There is often a fair amount of conflict between providers of inpatient care, and pre-hospital and ED providers. Granted, that sometimes people are unreasonable and like yelling at people, and that is inexcusable, but outside of that, there are issues where Emergency and Inpatient providers have conflicting perspectives. I think it would be helpful to talk about this a little.
Early in my career as a trauma director, I walked into a trauma alert and saw the neurosurgery resident and EM attending arguing. I asked what it was about and was told neuro did not want the patient sedated, and EM wanted to give Versed to make the patient easier to deal with. Perhaps in too brusque a manner I said “no versed, do what neurosurgery advises” and that was that since at that point the patient was now under my care. We had a discussion about this a few days later with the Chair of Emergency Medicine and the EM attending where they said I was inappropriate and not respectful (perhaps). I said “look, this patient was awake but had an abnormal neuro exam, if we sedate him, then neurosurgery and trauma cant get an accurate neuro examination (we already knew the head CT was abnormal but not operative). If we cant get an accurate neuro exam neuro needs to place an ICP bolt. If we place an ICP bolt we need to give the patient significantly more sedation to get it done, if we place an ICP bolt we get into a bunch of other issues…etc…..etc……etc. So, it made a lot more sense to me not to anything that might sedate the patient, get them to the ICU, and let it be our problem and not do something that is going to make care much more difficult for us in the long run.” They both said “OK, now we undertand, couldnt you have said that then?” and I said I probably should have instead of barking.
Anyway, the moral of this story is that in-hospital providers often do not have a good perspective on what goes on in the field and ER, and pre-hospital providers and EM providers often do not have an accurate grasp of the issues we are dealing with in the ICU. EM tries it’s best to get that perspective by having their residents spend a fair amount of time during their residency on the trauma and ICU services. This helps a great deal, but an EM attending who is 15 years out of residency may have completely lost their perspective on what happens after the patient leaves the ED.
For pre-hospital providers, unless they have an inpatient job, they get very little exposure to care beyond the ED, and I think that is not optimal. I think it is essential that for at least 10-20 hours a year (at a minimum) pre-hospital ALS providers need to spend quality time in the ICUs. They would Ssee how a few minutes of hypoxia in the field essentially eliminates the possibility of a good outcome from severe head injury. Also, a few minutes of poor monitoring of perfusion and deep shock causes a tremendous amount of problems down the road with pneumonia, and multiple organ failure.
I tell people “you can put 90% of trauma patients with femur fractures, pelvic fractures, small spleen and liver injuries on a park bench with a bottle of Dasani within reach and come back 24 hours later and they will still be alive and probably doing just fine” and thats the truth. The gross rate of major trauma patients where optimal Level 1 trauma center care means life or death is 1000 patients per million of population or about 0.1%. Of those, only 7% (or 0.007% of the population of 1 million) present either hypotensive or with coma from a severe head injury. It is very easy to say “look, our system works well for 99% of patients so cant turn everything upside down for 1%” and that used to be a valid argument, but no longer. In 2012 top hospitals are now being held to incredibly high standards. The way I describe it is that a top hospital needs to save every single patient they should save (based on injuries and disease) and must save 50% of patients who would be expected to die in any average hospital. To save that 50%, you cant make big mistakes, or even a lot of little ones. If one of those patients is aspirating pre-hospital, or in the ED and getting hypercarbic because they are not being closely monitored, the chance of saving them drops precipitously. If a patient looked good at the scene but rapidly deteriorated during transport, but that wasnt picked up and treated, it’s really hard to save them if they’ve had 5-10 minutes of a BP of 70mm Hg and no one noticed. More importantly, if a patient spends 2 hours at a community hospital that sees very little trauma because the paramedic thought it would be too much trouble to call a chopper to the scene, there’s not going to be much we can do once they get to us.
The special forces for a long time have stressed that it is imperative for all members of a team to at least understand the job of each other member. With that knowledge, you can facilitate the other persons actions, remove obstacles, get necessary equipment before they ask for it, etc. Knowledge is good (from the Faber college motto) and more knowledge is better. Learning more about what each member of the team faces each day can only improve overall performance and outcomes.