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Chapter 30

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Case

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Emergency medical services (EMS) calls into the community hospital where you are working to alert the staff that they are bringing in by ambulance a 34-year-old male driver who survived a head-on automobile collision. Initial details over the radio inform you that he was found conscious in the car. An IV was started while he was placed in a cervical collar and on a trauma board for transport. He is currently lucid and conversant with EMS staff. His vital signs are BP 100/70 mm Hg, pulse 100 bpm, respiratory rate 18 breaths per minute, and pulse oximetry 99% on nasal cannula. He denies pain, but the EMS staff can smell alcohol. Initial field physical examination revealed head lacerations with some bleeding, but he is moving all extremities, and he has no gross deformities.

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What other information would you seek to elicit from the EMS staff? What instructions would you convey?

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Initial reports from the field tend to be brief and consist of bare essentials to alert the receiving facility. The field staff focus on major presenting signs and symptoms that can be managed or temporized while preparing for and implementing transport to the hospital. Interventions such as splinting, intubation, IV placement, and, in some communities, drug administration are performed. Review and advice from the receiving physician or facility is often sought. The current paradigm emphasizes “scoop and run” or rapid transport to a definitive facility rather than aggressive and prolonged management in the field.1 Some would even advocate against placement of IVs prior to beginning transport in urban areas, since the time to place IVs may be equivalent to the time of transport. Location and time of transport probably have a major effect on level and outcomes of care. Advanced life support (ALS) providers are more prevalent in the urban than the rural setting, which is probably the opposite of what is required. Interestingly, however, ALS has not been shown to provide benefit in the EMS setting, and the use of EMS causes delays in time of transport owing to advanced interventions for severe trauma. More concerning, ALS measures, particularly endotracheal intubation, worsened outcomes for patients with initial Glasgow Coma Scale (GCS) scores < 9.2,3

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Estimated time of arrival (ETA) and information about the nature of the injury and patient help the receiving facility prepare personnel and resources appropriately. Further exchange of information might consist of requests for guidance from the receiving physician; otherwise, the EMS staff will focus on transport and patient stability. Transport, IV placement, and directly applied pressure to the head wounds along with vital signs and basic patient observation are the key at this time, which is known as the prehospital phase.

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The patient is en route to your facility, which is a 50-bed rural hospital with a surgeon on home beeper call. ETA is 15 minutes. You are the only physician covering the emergency ...

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