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Thread: Response time as function of emergency planning

  1. #1
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    Response time as function of emergency planning

    Obviously there are those that train for a breakdown of civilization. This may not apply to you, or may be something you're only using when those services are still operational, or while you're training for that breakdown, or whatever.

    But for most of us on a given day, EMT response time is probably under 30 minutes, which equals maybe an hour to a hospital or trauma center. Even in the boonies, given life-flight type helicopters you're probably looking at an hour at most.

    Is treatment like a tourniquet (for an extremity hit) or a chest seal or one of the other popular IFAK components critical at that point? Or are these treatments that are meant for longer response or evac times?

    If someone is concerned primarily with accidental shootings on a range, do the same requirements apply as they do in a combat zone?

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    Bleeding out can occur within a matter of seconds or minutes, not allowing time for EMS to respond but you have to control the bleeding as quickly as possible in any case, the use of things like clotting agents (Celox, etc.), direct pressure, and pressure dressings are immediate action. A tourniquet is a last resort effort in most cases, other measures will be effective.

    IFAKs, blowout kits, whatever you call yours is always a good idea, especially when firearms are involved in the days activities.

    I live in an area that is densely forested, so no life flight option, and EMS is a minimum of 30 minutes response time (running code, and wide open).

    Trauma is trauma, the only real difference between everyday and combat (most of the time) is the added pressure of trying not to get shot yourself while providing treatment.

    Don't count on the ambulance arriving quickly, I've been in wrecks in emergency vehicles that required us to tone out a different unit, delaying response times even more.
    Last edited by FMF_Doc; 06-16-09 at 17:50.

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    TKs and chest seals sustain the ABCs. As such, they should be regarded as early interventions rather than later. EMS curriculum, such as it is, is reflecting that thinking in recent and pending revisions.

    Also, I think you're accurate in saying "most" folks have good EMS resposne and access to air evacuation. That's only because the majority of the population (by number) lives in major metro and urban areas. A large number still live outside those areas, where ambulance response times will run an hour and more for some agencies/services. I know one service that has runs to a certain area ~1.25hours from the barn in good weather with good roads. When they go there, a fixed wing is sent from the med center to a strip ~45 minutes from the injury site.

    In the case of a sudden traumatic injury, survivability decreases by ~5-10% (depending on what you read and what's afoot) for each minute that definitive care is not provided. "Definitive" is subject to some definition, but TKs and chest seals (for ptx) would be part of it in my book.

    More bad news: It takes 1-2 minutes to process a 911 call and dispatch a unit for most PSAPs. Add actual response time. Add care and load time on scene. Add transport back to advanced care.

    Short: If you're not able to self-aid, or you don't have someone to apply first interventions, you're well on your way to being screwed.

    Knowledge is king, gear is employed or improvised with it. Helps to have the tools too, though.

    Anecdotes about folks applying purpose-built and improvised TKs to extremity injuries, that saved their lives, abound. Even in major metro area with great EMS coverage.

    Food for thought.

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    Quote Originally Posted by FMF_Doc View Post
    Don't count on the ambulance arriving quickly, I've been in wrecks in emergency vehicles that required us to tone out a different unit, delaying response times even more.
    True. Most agencies will reduce to "code 2" (routine traffic) if weather or road conditions deteriorate.

    As a paramedic, I'm not sold on the tourniquet idea if EMS is <30 minutes away unless a major artery is ruptured. If bleeding is minor (not spurting) simple direct pressure is usually enough to stop or control it.

    As for your question regarding chest seals...I'm a definite proponent of occlusive dressings for civilian use. A collapsed lung severely reduces exterior respiration by way of reducing surface area of the lungs by 50%. This, in turn, reduces interior respiration (exchange of oxygen and CO2 in the lungs) which can lead to hypoxia and death. Occlusive dressings, if applied quickly, can delay or prevent lung collapse and greatly increase the chance of survival if EMS response is delayed.

    Many comercial occlusive dressings are available. I prefer the Ascherman Chest Seal if you're buying commercially available products. However, in a pinch, a simple piece of plastic, alluminum foil, or candy bar wrapper can be utilized. Place the piece of plastic centered over the wound and tape down all four sides, leaving a corner un-taped. This will allow air to escape, but not enter.
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    The one thing very very very very few ambulances, and even ER's for that matter, can fix is a lack of oxygen transporting fluids (i.e. blood) in the body. In the next 10 years you will see a tourniquet become the 1st line treatment for any moderately serious extremity bleed with ALS care able to remove the tourniquets and attempt other bandaging with good judgement on how long to try other methods before re-tightening the tourniquet.

    citizensoldier16 - I can truly understand your hesitancy and most of our co-workers across the country will agree with you. I promise you that over the next ten years however, you will change your mind and come along as will most providers.

    I without hesitation think that the minimum truly life-saving equipment is, (for a medical provider not in a transporting unit) in order:

    Tourniquet
    Gloves
    AED
    BVM
    60 cc syringe with 6 in of suction tubing
    1.2 mg Epinephrine 1:000 in a 2cc syringe with a needle
    Bandaging/Wound packing/hemostatic supplies


    I would challenge you to come up with a truly life-threatening situation that cannot be fixed with those items that you would realistically be expected to face. Everything else is just a nice to have in my opinion.

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    Things have changed a lot in prehospital care in the last 20 years, I remember when a tourniquet was the absolute last ditch effort.

    But then again, Sodium Bicarb and Isuprel were first line drugs in ACLS at the time as well, and we now know we were doing more harm than good with them the way they were used.

    There has been a quantum leap in some of the thought processes and treatment protocols, Paramedics are gaining more skills and a lot more responsibility as time goes on.

    I am on my own for at least 45 minutes realistically, even longer if EMS is busy so I tend to keep my skills and my equipment ready for the worst case scenarios.
    I can treat and transport more efficiently than waiting for the ambulance, my patients would be family members and a select few close friends. I think from the mindset of being the only medical care around and help is not coming in time, operational medicine does that to you.
    Last edited by FMF_Doc; 06-17-09 at 01:21.

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    I agree, sometimes I think we are trying to go to far and a lot of my fellow medics seem to be so hell bent on fixing the person in the field that they forget that they drive an ambulance to the call for a reason instead of a BMW sports car. At the end of the day Mr. and Mrs. Smith expect you to A-Be Nice (compassionate, caring, respectful and truthful), B-Treat Their Pain (Physical and emotional), and C-Take Them to Definitive Medical Care as Best You Can While Making A Effort To Keep Them Alive. (Sorry bout the capitals the last one was longer than expected lol) And thats it. People die, people die at home, people die in our ambulances, people die at the hospital, none of us make it out alive in the end. People realize this truth and at the end of the day what they care about is those three things.

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    Quote Originally Posted by TacMedic4450 View Post
    The one thing very very very very few ambulances, and even ER's for that matter, can fix is a lack of oxygen transporting fluids (i.e. blood) in the body. In the next 10 years you will see a tourniquet become the 1st line treatment for any moderately serious extremity bleed with ALS care able to remove the tourniquets and attempt other bandaging with good judgement on how long to try other methods before re-tightening the tourniquet.
    What about whole blood? Critical care ambulances (both air and ground) have the ability to infuse whole blood and other blood products enroute. I know for a fact that the local CC trucks, UNC and Duke, will treat blood loss that affects the transport of oxygen with more blood, rather than a tournaquet.

    TacMedic4450, I have to disagree with you on the premise of such availability of whole blood products in the critical care setting. Rather than tournaquets coming back, I think that whole blood infusions will eventually trickle down to the ALS level and offer a more medically effective treatment. Whole blood replacement combined with direct pressure would yield, in my opinion, a more positive outcome for the patient and reduce the possibility of loosing a limb due to a tournaquet.
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    Quote Originally Posted by citizensoldier16 View Post
    What about whole blood? Critical care ambulances (both air and ground) have the ability to infuse whole blood and other blood products enroute. I know for a fact that the local CC trucks, UNC and Duke, will treat blood loss that affects the transport of oxygen with more blood, rather than a tournaquet.
    Having the ability is one thing, having the appropriate blood is something else. I'd be curious about seeing UNC/Duke's protocols on the issue.

    TacMedic4450, I have to disagree with you on the premise of such availability of whole blood products in the critical care setting. Rather than tournaquets coming back, I think that whole blood infusions will eventually trickle down to the ALS level and offer a more medically effective treatment. Whole blood replacement combined with direct pressure would yield, in my opinion, a more positive outcome for the patient and reduce the possibility of loosing a limb due to a tournaquet.
    It's been pretty definitively shown that the risk of loosing a limb to tourniquet is fairly overstated. In fact it's become standard procedure in the military to apply a tourniquet first and ask questions later. A corpsman buddy of mine who is now a PA with the 82nd ABN, said quite plainly that the available studies indicate no loss of extremity even after multiple hours (though the guy would have been in complete agony).

    I'm skeptical of whole blood being broadly used outside of a specialized medical unit without more information as to the basis of your opinion.
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    Quote Originally Posted by Gutshot John View Post
    Having the ability is one thing, having the appropriate blood is something else. I'd be curious about seeing UNC/Duke's protocols on the issue.
    Blood products and substitutes are indeed carried by some, but they're the exception...and few in number...not the rule. I'd be curious to see the protocols on that as well.

    Most cite lack of significant benefit, refrigeration requirements, shelf-life, and related variables as reasons not to use them in the field.

    It's been pretty definitively shown that the risk of loosing a limb to tourniquet is fairly overstated. In fact it's become standard procedure in the military to apply a tourniquet first and ask questions later. A corpsman buddy of mine who is now a PA with the 82nd ABN, said quite plainly that the available studies indicate no loss of extremity even after multiple hours (though the guy would have been in complete agony).
    Current bleeding control procedure in PHTLS is direct pressure (manual or mechanical), then TK. This will be in the new DOT curriculum for EMTs (or whatever labels we have then). No more elevation or PP.

    There's a lot of handwringing over applying the TK, both with services and medical directors.

    Historically, we've always seemed to make our greatest progress, and reducation on the basics, in times of war.

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