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On the Cult of Mechanism:

Rogue Medic weighs in with his opinion on evaluating vehicle intrusion as a predictor of injury, which was the subject of a recent episode of the excellent EMS Research Podcast. In his post, he states: 

"We want EMS to pay attention to the assessment of the actual patient, rather than the assessment of the possible cost of repair of the vehicle."

Word to your mutha, RM. In fact, I'm stealing that line. Next time one of my co-workers makes a silly decision based solely on what the vehicle looked like, I'm going to ask him, "Are you an EMT, or an auto insurance adjuster?"

I've opined before on the irrational degree of faith EMS places in mechanism of injury criteria. For some, it's a belief system bordering on culthood. MOI criteria were developed as a conceptual tool to give us an idea of where and what to assess, and a rough means of predicting what injuries may be present.

It is not the assessment itself.

The proper use of MOI is to guide assessment, not to dictate treatment and transport decisions.

Further in, Rogue Medic points out:

Why do we treat STEMIs (ST segment Elevation Myocardial Infarctions) with the opposite approach?

The dichotomy is that with trauma triage, we accept a 1,000% to 2,000% overtriage rate, while with STEMI triage, we consider a 5% overtriage rate to be unacceptably high.

The reason is because we're activating trauma centers based on what the car looked like, and we're doing STEMI alerts based on what the patient looked like.

While their pack/day cigarette habit, the number of cheeseburgers they routinely scarf down, and whether their daddy died of a heart attack may be pertinent history, we're activating the cath lab based on presentation.

We should be using the same approach to triage our trauma patients.

Comments - Add Yours

  • JB on the Rocks

    Trauma surgeon friend of mine once said “Mechanism is nice, but it’s not like you can take a calculator, add 65 mph + 2 rolls, subtract .75 for the lap belt, subtract .75 for the shoulder belt, and get a total of ‘Spleen laceration, pelvis fracture, and pulmonary contusion.'”

  • Thehappymedic

    Agreed. Now to get the Medical Directors to write it out of destination decision and trauma activation protocols we’ll be all set.

    • Anonymous

      It’s still there because they don’t trust us to think because 1) we are poorly educated, and 2) those same medical directors serve only as a rubber stamp, and never actually, you know, provide medical direction.

      • Scott Brown

        Here’s the problem with this thinking…it leads to underassessment, and minimizing clinical S/S. The fact that the car is mangled ought to raise your suspicion well beyond the clinical presentation of the patient. I can SEE a STEMI, I cannot see a subarachnoid bleed or a small spleen fx or an occult c-spine fx. You get used to minimizing MOI, its a short walk to minimizing important but subtle S/S, especially for new folks. Cars are designed to provide a tremendous level of protection for occupants…its not unusual for somebody to be standing in the road next to what 20 years ago would be a fatality wreck…I get that, but it doesn’t alter the fact that trauma is the area where we have the least amount of assessment and dx tools available, and the greatest area for unusual or abnormal injuries. Teach MOI…I’m ok with overtreating serious MOI

        • http://hybridmedic.com HybridMedic

          Going by vehicle damage is like going outside on a dry day and your neighbor turning on a garden hose and saying it’s raining because the ground is wet. By the same logic, you would believe him.

          I had a guy roll his vehicle 5 times into someone’s front yard, leave the scene and ride a bicycle to the next house over a mile away to call 911. He refused care. Vehicle damage is NOT a reliable indicator. Ever.

          In a properly applied transport scheme (look at CDC, they have a good one that pretty much everyone has adopted) with properly guided and educated providers will produce an undertriage in less than 5% of all cases. Since all hospitals are capable of some trauma care or at least stabilization, the chance of appropriate care not being received when it is needed is a bogus argument. I’m sure that that MOI was created by the same people that perpetuated The Golden Hour, in order to boost and justify the trauma centers by flooding them with non-critical and minor injury patients.

          • Ben Waller

            I disagree. The CDC scheme relies heavily on MOI for trauma center triage. Using that scheme will continue high levels of overtriage based on MOI instead of more appropriate trauma patient destination decisions based upon patient assessment.

        • Anonymous

          Let me clarify my point: I’m not saying we abandon the concept of MOI, I’m saying we stop placing more faith in it than our assessments.

          And I disagree with you about minimizing MOI criteria leading to underassessment. My belief is that putting so much emphasis on MOI leads to shoddier assessments. After all, why spend the time to learn proper assessment when you can memorize a list of Bad Things from a textbook, and transport and treat the patient based on that?

          “I can SEE a STEMI, I cannot see a subarachnoid bleed or a small spleen fx or an occult c-spine fx.”

          And how many subarachnoid bleeds, spleen lacs and occult C-spine fractures have you seen that were diagnosed purely on MOI? More to the point, how often do those things happen with no outward signs of injury, or pain?

          I submit that such cases are extremely rare, if they even exist at all.

          I can accept treating and choosing transport destrinations based on MOI criteria if the patient is unreliable – intoxicated, altered mental status, major distracting injuries, etc. – but if the patient is a reliable historian and can tell you, “Hey man, that doesn’t hurt,”,/i> treating him as if he was hurt is just foolish.

  • Thehappymedic

    Agreed. Now to get the Medical Directors to write it out of destination decision and trauma activation protocols we’ll be all set.

  • Wonder_Aloud

    But with a STEMI you can do an EKG and say STEMI vs not. If we are truly going on presentation alone, gallbladder can present like STEMI without the EKG to differentiate. There isn’t the field equivalent of the EKG for trauma yet, so pertinent history has to play a larger role.

    • Anonymous

      We have two reliable means of identifying underlying injury: pain, and external signs of injury.

      Yet many EMTs routinely ignore the total absence of either of those things in favor of trusting crumpled metal or a magic word like “rollover.”

      Your point about diagnostic capabilities is well taken, but when those patients reach a trauma center, and those areas still don’t hurt, do you think they’re going to get ultrasounds and x-rays just to prove that it doesn’t hurt?

      • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

        While I completely agree, I have to ask.

        Why aren’t we teaching assessment based treatment in school?

        Why aren’t medical directors allowing assessment based treatments? I know in California, a lot of counties allow selective spinal immobilization for paramedics, but EMTs are required to rely on the “TRAUMA!=immobilize” concept.

        • Anonymous

          The entire state of Maine has been using a C-spine clearance algorithm for all levels of EMS providers since at least 2006, and they dropped MOI criteria from the algorithm several years ago.

          Yet there has been no word of landmark negligence lawsuits out of Maine for lack of spinal immobilization, nor do there seem to be an inodrinate number of quadriplegics and paraplegics motoring around Portland and Bangor in their motorized wheelchairs.

          Either their EMTs are a lot smarter than California EMTs, or the Maine EMS medical directors are.

          My money is on the latter.

          • Too Old To Work

            Since 1995, and at all levels, including FR.

        • http://roguemedic.com/ Rogue Medic

          Why?

          Because of the National Registry of EMTs examination and because of similar examinations created by other organizations.

          And because of the experts who claim that these are useful evaluations of beginner competence.

          • Ben Waller

            You have taken your misplaced blame on the NREMT examination from one forum to another.

            There are many state exams that have nothing to do with the NREMT examination that also use MOI-based skills assesements. There are many local EMS systems whose trauma protocols are based on MOI assessments. There are some state EMS systems whose trauma destination guidelines are at least partially based on MOI assessments. It’s not the NREMT or “other” examinations, and it’s not those other mysterious, unnamed “other organizations” of which you vaguely speak. If you’re going to look at the real causes, singling out one specific variable in a multivariate problem is an oversimplistic look along with misplaced blame.

            The new CDC “Trauma Field Triage Guideline” has a lot of MOI-based triage. Last time I checked, the NREMT didn’t control the CDC or have anything to do with it. Yes, MOI-based overtriage is a problem. No, the NREMT exam isn’t to blame for it.

          • Anonymous

            I share Rogue Medic’s disdain for the NREMT exam, although I would posit that the various state exams are no better.

            But like you, I think the inadequacies of the various exams are a symptom of the disease, not the cause.

            Ambulance Driver

    • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

      Yes, there is no prehospital x-ray yet, but there’s a reason why one of the two big tools used to determine the need for spinal immobilization (the National Emergency X-ray Utilization Study (NEXUS) criteria) was designed to determine, specifically, if imaging studies were needed. If the patient doesn’t need an x-ray based off of clinical presentation, they definitely don’t need immobilization. Similarly, there’s nothing specifically difficult about NEXUS criteria that precludes paramedics, or EMTs for that matter, from using the criteria.

  • AT

    Amen. With the way modern vehicles are designed, they are supposed to crush, and “fall apart” as a way of absorbing and redirecting the impact away from the passengers. I feel like some protocols were written when cars were older, more solid beasts, and haven’t been updated. In no way am I saying to dismiss the vehicle condition as MOI, but I have seen people being “forcefully” c-spined because of how the car presented, not how the patient presented. Use vehicle MOI as a guideline, but TALK TO YOUR PATIENT. Sorry for ranting.

  • Anonymous

    A while back a man drove his truck through a sign. Then drove another mile to his house. The truck had the roof caved in, and the windshield shattered and peeled out. It looked like a passenger was ejected, though there was no one else in the truck. The front end was torn to hell and there was a bit of roof cave at the front of the driver side. The air bag was deployed and there was no major intrusion on the driver side. The patient had a scratch on her left pinkie finger and blew a 0.00. Pt had a pulse of 102 BP of 180/90 (hx of HTN) resp rate of 22, clear lung sounds, O2 98%, pink warm dry, denied any pain, PERRL pupils BG of 115. The “patient” had long been walking around and sat on the steps that led in to his trailer. EMS supervisor arrives on scene and talks the “patient” in to going to the ER. Tells the BLS crew once they get him in to the back, backboard and c-colar him so the ER dosen’t freak out. Per the EMS supervisor, “He needs to go, that is a serious MOI.”

    • CBEMT

      Sounds like you would have let him refuse. Fair enough.

      Guy goes 30 feet off a roof with no physical findings on exam or complaints of pain. Does MOI play any role in this decision?

      • Anonymous

        Yes.

        It should always play a role, just not nearly as big a role.

        In your hypothetical case, the role of MOI is to remind you, “Document your ass off if you choose not to immobilize.”

        Good documentation is a better lawyer repellent than unnecessary immobilization any day.

  • Silverbackmedic

    Hey, I’m likin this concept…. STEMI Mechanism….. “Dispatch, I have a 55 year old male involved in a BLT with obvious incursion. Patient was unrestrained with notable mayo to the face and upper torso. Patient was also found to have several camels, 2 lighters, and pack of chewing tobaccoto the left rear pocket. Patient needs to be transported to a level 1 cardiac center based on history, mechanism and bad breath

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  • Runningblond

    At what point do our assessments and knowledge of trauma medicine get usurped by the inevitable litigisnous of those seeking to provide a better life through the “he didn’t c spine stabilize me and I suffered whiplash which has caused permanent paralysis of the following body structures” crowd? Hence… The proverbial rule if thumb, cover your ass.

    • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

      At what point do the people who suffer side effects from improper immobilization begin to sue EMS systems for not practicing evidence based medicine and improperly screening patients for immobilization based on mechanism alone?

      At what point do EMS providers and systems start being liable for HEMS transports when a patient spends less than 24 hours in the hospital?

      I think there will come a time when hiding between the “throw the kitchen sink at everyone just in case” will become more dangerous than trying to apply EBM to EMS.

    • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

      At what point do the people who suffer side effects from improper immobilization begin to sue EMS systems for not practicing evidence based medicine and improperly screening patients for immobilization based on mechanism alone?

      At what point do EMS providers and systems start being liable for HEMS transports when a patient spends less than 24 hours in the hospital?

      I think there will come a time when hiding between the “throw the kitchen sink at everyone just in case” will become more dangerous than trying to apply EBM to EMS.

    • Anonymous

      A better question would be, “How long are we going to keep doing painful and unnecessary things to our patients because we’re afraid of lawyers?”

      If I were an enterprising personal injury attorney, I could probably make a good living on “wrongful immobilization lawsuits,” since there is far more evidence of harm caused by the procedure than there is of benefit.

      If all we’re worried about is lawyers and not medicine, we’d still be using rotating tourniquets for CHF and giving prophylactic lidocaine to MI patients. Those were the standard of care back in the day, yet we don’t do them any longer. Ever wonder why?

      Because they do more harm than good, that’s why.

      See, you’re still operating under the assumption that immobilization does some good for some patients. Problem is, there is NO – zero, nada, none, zilch – evidence that it does any good, even for the patients with spinal cord injuries.

      When you get sued for not immobilizing someone, the standard of care if going to be determined, as it always is, by 12 people who don’t know how to get out of jury duty, making a decision based on which side’s expert witness is more believable.

      On our side, we’ve got a scholarly doctor type who can confidently state, backed up by reams of scientific papers in front of him, that immobilization provides no benefit, and in fact quite often causes harm.

      On the other side, they’ve got some guy sitting at an empty table, and all he’s got on his side is, “Well, that’s the way we’ve always done things.”

      Personally, I’ll put my money on the first expert witness.

    • Anonymous

      A better question would be, “How long are we going to keep doing painful and unnecessary things to our patients because we’re afraid of lawyers?”

      If I were an enterprising personal injury attorney, I could probably make a good living on “wrongful immobilization lawsuits,” since there is far more evidence of harm caused by the procedure than there is of benefit.

      If all we’re worried about is lawyers and not medicine, we’d still be using rotating tourniquets for CHF and giving prophylactic lidocaine to MI patients. Those were the standard of care back in the day, yet we don’t do them any longer. Ever wonder why?

      Because they do more harm than good, that’s why.

      See, you’re still operating under the assumption that immobilization does some good for some patients. Problem is, there is NO – zero, nada, none, zilch – evidence that it does any good, even for the patients with spinal cord injuries.

      When you get sued for not immobilizing someone, the standard of care if going to be determined, as it always is, by 12 people who don’t know how to get out of jury duty, making a decision based on which side’s expert witness is more believable.

      On our side, we’ve got a scholarly doctor type who can confidently state, backed up by reams of scientific papers in front of him, that immobilization provides no benefit, and in fact quite often causes harm.

      On the other side, they’ve got some guy sitting at an empty table, and all he’s got on his side is, “Well, that’s the way we’ve always done things.”

      Personally, I’ll put my money on the first expert witness.

  • Jake Bigelow

    Thank god for this article. It is like pulling teeth to get people to agree that immobilizing based off of MOI is BAD patient care. I cannot state how important an ASSESSMENT is. I don’t care if a patient fell out of an airplane without a parachute. If my assessment reveals no injuries and my patient is reliable, why in the hell would I treat them as though they have injuries. We work in a field that is so damn inbred, IE I learned this from A, who learned it from B, who learned it from C going back to the dark ages, that we can’t seem to look at what works now and what is best for our patients NOW. We take our teachings at such a face value that very few of us actually look to EBM or care about changes.

    I can say that I don’t always agree with you, but on this subject we are reading the same copy of the same book my friend. Now to get the rest of the community to agree.

    And to anyone who has the “I once had this patient who had this happen and they were acting fine but then showed up with an unstable c-spine fracture”. To those who tell that story, my response is the following. You OBVIOUSLY did not assess your patient if you missed an injury like that, or you failed to recognize that your patient would provide an UNRELIABLE self assessment.

    I always get one or two “WTF” looks when I clear a patient or do not place them on a backboard based off of a, you guessed it, ASSESSMENT. Someone always says, “yeah, but did you see the car”. My response is always, I don’t care about the car’s assessment, I care about my patient’s assessment.

    Long story short, good article. I would be interested in reading more on the topic from you.

    Jake

  • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

    Oh, yea… almost forgot the obligatory references for any c-spine posting.

    Dalhousie University Division of EMS’s Evidence Based Protocol listing. Notice that the clearance protocol has a higher evidence based rank (“B”) than spinal immobilization (“C”).

    Spinal Immobilization: http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal%20Immobilization

    C-Spine Clearance: http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#C-Spine%20Clearance

    Freeway Patrol Episode 5: The One with the Mechanism of Injury
    http://www.youtube.com/watch?v=YzYxz_uvtSI

  • http://profiles.google.com/david.e.hemp David Hemp

    Just yesterday, one of the neighboring EMS Services had a two car accident with one vehicle on its side in the ditch. Based upon this report a helicopter was auto-launched and the trauma team activated – all before the first EMS unit reached the scene. Our locale is 20 minutes flight time from the nearest level II trauma center and 45 minutes from the nearest level I. Is the activation of this many resources warranted based upon distance from trauma centers in rural areas? Your thoughts would be welcomed, because as chief of a small ambulance service I struggle with these sorts of decisions. Yes – it may save a life, but how far up are we driving the cost of that care due to these pre-assessment decisions?

    • Jason

      I have always been taught, and personally believe, that is is better to have too many resources available, than not enough, especially when time and distance are a factor. You can always turn the bird around after a crew arrives on scene and finds that they are not going to need air trans.

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