Aoccdrnig to rsceearh at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist

Transcription

1 Aoccdrnig to rsceearh at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit porbelsm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe and the biran fguiers it out aynawy.

2 Emergency, Crisis Medicine, And Surgery

3 Nurses Administrators Quality Review Personnel Physicians Data Registry

4 Clinics Hospitals Offices Corporate Finance

5 Intergrated Health Care Personnel and Organizations Accountable Care Integrated Collaborative Networks

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7 Acute Care Surgery Emergency Medicine Surgery Critical Care Emergency Surgery Disaster

8 I need 3-4 volunteers to read the next slide

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10 Upside down, backwards Does not matter, you cannot read it correctly anyway

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13 EMS Medical Direction Pre-hospital protocols Anatomic descriptors Mechanism of Injury Physiologic findings TREMENDIOUS variability in Rx Variability in credentialing Basic, Advanced, Air Standardiaziable??

14 Specialty since 1970 Emergency Evaluation & Triage Medicine Resuscitation Dispositions Interacts with many disciplines Psych, Pediatrics, Medicine, Geriatrics, Surgery, & others

15 Decreasing numbers of surgeons Extension of General Surgery surgery Emergency Surgery Episodic Military Acute Care Surgery Disaster Surgery Response Nocturnal Surgery Innovative

16 5 specialties have interest Not universal knowledge base Monitoring, 2:1 nursing Consultants common Critical Care Super sick patients Turf battles Ventilation, Sepsis, Infections, DVT, Nutrition, etc

17 Declared by government agency Rescue, evacuation, shelter Public health issues Acute health Care Infection Medicines Disaster Critical Care

18 EMS Emergency Medicine Critical Care Acute Care Surgery Disaster

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20 Interaction Among EMS, EM, ACS, & CC Words & Principles Areas of Interaction Hinder Help Turfs & Conflicts Areas of Cooperation

21 No Tricks Simply count # of F s in the MAROON background on the next slide There is a short sentence on the next slide which you will be asked to read

22 No Tricks Simply count # of F s Below FINISHED FILES ARE THE RE- SULT OF YEARS OF SCIENTIF- IC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

23 No Tricks How many F s did you count -Two -Four -Six -Eight -Three -Five -Seven -Nine

24 No Tricks How many F s did you count Do you wish to see it again? Would you like to pole the audience? Would you like to remove 50% of the answers?

25 Ok, we have removed four INCORRECT answers, the correct one is below -Three -Four - Five -Six

26 No Tricks Simply count # of F s Below FINISHED FILES ARE THE RE- SULT OF YEARS OF SCIENTIF- IC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

27 Ok, how many F s did you count -Three -Four - Five -Six

28 The Correct Answer Is 6

29 FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

30 Learning from PAST successes and errors It is all about FOCUS, concentration, bias, vision, values, & background

31 First: Words about trauma codes & classifications

32 3-5 Levels of Severity 1. Minor 2. Mild 3. Moderate 4. Severe 5. Terrible

33 This talk is about the SEVERE & TERRIBLE clinical conditions

34 Second: Words about Centers

35 Many names for Centers Level 1-3 Level 1-5 Rural Military University

36 Common to ALL Centers Commitment Surgeons Operating sites Communications Transfer Capability

37 Third: Over Riding Governing Principles

38 Over Riding Governing Principles 1. Each of us will be a patient 2. 1 doctor :: 1 patient 3. Consultants do not Rx, they advise 4. Tests & Rx Data Based 5. Standardize Rx & outcomes

39 Over Riding Governing Principles 6. Tests & Rx based on knowledge of anatomy & pathophysiology 7. Review all decisions & outcomes 8. Provide to patient = BEST

40 Fourth: TURF Questions

41 Turf Groups 1. Paramedics 2. Nurses 3. Quality Review Teams 4. Surgeons 5. Emergency Physicians 6. Anesthesiologists 7. Intensivists

42 Nurses Administrators Quality Review Personnel Physicians Data Registry

43 5 TOWERS who share the same patients EMS Emergency Medicine Acute Care Surgery Critical Care Disaster Medical Response

44 SILOS

45 SILOS

46 Silos Anatomy & Physiology Tall Imposing Windowless Imbedded in weeds Disconnected Isolated Not integrated Aloof Fills from the top

47 Silo Anatomy & Physiology Contains uniform stuff Can be contaminated Sometimes EXPLODES Cannot see contents (unless inside) Top down management

48 Silos Weeds Communications from one silo to another often involve wading around in the weeds

49 5 TOWERS that share the same motivations Rx Policies Billing Politics Procedures

50 Fifth: Words about the EMR

51 Finally: Key Questions

52 Key Questions 1. EMS & EC Protocols? 2. Who calls Activation? 3. What Rx in Field & EC? 4. What kind of fluids? 5. Who does procedures? 6. Who manages critical care? 7. How & Where is ALL QAed?

53 Special Issues Family presence in shock rooms Family visiting hours everywhere Who writes orders Standing & Implied orders Who requests & pays consultants Determining end game

54 It s all about OUTCOMES

55 Outcomes Good & Bad Individual responsibility Risk adjusted CODING essential QI, PI, Peer review etc. is a group activity Seeking improvement, NOT BLAME Addressed real time

56 How can EMS, EM & CC HELP & HINDER the SURGICAL team?

57 What does the Surgeon want to know from EMS & EC Physicians?

58 DEAD?

59 Verbal Response & Movements?

60 Peripheral Pulse?

61 Family & other patients?

62 IV Sites?

63 Fluids?

64 Medication?

65 Where to go with patient?

66 Any Procedures?

67 Time?

68 Hindrances

69 MAST

70 MAST & fluid restriction Action Increased complications Increased death NOT a good splint No extra value in pelvic fractures

71 ? Blood Pressure

72 Large Bore IV Line (s)

73 IV Line in anticubital fossa

74 Volume of ANY crystalloid more than 200 ml

75 Use of Helicopters vs Ground EMS

76 INCREASE: Air Ambulance EMS (several meta analyses) TIME from injury to Center DEATH COSTS by X Complications Risk of EMS accident DECREASE Donor recovery for transplants

77 Elevation of Blood Pressure

78 Concerns Diluting the blood volume Diluting the clotting factors Turning on cytokines Popping the clot Masking physical findings Creating a new injury

79 Needle Decompressions

80 Airways, when endo tube, etc. was not really indicated

81 Interosseous Infusions

82 Drugs

83 Vasopressors Steroids Antibiotics Anticoagulants

84 Let s talk about cervical collars

85 Cervical collars in penetrating trauma

86 Stuff put into an open wound, Except a routine dressing

87 Blood drawn in field for EC blood tests

88 Help

89 Information

90 IV Site in hand with small needle

91 IV Crystalloid Volume less than 25 ml.

92 Back boards

93 Estimated Blood Loss at scene and in ambulance

94 Changes during transport

95 Peripheral Pulse Status Wrist & Ankle

96 Deformities noted

97 Pressure Dressings

98 Neutral +/-

99 Oxygen mask

100 Tourniquets in civilian wounds

101 Cervical Collars Data & Slides Courtesy Dr. Pelig Ben Galem

102 Pull - Traction reality of Airway and C- Spine protection

103 What is known about Collar stabilization. Collars will limit head motion In healthy INTACT volunteers.

104 Internal Decapitation Complete, through and through dissociation from front to back Ligament Rupture Soft Tissue Rupture

105 Secondary!!! High cervical quadriplegia 17 Y/O, FEMALE, HIGH ENERGY MVA

106 Acceleration-deceleration Human Trials NBDL database

107 Hypothesis: collar creates distraction?

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111 Acute Care Surgery Emergency Medicine

112 Key Issues Timing Procedures Position & Incisions Drugs & Ventilation

113 Which Examinations, LABs, Imaging?

114 Who determines location & details of admission?

115 FLUIDS

116 PROCEDURES

117 Procedures in super sick patients should be preformed by the best person available at the time

118 INTUBATION

119 CHEST TUBES

120 ULTRASOUND

121 Thoracotomy

122 CT SCANS

123 ANTIBIOTICS

124 STEROIDS

125 Automatic (Standing) orders & Protocols

126 Lab Panel ABG? Urine Drug Screen? Clotting Studies? CBC? Metabolic Panel?

127 Ultrasound Chest X-Ray CT Scans Arteriograms

128 Consultants Surgery Critical Care

129 Who Writes Orders?

130 The Patient s Doctor

131 Ventalatory Settings

132 Protocols

133 Quality Review

134 Automatic consult Who Calls? Who pays?

135 Government Disaster Public Health Emergency Medicine

136 DISASTER Confusions

137 Disaster Planning Need for changes Network among Civil, Public Health, Medical Responses FEMA, NDMS, Rangers, DMAT teams, etc. etc. Humanitarian responses

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139 10% Rule

140 10% Rule Of Disaster survivors 10% will have serious health issues 10% of which will be CRITICAL

141 Finally: FIVE RECOMMENDATIONS

142 1. Regional Acute Care Advisory Council

143 2. Regional EMS DISPATCH 911

144 3. Regional EMS STANDARDIZED Protocols

145 4. Hospital Wide Acute Care Committee, STEMI, Stroke, Heart Attack, Sepsis, Pneumonia, Diabetic Coma, Complex OB

146 5. Evidence Based Acute Care Practice

147 Systems 2013 Standardized classifications Standardized trauma centers Standardized verification process Standardized ATLS ONLY national system of care Network safety net for surgical critical care

148 Impact of war 2013

149 Korea, Vietnam, Iraq, Afghanistan Air Ambulance Vascular trauma Registries Hypotensive Resuscitation FST concepts Damage Control Top Knife Surgery 1:1:1 Hemotherapy Rapid transportation CCAT

150 Putting it all together Emergency care is complex Network of care Should & can be STANDARDIZED We are all together in the treatment of patients Evidence based data exists Need for QA Closure of Loop analysis

151 You have a PROBLEM 97.3% of what I have said today is absolutely true!

152 You have a PROBLEM 2.7 % was said merely for effect

153 PROBLEM YOU don t know which is which

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