I think. If we accept the findings of the exit project, which is that we should relieve entrapment as quickly as possible and extricate patients in as timely manner as possible, then our historical learning about what we should deliver in the car has probably changed quite significantly. I think it's always worth saying there's outlying cases that are people who are genuinely entrapped for a long time, who there is no way to relieve that entrapment despite having the right people, the right tools, the right equipment, the right expertise. And some and that that is a that is a different patient group to the ninety nine point five percent we see kind of as part of our jobing work on an everyday basis. Yeah. speaker-0: Yeah, I I couldn't agree more. And you know, I think one of the one of the telling things is that there's a lot of dogma, right, in in pre hospital medicine and EMS that, you know, we've you know, we were told for all the all the years that we had to be very careful about ⁓ spinal motion restriction or whatever whatever we're calling it now. And you know, we're learning from some of the great data that ⁓ that that you've been able to ⁓ compile that those those true spinal injuries are actually fairly, fairly rare. And it it would seem as though the things that are actually killing our trauma patients are things that w it would be better if we quickly extricated them and were able to perform those interventions outside of the vehicle in a more controlled environment. Is that a fairly fairly accurate state? speaker-1: Yes, yeah. I I always like to bring the two things together. So one is the rate of spinal cord injury is is is lower than we thought it was. So around about zero point seven percent of trapped patients. ⁓ and that we've been shown to kind of numbers of that magnitude, it seems to be a common internationally when we look at ⁓ global burden of disease data. But it's more than that, it's that actually The slow and steady approach didn't work to restrict or minimize spinal movement. And so I think the two need to come together, because otherwise it sounds like we don't care about spinal cord injury. It's a devastating condition, which is really important. And I think it makes logical sense for those patients to keep the spine in a in a position of comfort. I'm not sure immobilization is the right word. I'm not sure restrictions are in the right word, but they certainly need to be handled gently and respectfully, as does every major trauma patient. But it's the combination of the two. It's the low rate of spinal cord injury, which slowly floated its way up in all the historical manuals from being at the bottom to being at the top of our priority list, right next to airway. ⁓ and it's the and it's the fact that actually the slow and steady approaches that we took aren't actually minimizing spinal movement. Anyway. Right. So it's the combination of the two, ⁓ techniques that don't work as we think they did, and that low rate. And we need to offer proportionate for care to our patients. Even those patients with spinal cord injury, more than half of them have got a time critical injury, which means they can't look after their spinal injury. So something like hemorrhagic shock, for example, non-compressible hemorrhage, often often a significant chest injury, which means they can't ventilate effectively and deliver that oxygen to their spinal cord. So we're also prolonging the time of secondary spinal cord injury by leaving them in traps. So I think kind of yeah, ⁓ it it's it's important to capture all of that. But yeah, I think that's ⁓ that that changes what we do in the vehicle because our absolute focus should be to get that patient out of the vehicle in a vast, vast majority of cases. speaker-0: Hundred percent. I couldn't I couldn't agree more. While we're addressing some dogma, ⁓ I'd like to also kind of get your get your perspective and and what your ⁓ what your data says on ⁓ mechanism of injury and how predictive that that truly is for severity of of injury. As as you know, I'm a so I'm a flight clinician, ⁓ and I you know I don't I don't know how many times I've had a a provider ⁓ summon our air ambulance based on mechanism alone. Not faulting them for that, but ⁓ how how reliable is mechanism injury in your in your experience? Do speaker-1: way I like to think about what injury is, and I I can't remember if we called this, ⁓ if we covered this in the last podcast, but ⁓ you start with your initial kinematics, your crash pulse, whatever you want to call it. I'm I'm a simple emergency physician, so let's start with a a big force that we need to do something about. And that's essentially your mechanisms of injury. It might be rollover, it might be front on front, it might be a very heavy truck versus a smaller car, but you've got a force. And then that force is attenuated by the safety systems that you have. So that might be a crumple zone, it might be a central safety zone, it might be ⁓ you know, all the all the the modern things. It might be your ⁓ airbags, everything. All and that does something to that force. And then, and I think everyone understands that, but I think what people often forget is what's called tissue tolerance. So this is the ability of the body to absorb the force before injury. Is caused. And essentially, how much of that force is left over your tissue tolerance tells you the likelihood and significance of the injury you're going to get. So if you've got a big force, you attenuate some of it. You've got a small tissue tolerance, you're going to end up with a significant injury. If you've got a tiny force, a very low mechanism of injury, no matter what happens with attenuation, as long as your tissue tolerance is okay. You're not going end up with injury. But we see elderly people, older people with osteoporosis, have a very low front shunt RTC. Mechanism of injury is, you know, it enough newtons just to set off the airbags. The airbags go off, the ⁓ restraint systems go off, ⁓ and they end up with bilateral rib fractures. And that kills that person at day three or four. And you get the same intoxicated 17-year-old driver going at 100 miles an hour who rolls their car 18 times on the highway, and they get out laughing with their mates, and everything seems to be okay. And those are at the two extremes of of what we see. But it's a combination of all those things. So the mechanism of injury speaks to you know the kinematics, the exchange of forces. And then we've got our modern cars versus old cars and there's something very significant there. You know, I've I've lived through cars, seen cars in the road pre airbags. It's it's very rare now that you see that. Cars without crumple zones, et cetera, you know, it doesn't take much with those cars to cause very significant injury. And then it's the tissue tolerance. And tissue tolerance seems to drop off kind of from fifty to seventy and then very significantly after seventy. And obviously we all age at different rates and that's that's kind of a very broad thing. What I will say is one of the highest risk groups seem to be people in their seventies, because they drive like a fifty year old. ⁓ but with so they they have that high mechanism of injury, ⁓ but yeah, but don't have the tissue tolerance to abs to to absorb and and deflect that. And if you look at things like deaths per mile driven, it's people in their eighties who are who are dying most. ⁓ because they drive low drive low number of miles and actually minor bumps can lead to very significant injuries of morbidity and mortality and young people drive lots of miles but some of them have you know they're they're the they're the second most common group to die per per mile driven. That said, there are some mechanisms of injury which are are very, very important. ⁓ and they probably fall under the mechanisms of injury ⁓ category. ⁓ and those seem to be Evidence of energy transfer to another person. So if you've got one person in the cabin who's got severe injuries, we know that there's been a mechanism of injury consistent with major injuries. So if you've got death in a cabin or very injured person in a c in in one part, consider what's happening to the to the other person. And then the other is intrusion in a modern car. So intrusion more than fifteen centimeters into the the central safety area seems to be highly correlated with with With major injury. And we've got various data looking at other nuance, but it's really difficult to kind of like r report the test characteristics of each of these. But if you think about it from a ⁓ what was the force at the start? How is it being attenuated by safety systems? And it's really important, did those safety systems work? So some safety systems won't fire in certain circumstances. So if the driver's unrestrained, for example, some cars. ⁓ many years ago now the safe systems wouldn't work at all. But what often happens now is it will do a calculation based on how close you are to the steering wheel. If your seatbelt's unplugged, it may say the risks of this airbag we think are more like more than the risks of the collision itself. And then me or you might arrive at scene and say, All right, the airbag's gone off. It must have been a low low ⁓ a low energy collision, but actually that person might be very majorly injured and the car Is is is super smart and just trying to protect them from the the the the the potential damage from the airbag. ⁓ but if you yeah if you start big energy or small energy, safety systems or no safety systems, and then very, very importantly, what is the tissue tolerance of this person? Because a young person will absorb that energy without major injury and the other person won't. And if you think of it just in very broad strikes, what you've got left at the end is going to cause damage. And if it's loads, that person's gonna have major injury. speaker-0: Awesome. That's ⁓ that's that's one of the best explanations I've ever heard of mechanism of injury. I really I really appreciate you going into that detail. And you know, it's I think that you know the the two big takeaways there are, you know, death or serious injury in that ⁓ in that patient compartment and then the obviously intrusion into the compartment because that's gonna affect how that ⁓ how that energy is transferred. So that that definitely makes speaker-1: sense. And particularly in a modern car, by the time you've got that intrusion, I mean you you know far more about the ⁓ you know the design and construction of these vehicles than I do, but by the time you've got an intrusion, the forces involved are massive. And ⁓ yeah, and and and that force has been has been inadequately diverted by the car structure elsewhere. So you you're very likely to have major injury. Yeah. speaker-0: No, that's like I said, that's a a perfect explanation. ⁓ one other thing I wanted to ask you and just kinda ⁓ you know, based on your experience, what are what are some some red flags or some things that alert you that hey, we've got to we've gotta really concentrate on getting this patient out of this vehicle now. ⁓ so maybe those top two or three things that at you as a clinician you see and experience. That maybe you can pass along to the listeners that can help them have a higher index of suspicion that they need to get the patient removed as soon as possible. speaker-1: I guess my my challenging answer to that is that every patient comes out as soon as possible. On the basis that I I do not believe in the concept of stability. I used to talk about is this patient stable? Have we got 15 minutes? Have we got 20 minutes with this one? Anyone who says they can predict that is is lying to you. You you can't. Either a patient is uninjured, in which case they need to come out quickly so we can reopen the roads. go back to our tea and cakes, whatever whatever we other stuff we had to do, back to our training, ⁓ or they're injured. And once they're injured, our ability to determine who's very injured versus moderately injured is is as cl it it's a it's like flipping a coin and that's not fair to do with people's lives. And if they're majorly injured, you want them out as soon as possible. And if they're moderately injured, you want them out as soon as possible as well. So I think the the idea of red flags, even though it's It's it's an interesting one. Most of them are very obvious to a passerby. If someone's unconscious, pale, sweaty, clammy, can't breathe properly, you're going to get those people out as soon as possible. But what's more important is anyone can identify those patients. You know, you hold up a picture to a passerby and say, Hey, what's this person look like? And they go, They look sick. Yes, yes, they need to come out as soon as possible. But ⁓ it it's it's it's the nuance around if you drop a point of GCS. Just one point, your risk profile changes massively. Of course, it might be intoxication, it might be stress, it might be a fawn response, it might be a freeze response to trauma, but let's not assume that. Let's get that person out quickly. The actual physiology, once you take out the sh extremes, so take out the really high heart rates, the really low heart rates, the really high blood pressures, the really low blood pressures, the same for respiratory rates, you're left with a very heterogeneous group in the middle, i.e., Some of them are gonna die, some of them are gonna live, some are gonna be fine. Your ability to distinguish between them on numbers alone is close to zero. Once again, it's flipping a coin. So for me, my approach is if they're uninjured, they need to come out quickly for operational reasons, economic reasons, getting roads open, you know, it's stressful to be trapped. Let's just get get them out. If they're really sick, it's really obvious anyway, they need to come out because they got definite time critical needs. And if they're in that middle group, I do not know if they're going to develop time critical needs and I'd much rather they develop time critical needs ideally in my resuscitation room with immediate access to damage controlled surgery, if not on the way to that, and if not out of the vehicle. If they develop it in the vehicle, their chances of survival of ⁓ you know you you'll yeah. You are unfairly placing them at risk. speaker-0: No, and and that that totally makes sense, obviously. And so since you brought it up, ⁓ being in your in your trauma bay and having access to damage control surgery and and all the things, let's say you're you're at a scene, you've got a trauma bay waiting, and you have one trapped patient. What are you really concentrating on in those first ten minutes with that person? speaker-1: So I I guess, you know, all of us know know the basics, don't we? So we're gonna keep our team safe and we're gonna keep us safe. So we're gonna make sure it's safe for us to approach. Right. I'm gonna take that as as a as a golden rule. Yep. Seen safety issued. Yeah. And and then what I want to do is I do want to get an idea of what is how sick is this patient and what are their immediate time critical needs. And what can I do to to to to make the extrication as speaker-0: Safety's assumed. speaker-1: easy as possible for those delivering it. So in the UK we have paramedics, we have critical care teams, and then the fire and rescue service is a completely separate entity without they have ⁓ basic trauma skills, but they they don't have a paramedic type type skill set. And I know in the US it's more of a ⁓ a mixed system. I know from research we've done, observational research we've done, that each time I go to check on that patient, I prolong the extrication time by about eight minutes. So even if I go and spend 30 seconds checking on that patient, checking on them, I'm going to add a significant time to that patient's extrication. So I need to think in my first assessment, what can I do which is meaningful for this patient, which means that I can optimize their safety and then get out of the way so the fire and rescue services can do their job. And I need to give permission for those fire rescue services to get the patient out as rapidly as possible. And that might be using quite blunt language which makes sense ⁓ and is easily understood across professional boundaries. Everyone understands someone is big sick. Everyone understands they just need to come out. ⁓ and and ensuring that message is being transmitted is really important. So I'll go in, I'll do a very rapid assessment. It's not something like a formal primary survey, because I know Listening to the chest isn't going to add any value because what am I going to do about a chest problem? I'm going to get them out. What am I going to do about, you know, I I'll run my hands down their legs, make sure there's not any catastrophic hemorrhage, but anything else, a pelvic assessment, so what? An abdominal assessment, so what? It's not going make any difference to that patient. I'm going to decide what do they need? They might need some oxygen, they might get some intermuscular tranxemic acid, they might get some analgesia. I'm not going to mess around with IV access at this point if I unless I need it for an immediate intervention. And then I'm gonna step back and I'm gonna keep out of the way and I'm gonna observe from a distance because I know as soon as I get in, whether we know it whether we accept it or not, those those people who are doing the cutting, if cutting is needed, are going to slow down to try and keep me safe. They're gonna be like, ⁓ he's coming in again. Even if I've got a helmet and a visor and all my PPE, and which I really try to maintain, ⁓ they're gonna slow down and it's gonna be bad for that patient. So you're gonna ⁓ Try and have one intervention session where we meet all their needs and then get out of the way. And then I'm going to be preparing for that patient. I'm to be, are they going to need anaesthetic? Are they going to need needle ⁓ tube for a cot? What they're going to need. I should have an idea by then and I can start setting up whole blood transfusions, and whatever you think they need, you can start getting ready. If you're around the corner, you can give a pre alert to the hospital, but you're out of the way of the extrication process so those folks can get get get doing their job. speaker-0: Yeah, I I you know, I think that's a that's a great mental model to use and you know, I think that really makes sense. ⁓ you know, and it it's a really good explanation of why each time we insert ourselves as the healthcare provider to do something that we think is ⁓ some sort of necessary assessment, ⁓ you know, when we've already discussed we're not all that good at determining how sick they are. And if that's going to cause significant delays in how quickly we can get them delivered to us, then it's not ⁓ you know, the the risk benefit doesn't doesn't doesn't line up in the patient's favor. So no, and I I really appreciate your time today. And as we kind of start to kind of start to close this out, ⁓ just just curious what's coming from you next, ⁓ from ⁓ from your group or what are you what are you working on? What are you excited about? speaker-1: One of the things I'm most excited about sounds incredibly boring. So ⁓ I'm gonna I'm gonna I I'm gonna say it with for that. So I think there's two things. So one thing we need to solve ⁓ as a group is who owns post-collision care? And the answer is all of us. And I think at the moment it's too broken between ⁓ police and collisions and fire and rescue, and in the UK we have national highways and we have all these other groups. And because no one owns it, no one brings people together to discuss how we do best for these scenes. For me, it's about putting the absolute patient at the front of what we do. And if a police officer arrives first, it's their job to deliver care. If a fire rescue person arrives first, it's their job to arrive care. If it happens to be a clitian, it's their job to provide care. And I think that due joint ownership isn't something that we we see. But I think we're starting to make some headway in the UK in terms of how we train together, how we work together, how we get some whole system acceptance of this as a problem. The other thing I'm really excited about, I'm going to do two more, is one sounds really boring, but we're working with the Lardell Foundation around what's called Utstein. So that is what data do we collect at the scene of a road injury, which means I can compare what I'm doing in the UK with what you're doing in your part of the world. Or with what's happening in Southern Africa, which has the highest rate of road injury in the world. So we're comparing like with like. So like we did with cardiac arrests, we can work out what is the right ratio of chest compressions, what is where do we put our community DFIB schemes? What is the time to resuscitation? We can do that for road injury and learn through sharing data and making comparisons. Because we're doing some amazing work all over the world world and we don't know what works and what doesn't, and being able to share that. ⁓ is really, really important. ⁓ and the third thing that we're doing is ⁓ we're really researching and looking at the role of the bystander. So how the first person on scene can be truly enabled to help in a way which is meaningful for the patient. And that's not necessarily clinical care. It might be enacting self-extrication. It might be making the perfect nine ⁓ nine call. It might be psychological safety for the person who's been you know offering psychological support for the person who's been trapped. That sounds complicated, but I think it's probably just being kind. you know, there's there's all ⁓ those I think are the three things which really excite me at the moment. And I really like the fact that, you know, there's I'm meeting fantastic people around the world who are interested in this area and want to do better. And that's that's incredibly exciting. speaker-0: Yeah, it is it's very exciting. And I've you know, I've always enjoyed our our conversations and I don't think any of that's boring. ⁓ you know, I'm I'm excited to ⁓ I'm excited to see what continues to ⁓ what continues to come out and I I really think that learning what we're doing in different areas of the world and being able to bring that all together much like we much like we do in cardiac arrest resuscitation, I think that's I think that's really key. And I think that's you know, has has some potential to ⁓ to drive how we ⁓ how we care for and resuscitate ⁓ trauma victims. So again, Doc, I really appreciate your time and thank you so much. And as your ⁓ as your new work comes out, we'll have to ⁓ continue to connect. So thank you. speaker-1: No, thank you very much. That's great. Thank you. speaker-0: Yeah. Have a great day. speaker-1: Cheers.