The team response to new trauma patients at trauma centers works on a basic principle, you should have a full response present in the ED (about 10 people including an attending surgeon, 2-3 surgery residents, respiratory therapy, anesthesiology, and even a Chaplain) 30% more times than needed. The reason is that if you only have that response in the ED when you need it, you will either wait too long (until the patient arrives) to activate it (thus not having the resources in place and ready to go when a patient may need them), or you will not activate it when you do need it. This is called overtriage and it is expected in trauma centers. Why? Because in about 10% of cases you will need every one of those resources at the bedside on arrival to save someones life. In our opinion, it is worth overreacting 3 out of 10 times to insure you have the right people at the beside 100% of the time when they’re needed.
Naturally, this can be annoying since many times (30%), you are wasting resources. But we feel its the safest way to do things. This tension between “overreaction” and “let’s just wait and see” is present throughout clinical care, from 911 dispatch to the ICU and beyond. Fire departments also err on the side of having more resources available immediately, than to wait and call them when the situation overwhelms the initial response. The problem with “wait and see” involves the concept in my previous post on inertia. It takes time to call help, have them respond, and figure out how they can help in a high risk clinical situation. It is far easier for everyone to arrive before the patient and assign tasks then. Obviously EMS cant be at the scene before they are needed, but fire/ems often has predetermined plans for delegation of tasks when there are multiple assets responding.
This tension is also evident when you are making diagnoses and initiating treatment in the hospital. As I’ve said in previous writings, any idiot can figure out when someone is dying, the good clinician intervenes before the patient crashes. In order to identify those patients who are beginning to decline, you need a high index of suspicion, and since they are not obviously crashing, you will need labs and studies to obtain data that will demonstrate things are not going on the right direction.
The pressure to obtain less tests and less studies to contain cost often comes into conflict with the desire to make certain that your patient is on the right track. It is a fact of life that when a patient clearly demonstrates they are very sick, it may be too late to save them. Also, despite the costs of additional tests and studies, these costs pale in comparison to the cost of ICU care for someone whose negative trajectory is not detected. Protecting the patient is our first duty, and to protect we must look for problems. Remember it’s not the patient’s job to prove to you they are sick, it is your job to prove they are OK.

TV shows have ruined most medical care providers sense of time. All the way back to “ER” and “Emergency”, people asked for things and they magically and instantly got done. CBC’s, intubation, and IV’s took about 2 seconds to do. Unfortunately reality is different. Inertia (by my definition how long it take to get things done and move forward with care) can be a big problem in emergencies.

On the new podcast Battalion Chief Chip Walker talks about staying one step ahead of the patient and being “active” instead of “reactive”. It is a very very important strategy in emergency care. Next time you’re intubating, starting an IV, central line, chest tube, whatever; have someone time how long it takes from decision to do the procedure..to when it’s done. You will be amazed at how long it actually takes. You dont realize it because you are focused on what you are doing and dont notice the passage of time. In addition, if you dont have the equipment ready to go, and have the mental mindset to get things done rapidly, it can be much worse.

In hyperurgent situations, where what you get done in 1-2 minutes could mean life or death to the patient, deciding to do something that you think takes one minute, but actually takes 10 could be a big problem. One situation I talk about in the podcast is transfering a patient from the prehospital stretcher to the ED bed. Even though you think this can go quickly (and it can if conducted properly) it often takes 2-3 minutes to get the patient ready to move, move them, deal with the lines and cable, get the stretcher out of the room, and then get your first set of ED vital signs. A lot of things can happen in a hyperurgent condition in 3 minutes.

Awareness of the problem is a big part of the solution. If you are cognizent of the fact that things take longer than you think you can make better decisions. For instance, when we have a hypotensive gunshot victim coming in, we will get the OR arranged and then the Chief resident or I will meet the ambulance at the front door. The reason is that I dont want to make a left turn into the trauma bay unless I absolutely have to, and the only reason I would stop in the ED is if the patient’s airway is unsecured and the patient is hypoxic, or they have no pulse, otherwise we go straight to the OR. The reason is that if someone’s BP is 60 systolic, and they are bleeding to death in their belly, realistically it will take 8-10 minutes for me to get into their abdomen and start to get control. Opening up the abodmen in most ED’s is not a good thing to do (my maxim is that you do procedures in the emergency department, and you do operations in the operating room). Operative actions(sewing things shut, clamping and tying vessels, etc.) should be done in the OR since most ED’s dont have the necessary sterility, equipment, lighting and personnel to do this safely, unless they are specifically set up to do it.
JY