Emergency medicine doctor at UPMC, Dr. Joshua Brown talks about the golden hour in medical transportation for rural areas.
Interview conducted by Ivanhoe Broadcast News in 2023.
We’re talking about your research on transport to trauma centers. Can you give a quick overview for our viewers, what you and your colleagues looked at?
BROWN: What we’re really interested in is the situation in rural America, where the paramedics who show up to take care of an injured patient really have two choices. One is to drive them to their local community hospital, that’s not a trauma center or the other is to call for a medical helicopter to transport to trauma centers. We compared patients who were brought directly to a trauma center from these areas when they met criteria for needing trauma center care, and looked at patients that were first driven to a community hospital, and then later had to be transferred to a trauma center. Finding that the patients brought directly to the trauma center had almost a two fold increase in their survival as a result of getting to that trauma center earlier.
When you’re talking about having to go directly to the trauma center, is there a transport time paramedics looking at? And does that time play a part in how the patients do?
BROWN: Absolutely. The situation and scenario that we really wanted to study was where that time became prohibitive. It wasn’t on the table for those ambulance crews to take the patient to the trauma center themselves, and they had to decide, “Do we drop them off at the local hospital or do we get the helicopter?” Because the time to drive to that trauma center, is too long, and we may be leaving our service area without an ambulance for up to four hours. That was really not on the table for them at that point.
Tell me a little bit more about the study. Did you study a large data set from 2000?
BROWN: We looked at all trauma patients who came to a trauma center in Pennsylvania from 2000 to 2017. We had thousands of patients to look at. We matched patients. Wee took patients that had the same types of injuries, same age, same characteristics, and matched them together. We really made sure when we’re comparing the outcomes of those patients that it was an apples to apples comparison.
What does this suggest?
BROWN: What we really wanted to do is, look at a set of criteria that the paramedics in the field can identify types of injuries, and say, it’s this patient that has this certain criterion that we really need to call for the helicopter, and not agonize about whether we drop them off or we call those patients we know are going to do better. The patients that don’t meet those criteria, you can bring to local centers so they can be evaluated, and transferred later if necessary.
Can you run down on some of those types of injuries?
BROWN: It was patients that had abnormal vital signs. Their blood pressure was low, they were breathing too fast or too slow or they had altered mental status, meaning they were confused as signs of a head injury. It’s also patients that had spinal cord types of injuries. Patients that had really severe chest trauma would collapse lungs. This group of patients that we can tell, upfront, really need to get to the trauma center quickly.
Why is it important that paramedics have this information to guide them as they’re making these decisions?
BROWN: They’re really operating in an environment that’s challenging. They don’t have the same resources that I might have in the hospital. Being able to give them this set of criteria can really help them make a huge difference in the patient’s outcome. If you’re talking about doubling the chance of survival that can make an impact for a lot of rural Americans.
Type of injury was one of the criteria. Were there others?
BROWN: It was really based on the type of injury, because that’s the information that they’re getting very quickly at the scene, and they don’t have a lot of time to look at other types of characteristics. We wanted to make this as easy as possible for the paramedics. Very quick checklist of three or four things that they can look at at the scene of an accident, and decide if we need to call for a helicopter.
You mentioned the abnormal vital signs and the spinal cord injuries. Was there anything else on that checklist?
BROWN: Yes. If they suspected that they had collapsed lung, was one, and if they had evidence of injuries in multiple body regions. That was the last one indicating those patients who are going to need a higher level of care.
Now that you have the information, where does it go? What do you do with it?
BROWN: This is where our outreach really comes in, and I do a lot of education with our EMS partners throughout the area, and then disseminating this out to other trauma systems, and helping them understand all these things that can be easily implemented in their system. Really raising their awareness of paramedics, of these are patients that you’ll encounter in your practice that really should just get flown to the trauma center.
In a state like Pennsylvania, why is it important to have a checklist or some criteria based to decision?
BROWN: In my practice here at Presbyterian Hospital, we serve a very large catchment area and includes other states, but a lot of Central Pennsylvania gets very rural very quickly, and those patients we know when we compare to the patients who come from more urban areas, have worse outcomes after injury. This is one way that we can really close that gap and disparities between urban and rural Americans after injury.
Are there any EMS organizations, any groups that you and your colleagues are working with to develop further guidelines or to get the information out there?
BROWN: Yes. I worked with the American College of Surgeons to new develop triage guidelines, and we just finished working on some of the triage guidelines to help paramedics decide what type of hospital to bring a patient to. We’re working with them in some of the National EMS Physicians Associations to look at how we can put out position statements, and really get this out to EMS clinicians across the country.
How important is the clock?
BROWN: It’s really critical, but what we found is, it’s really critical for a subset of patients. In trauma, we always talk about this golden hour from the time of injury to getting to the trauma center. What we know.is for some patients it’s less important, but for some patients it really matters. There’s this perception of, if we get them to any type of doctor that can evaluate them as quickly as possible at some of these non-trauma centers, that can help. But when a patient is bleeding internally, they really need to be in a surgery or trauma center, so that I can stop the internal bleeding, and you can’t get that at these other hospitals. The clock doesn’t stop just because you brought them to a local community hospital, if they can’t really provide the care that you need.
Is there anything I didn’t ask you that you would want people to know?
BROWN: I think, it’s really important that we partner with our EMS clinicians, and that having come from a background as a paramedic, that’s been important to me, and really being able to work with them, and look at these things in a way that we can fit it into their workflow, and make it easy for them to provide the best care for their patients.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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