Forum Remix: Trauma Care in the Prehospital Setting

Posted on January 23, 2008
Filed Under Research, Medical Students, Premedical Students

by Alison Hayward, M.D.
SDN Staff Writer

Mark J. Seamon , M.D. is the director of trauma research at Temple University Hospital in Philadelphia. He has a keen interest in pre-hospital care and how pre-hospital interventions affect trauma patients, and recently published an article in the Journal of Trauma titled “Prehospital Procedures Before Emergency Department Thoracotomy: ‘Scoop and Run’ Saves Lives” which was hotly debated in SDN’s Pre-Hospital Forum.

After earning his medical degree from the University of Pittsburgh School of Medicine, Dr. Seamon undertook a general surgery residency at Temple University Hospital. He later completed a fellowship in surgical critical care at the Hospital of the University of Pennsylvania. An active researcher, Dr. Seamon has several dozen book chapters, manuscripts, abstracts, and presentations to his credit. He was recently kind enough to sit down with SDN to discuss his article and give us some insight into the life of a trauma surgeon.

Your article advocates “Scoop and Run” (the rapid transport of patients to the hospital with minimal interventions) , but is specific to patients who underwent thoracotomies after arrival in the ED. What are your feelings on less critically injured trauma patients and pre-hospital interventions?

This is a difficult issue. There are a few things at work here. Not only did we look at the most critically-injured patients, but all were penetrating injuries, and all in an urban setting. We have to remember though, Advanced Life Support (ALS) really came into being for cardiac arrest victims where prehospital interventions such as CPR, cardioversion, or the infusion of cardioactive medications are potentially life-saving. This scenario is completely different than the patient who is exsanguinating from two gunshot wounds in [the left ventricle of his heart]. While prehospital interventions in the less critical penetrating trauma victims probably have less impact on patient outcome, several previous studies are strikingly consistent throughout trauma literature: prehospital intervention and resuscitation of penetrating trauma victims in urban environments with rapid prehospital times (eg. <20min) seems to be detrimental to their ultimate outcome. There are a few possible reasons for this—either too much time is spent performing these prehospital procedures, the interventions and prehospital resuscitation itself are detrimental, or some combination of both.

One theory that has been well studied is permissive hypotension. At lower blood pressures (systolic blood pressure <90 mmHg), injured structures tend to coagulate and clot, lessening further bleeding. If a patient is aggressively resuscitated with IV fluids before surgical control is achieved and blood pressure rises to “normal” values, the injury clot may “pop” off [worsen the hemorrhage]. This has been directly studied in animal models and indirectly studied in [human] penetrating trauma victims by measuring bleeding and mortality after patients were randomized to aggressive IV fluid resuscitation or minimal fluid resuscitation groups.

Many EMS providers in the forums seemed upset about the article because it appears to be saying that their services hurt rather than help patients, at least in some cases. What are your feelings on EMS providers and the role they play in patient care?

Our article was never intended to upset anyone. EMS providers are absolutely essential to the care of injured patients, including critically-injured penetrating trauma victims. Again, we offered this report not as a criticism but as a hope for future refinement. So much of medicine is learning what we could do better, and I think this is just one more example. In the end, we are all after the same thing, aren’t we? We should all strive to give our patients the best possible care, whether you are a paramedic, EMS provider, emergency medicine physician, trauma surgeon, nurse, social worker, case manager, resident, medical student, or hospital volunteer. Every member of this team is essential.

Could you tell us more about what a typical day for work is like for you for those who may be interested in trauma surgery?

Trauma surgery is a bit different than most surgical fields. There is no “typical” day. But usually I’ll get to the hospital around 7:00 AM and then after meeting with the trauma team at 7:30 to discuss admissions from the previous day, I’ll begin rounding in the surgical intensive care unit or the surgical hospital floors. I’ll usually finish around noon and work on some research during the early afternoon. Some days I’ll also cover the trauma bay where the injured patients arrive into the hospital. I’m on call roughly every sixth night, so on those nights I stay in the hospital, but otherwise I’ll leave in the afternoon. At night is when all the action is in trauma—that’s when we usually do the majority of our big operations.

What is the best thing about trauma surgery as a career, in your opinion?

The best thing about trauma surgery is that there is no set elective operative schedule—you are not fixing hernias and taking out gallbladders all day. In fact, we often don’t know what operation we will be doing until the patient is opened and we see exactly what is injured. I love the fact that we operate on all body cavities and do cardiac, thoracic, abdominal, or vascular surgery. I think most trauma surgeons went to medical school to help suffering and injured people. The patient population that we largely serve is indigent and uninsured. To me, this is what being a physician is all about, helping the less fortunate.

What advice would you give to students interested in trauma surgery as a career?

Stay with it, it’s a great field. If I had it to do over again I would do it again in a second. I would shadow a trauma surgeon on a Friday or Saturday night to see for yourself what it’s really like. Try different hospitals, rural and urban to see what excites you. By all means, work as a paramedic. The more exposure you have to this field (or any for that matter), the better your career decision will be.

Do you do volunteer work or teaching for students or EMS providers or both? If so, could you describe the teaching that you do? Have you done teaching in your area based on your research regarding penetrating trauma victims?

I have not taught EMS students or providers yet, although we certainly hope to. Currently, it is in the planning stages—we are trying to determine the best way to go about this since it is a somewhat sensitive topic. We will likely have to join with the other trauma centers of Philadelphia to formulate a prehospital practice management guideline for the care of our penetrating trauma victims and then present that to our EMS colleagues.

How has your field changed in the past 10-15 years? Have you noticed changes involving the increasing prevalence of emergency medicine residency programs and how emergency medicine intersects with trauma surgery?

Trauma surgery is a rapidly evolving field. As technology improves, operations for injuries are getting less common. Because of this, there is a recent push towards “Acute Care Surgery”, where the trauma surgeon is not only the injury and critical care specialist, but a “sick people” surgeon who operates on all surgical emergencies such as appendicitis or bowel obstructions.

In many rural or community hospitals, emergency medicine physicians may function as the trauma specialist and then triage or send patients to other centers with more severe injuries. At our hospital and most other university hospitals, emergency medicine physicians are involved in stabilizing the injured patient’s airway (eg. endotracheal intubation) upon arrival to the trauma bay. They are also involved with the decision to activate the trauma surgery team when an injured patient arrives. If injuries are severe, the trauma team is called. Emergency medicine residents typically rotate on the trauma surgery service for 2-3 months during their residency where they function as an integral member of the trauma team.

If you had your career to do over again, what would you do differently?

Except maybe center field for the Yankees, I would do everything the same. Seriously, I love what I do and would never give it up.

How do you balance clinical time, research, and teaching responsibilities?

The balancing act can be somewhat tricky at times. I spend my time divided between 50% clinical and 50% academic (research, teaching) time. It is important to me to have a nice balance of all of these areas. Many of them go hand-in-hand though. My clinical time is spent with residents, medical students, nurses, etc where teaching is a major responsibility of a university surgeon. We also involve our residents and medical students in our research projects, so they can learn this entirely different but equally important method of scientific thinking.

Were you ever an EMT or paramedic before you became a physician?

No, although less conventional paths into medical school are becoming increasingly common.

Do you coordinate in your research with EMS providers and emergency medicine physicians? Do you think that research in the EMS field is best done as a collaborative effort, or looked at from the perspective of different specialties?

Collaboration is ideal. The “Scoop and Run” project was completed by the trauma surgery group at Temple. However, we are currently involved with planning the next stage of this research effort—a randomized, prospective study involving EMS, EM physicians, and trauma surgeons examining the role of prehospital interventions for penetrating trauma victims. This would provide the best quality evidence to support (or refute) our opinions. This will have to be a city-wide effort and will involve a significant amount of planning and resources to achieve the collaborative effort that we will need.

Would you encourage EMS providers themselves to spearhead research in pre-hospital care, and how would you recommend they go about it, if so?

I would strongly recommend EMS providers to get active in prehospital research. Interested providers should contact their local emergency medicine or trauma surgeon who can put you in touch with their local Institutional Review Board once you have designed your study. The Institutional Review Board (IRB) is a governing body at each institution that ensures the ethics and safety of studies involving human subjects. By all means, get involved!!

Original Article Citation

Journal of Trauma-Injury Infection & Critical Care. 63(1):113-120, July 2007.
Seamon, Mark J. MD; Fisher, Carol A. BA; Gaughan, John PhD; Lloyd, Michael MS, RN; Bradley, Kevin M. MD; Santora, Thomas A. MD; Pathak, Abhijit S. MD; Goldberg, Amy J. MD

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Comments

4 Responses to “Forum Remix: Trauma Care in the Prehospital Setting”

  1. Jeff on January 23rd, 2008 3:43 pm

    I think that involving EMS providers in research involving prehospital care will help to legitimize the results in the eyes of other EMS providers; the findings will have more “street cred.”
    Involvement of EMS in research will also help to improve EMS’s position as a profession.

  2. chad stemm on January 24th, 2008 2:57 pm

    I agree! It is a profession and should be involved in these studies. We learn so much from working together and understanding each others point of views! EMT-I and senior in Pre-Med

  3. anonymous on January 24th, 2008 6:49 pm

    This was an excellent interview. Thanks for the discussion on such a controversial topic.

  4. G on February 2nd, 2008 7:15 am

    As someone that just completed Paramedic ride time last year in N.Philly and now an active 911 paramedic I feel that I should put in my perspective on this as I’m sure not many paramedics visit this site or know the area surrounding Temple Hospital. N. Philly and W. Philly are a few of the worst areas of poverty and drug and gang related crime in the US. Over 300 killed in the city and most in these 2 areas. Medic 22 and 25 cover these areas and I was fortunate to run at station 22 a few blocks south of Temple. Temple has a great Trauma unit although I do feel that to much trauma has left them a little jaded to what EMS brings in. Scoop and run vs on scene intervention because that is what medics do. Philly police have gotten into the habit of scooping a GSW and running L&S to the Trauma Bay. 5+ minute transport time. No C-spine precaution, no vitals enroute, no secure airway; just a limp body in the back of a squad car. Hopefully notification the the ER to have a stretcher waiting. Now let’s wait one more minute for EMS, trained in C-spine, quickly board the patient and verify a secured airway and hopefully a pulse, able in 1-2 minutes try to obtain some history before possibly never speak again if they are able, secure an IV enroute prior to arrival to the ER which can all be done in less then 5 minutes while driving through Philly on the worst roads I’ve ever driven on. In these areas if I was lucky enough to get access and have a patient in PEA what I was doing enroute was taken over and repeated by the awaiting trauma team. There are things that can be done by ALS providers that need to be done and can be done quickly and at the same speeds as police. I can drop a tube or put in a 16g IV in an EJ bouncing in a rig at 40 MPH while the cops just hopes he doesn’t bleed to much in his back seat. Scoop and run does the patient to justice unless there is some pre-hosptial intervention. A code is a code, CPR on PEA is done in hosptial or out of hospital, and a fluid bolus to get a pressure to 90 is going to attempted in either area so to say EMS may be harming patients by not moving quicker with less invention will put patients at risk and I will do everything I can to make sure the ABC’s are intact PTA.

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