These Are Your Protocols? How… Quaint.

In the recent mass stabbing at Lone Star College in Harris County, TX, fourteen people were transported to local hospitals by EMS. A blog reader pointed me to the CNN.com story on the event, and the associated photo gallery. There are a couple of video clips, as well. You EMS folks, go look at the photos and video, and come back and tell me what's wrong with those pictures.

I'll wait.

 

Okay, we all back?

If you answered, "Why are those penetrating trauma victims spinally immobilized?" you win the cement bicycle and a two-night's stay at Buford's Bed and Breakfast, Tire Repair and Oil Change in that lush vacation destination of LaDonia, TX.

Now, with the caveat that every medic is an expert about some other medic's call, I wonder if the ambulance crews who responded are aware of the research that discourages prehospital immobilization of penetrating trauma victims:

We performed a retrospective analysis of penetrating trauma patients in the National Trauma Data Bank (version 6.2). Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital spine immobilization, using patient demographics, mechanism (stab vs. gunshot), physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on Injury Severity Score category, mechanism, and blood pressure. We calculated a number needed to treat and number needed to harm for spine immobilization.

In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with non-immobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.

(emphasis mine)

It would seem that, given two groups of penetrating trauma patients, well-matched for mechanism, injury severity scores and blood pressure, the act of strapping a patient to a rigid board makes them twice as likely to die as simply placing them on the stretcher.

By performing prehospital spinal immobilization, you will harm or kill 16 penetrating trauma patients for every 1 it will potentially benefit.

I say "potentially" because there is still zero evidence that spinal immobilization to a rigid board does any good at all, even for people with broken necks.

Either there's a whole bunch of people upstairs wearing halo devices, or we're boarding way too many people.

 

Cy Fair Volunteer Fire Department, the primary response agency at the incident, is a combination paid/volunteer department that serves the Cypress and Fairbanks communities of unincorporated Harris County, TX. With over 500 members (200 paid) and 12 stations, they bill themselves as the United States' largest volunteer fire department.

In other words, this ain't some rooty-poot, half-assed, mom-and-pop ambulance service firmly stuck in the 1980's.

No, this is a major metropolitan EMS system firmly stuck in the 1980's.

Now, I'm going to give the Cy Fair medics the benefit of the doubt. Plenty of good medics are stuck in systems with ancient, outdated protocols that force them to do ineffective and potentially harmful stuff to patients every day. It is what it is.

Some might even say that it's easy to have liberal, progressive protocols at a smaller department. When you only have a couple of hospitals to convince, and a medical director who knows all his crews personally., training and education are a fairly simple matter. I knew that to be the case at The Little Ambulance Service That Could, when I wrote what were, at the time, the most progressive and advanced prehospital treatment protocols anywhere in our state. We could do anything short of opening the cranial cavity without direct medical orders, and we were good at what we did.

In 1997, after the Airway Call From Hell, I did a weekend's worth of research and developed an RSI protocol and airway management training program for that service. We implemented it a week later, and were using it for nearly a year before the state got wind of it, and shat their bureaucratic pants. Ultimately, after a couple of years percolating through the bureaucracy and my current employer throwing their not-insignificant support behind my proposal, RSI was added to the state EMS scope of practice.

But when you have 2000 medics to train, educate and monitor instead of 20, change comes slower. It wasn't too many years ago that my fellow Borg drones had to call for permission to start an IV, or do BLS CPR while the medic got on the phone to a hospital and begged for permission to implement ACLS protocols.

Thankfully, that is no longer the case, and The Borg has an extensive system in place to train, QA and educate their crews, and protocol revisions are an ongoing thing. We get minor changes frequently, and a major revision every few years. Things like equipment upgrades and protocol revisions to keep pace with current medication shortages are an almost monthly thing.

All this is to say that, if you've got good crews and a medical director who trusts them, change can come pretty easily, even in a big EMS system.

But what if your medical director is the EMS equivalent of Bigfoot or the female clitoris; lots of men have heard of it, but very few have every actually found one? What if your medical director has never even met the vast majority of the crews whose medical practice he is responsible for delegating, much less been actively involved in their training, QA and supervision?

I'm guessing that's how you get restrictive protocols, and wind up still doing things that were proven not to be beneficial ten or twenty years ago.

With a little digging through online public records by a couple of friends, I found Cy Fair's medical director.

Since 2008, he has been listed as medical director for 137 EMS agencies or entities in south Texas.

Of those, he is listed as the current medical director for 71 ambulance services or entities that provide EMS or EMS training. He let 48 licenses expire in those five years, and another 18 services he directed voluntarily surrendered their business licenses, either by going out of business or to avoid disciplinary action.

Busy man, that doctor.

Then again, not as busy as he used to be. Maybe he decided that a full-time medical practice and serving as medical director for 137 ambulance services was stretching himself a little too thin, and he cut it back to a more manageable 71.

Call me a wild-eyed conspiracy theorist, but I think I see a big part of the problem.