Hi there, everybody. My name is Sarah Dills. I represent UT Medical Center from Knoxville, Tennessee. So yay, Tennessee Thank you for coming to Nashville I am our trauma outreach coordinator, which means I work with EMS and our referring hospitals with trauma education and performance improvement I'm Danny Crow. I'm also with trauma services at UT. I'm our pediatric trauma coordinator and ATLS coordinator I'm Jake Edwards. I'm one of our trauma attendings I just started a couple years ago and very excited to be here and thank the think the TCAA for the opportunity for the podium All right, so the case we're going to discuss today is one that's very close to my heart I really enjoy this case because it highlights how important a team approach to trauma is and I don't mean that just in your trauma Center, I mean that as a trauma system So with this we're going to talk about EMS our referral facilities and then also what we did in our trauma center But I really want the big takeaway to be of how it took everybody involved for this So since this is an actual Patient information we do have permission from the patient to show some of the images some of the x-rays some of the IR things But we also have pictures of the patient and he said that was perfectly fine But for his privacy, I do ask not to take pictures of that. So All right, so we named this presentation synergy Why did we do that? The definition of synergy is the interaction and cooperation of two or more organizations Substances or other agents to produce a combined effect greater than the sum of their separate effects And that's what this story tells us. It takes us all big small Whether you think it's important or not. Everyone is involved to make patient care happen to be effective and efficient So a little bit about us If my TriStar folks are in here, I do apologize. This is an old graph. It's not been updated But these are our level ones in the state of Tennessee. You've got Johnson City Medical Center us in Knoxville Erlanger Vanderbilt also TriStar They are in the process of getting their level one if it's not already been verified and then we've got region one in Memphis So we serve a 21 counting region and as you start getting on the outskirts of this region You're getting about two hours away from any trauma center And so you start seeing those greater distances come into play of how we take care of these patients In this service area we do have 13 referring hospitals But that leaves a lot of our counties without any access to anything except an urgent care and a lot of our smaller hospitals Have very limited resources. We have a few that are a little bigger, but a lot of them are quite small So our volume at UT We see about 8,000 trauma patients a year with admitting close to 5,000 of those and as you can see with the graph Most of those are going to be coming from a referring facility or On-scene very few are coming in POV and we have a small amount that are flown in but primarily it's our referring hospitals That's why it's so important to have these really strong relationships with them and Collaboration and be able to work with our EMS to promote education and a friendship with them as they bring these patients to us All right, so our case This is mid-october And it is 1229 EMS gets the dispatch that they are being sent to a 37 year old male who has been struck by a wooden log if Any of you have worked pre-hospital? It's not unusual for that to be the amount of information you get so if you're driving to the scene You're having to think through your head. What is going on bigger than this picture. It's a severe minor. What equipment am I going to need? What other resources are there don't have a lot of information? Well, they didn't know on scene that was occurring was there was a patient who was lying on the ground Unable to get up and a 12 to 1800 telephone pole had fallen onto his abdomen and pelvis He was still awake and he couldn't move He said it took him several attempts, but he was finally able to wiggle himself out from under this pole And there was only one other person there with him who was working like a forklift type thing And so he called 9-1-1 and he's telling him what's happened The patient had worked law enforcement previously, so he had a little bit of knowledge He knew the dispatcher he knew enough to know that his injuries first were severe enough that he was probably gonna die And he told the dispatcher. I need to hang up and call my wife. I need to tell her goodbye and This started the response his brother was actually Working that day as one of the sergeants for the law enforcement and just had this gut feeling and Heard it come across the radio and started running to where he was at to see if he could get to him before EMS could So 1237 EMS arrives and the patients found lying on his back next to a tractor with a power pole on off to the side He's awake alert pale diaphoretic and complaining of abdominal and internal injuries He's denying neck or back pain. So when I talked to the patient, he said I Knew I was bleeding into my pelvis. He said I could feel the blood rushing out of me It was cold and I just knew more and more was emptying into me So EMS as we teach no matter whether it's physician EMS nursing We do a primary assessment with our trauma patients and this is what they found We've got a patient who's awake and he's talking with no signs of airway compromise He's got decreased breath sounds with in the right lower lobe with increased respiratory effort. He's clammy GCS 15 with some periods of GCS of 14 pupils are four millimeters bilaterally and they're reactive There's no uncontrolled hemorrhage and no obvious deformities Our vital sign trend very important so 1245 we've got a blood pressure of 97 over 60 a heart rate of 120 and he's 88% on room air Any red flags go up on that one? All right. We got some work to do 1,300 93 over 46 heart rates 128 94% on two liters we've applied our oxygen and 1305 we're 100 over 60 heart rates 119 and our respiratory rates 20 and our sp02 is 98% on two liters I'll go over here in just a second. The other treatments that were occurring during this time, but just based on that information We've got to decide What am I doing with this patient? So EMS has two questions. They have to ask themselves Load and go or stay in play Who would load up and go? Lots of hands. Yeah, not someone I want to sit and stay and play with Second one is where do I take this patient? So what if I told you you're 15 minutes from a local ER? But you're an hour and a half minimum by ground from UT the level one trauma center. What are you doing? Local all right So these are the things we're going to talk about how EMS makes those decisions So you've got the hard concrete ways to decide so just a few years ago ACS came out with their version of field triage guidelines of What definitively goes to a trauma center and what should be the highest level of a trauma center? They should go to that's within that region and then you've got your moderates Which should be considered for a trauma center and whatever is in your available region We also have to go off what's our resuscitation status So we've got the concrete facts and this gentleman definitely fit level one trauma center criteria However, when we start looking at his vitals, we already said he responded some but he's not responding a lot He's got two liters of fluid actively infusing during the BP checks So like you guys said I'm thinking local is he responding really well to what I'm giving him Not great So the big one transport and weather So if I get on a truck I've got to think about how long is it going to get to get there traffic considerations and those So a lot of times we opt to fly the patient out Luckily in our area we work with multiple aircraft services and in our 21 service County 21 County service area We actually have Lifestar which covers five different bases and they're scattered throughout. So they're pretty close to a lot of these areas But as usual weather happens So they actually contacted Lifestar right from the get-go as soon as the EMS dispatch went out and said hey We need an aircraft available and they said unfortunately we can't fly towards Vandy and we can't fly towards Knoxville. We're stuck in a weather pattern So again, our ground crews having to make decisions What do I do with this patient and where do I go? So when I'm teaching EMS one of the biggest things I tell them to consider about their transport considerations is access to blood product Because what's the number one cause of death and trauma patients? Hemorrhage, right? So in our area ground EMS does not carry blood product Now our aircraft services most of them do and in fact some of them carry whole blood, but not all So when you're thinking about where do I go most of our ERs have access to blood product? It may not be a large amount, but it's some now very few of them have access to readily available plasma products But they at least have access to Packed red blood cells. So when I teach them, I'm like if you've got a patient who shows signs of shock and is it hemorrhaging? Think about where that patient could get blood the easiest So for this patient, we already said Lifestar wasn't available. No one in the area could access the patient So what makes this case really interesting and why I really really like talking about it is this EMS crew thought outside the box They had just gotten TXA in their office They didn't even have a standing protocol for it yet. It was literally sitting on the educators desk and he goes Somebody go to the office Rendezvous with me. We're gonna give two grams of this so they have researched it, but this is brand new They just knew this was something that was gonna help their patient So they divided and conquered while one person went to do that. They started moving towards the local ER Big big factor here. So again, I said they're going to a smaller ER. How many of y'all have worked in a small ER? How many of y'all really liked getting sick trauma patients? Most of you are like, why are they coming here? So they gave them this heads up and said listen, we know this isn't the appropriate destination. However, this is what we have We need blood. Can you have it at the bedside as soon as we roll in? So kind of sidebar from this case One of our PI projects is or education projects we do with our referring facilities include simulation And we did a massive transfusion one here back of this with another local ER and we realized That if an ER did a pre activation to their blood bank it cut ten minutes off door to blood start So this was huge and this this ER already had that in process So by EMS letting them know we needed it they already had it at the bedside when the patient rolled in So like I said more was happening in the back of the truck while they were getting there They had done two IVs. You had an 18 gauge and a 16 gauge And when I was talking to medic about it, and he said he had LR going and saline I said, why'd you do that? He said cuz none of the literature says which one's better He said so I figured I couldn't go wrong if I did one of both and if we start blood we could at least go Through the saline line. It's a valid at least we're thinking good job Apply to oxygen how to 12 lead EKG So at 1304 we get to the outside facility and They have two units of pectoral blood cells ready for him and they go ahead and get that started They do a quick chest x-ray and they do a quick pelvic x-ray. Now. This x-ray is actually from our facility I didn't have access to theirs But it is the same patient and his x-ray at the outside facility Showed a displaced right superior and inferior pubic array my fracture He had abnormal widening of the left SI joint and pubic symphysis concerning for an open book traumatic injury Not really one. We like dealing with a whole lot. These patients are sick So, what did they do they applied a binder now this facility like many of our others in our area They don't have commercial binders so they used a sheet Which is one of the things I do when I'm teaching is let's think about equipment you do have Textbook says we need to do this process. But how is it actually practical in your facility? So they apply to sheet and EMS. They had the appropriate crew to stay on site It was an ALS crew with a critical care paramedic and they said you do what you got to do We're not gonna even leave and so by doing that you dropped out that delay of care on waiting another truck to get there for transfer Their unit secretary went ahead and called Lifestar dispatch and said we need an auto accept to UT. We've got these injuries If you're a trauma center, I'm sure you already have these in place but having auto accept criteria is a huge resource for your outside facilities because it Promotes them to go ahead and transfer even if they're not don't have imaging Because we all know sometimes that can be a bigger delay than actually getting that and then sending them So UT Lifestar was actually now able to rendezvous with this crew. It just wasn't close to the local hospital. It was a little bit farther away. But it gave them another option. So what they said is, okay, we'll move out of the weather pattern and we'll meet you there once you get the patient checked out of the ER. And the patient was transferred by the original EMS crew to Lifestar at 1324. All right, so there was another session where we talked about the golden hour. And a lot of times we talk about that as time of injury to definitive care or the care that they need. What I really like to think about that is is what was actually done in that hour. Because the things that we do in that hour make a huge difference three and four days later in the patient's outcome and their functionality of their recovery. So if we look at 1229, EMS got dispatched. But 1324, we've already been to a referring facility, gotten an assessment, got a binder, got blood product, TXA, and we're out the door in 20 minutes. Some of us have trouble even running a trauma in a trauma center in 20 minutes. So to be in a referring facility in a rural area and to have your team activated and this patient in and out in that time is almost unheard of. So that's where we transition to moving towards UT. All right, so as we move forward, we did cross time zones. So the times that you'll see from here on out are gonna be an hour ahead. But throughout his transport to UT, he had continued hypotension. Lifestar had initiated a third unit of blood product. They happened to have whole blood, so he received whole blood. But his systolic remained 80s, heart rate 110 to 130s. And then during his initial resuscitation on arrival to the trauma bay, you'll see his vital signs there. So 70 over 52. He had that sheet, makeshift pelvic binder in place. We did switch that out to a commercial binder. And that third unit was still infusing. On physical exam, not unexpected. He was pale, had some weak carotid pulses. His FAST was positive in the right upper and left upper quadrant. And he had blood noted at the urethral meatus. So as the resuscitation is continuing, you know, it's all kind of occurring at once. He's a transient responder to that blood product. So once that third unit had finished, his blood pressure continued to decrease. We initiated his fourth unit, two grams of calcium gluconate, and we're setting up for a REBOA. And I'll let Dr. Edwards talk a little bit about the REBOA. All right, so as Danny mentioned, he underwent a REBOA procedure. The indications are for blunt or penetrating trauma below the diaphragm and with evidence of hypotension, typically used less than 80 on the systolic blood pressure. Some centers expand that to less than 90. Contraindications, if you have suspected chest trauma, such as a pericardial effusion on your FAST exam or a widened mediastinum on your chest X-ray. The procedure itself is a percutaneous procedure using the Seldinger technique. After you get femoral access under ultrasound guidance, you place a sheath over a wire. That sheath, you can get your lab draws and also transduce an arterial pressure. And then you measure the balloon catheter length. This is based off anatomical landmarks. So you place it at the groin puncture site and stretch it up to the manubrial notch or jugular notch. And this allows you to land it in zone one, which is superceliac, above the diaphragm. It also keeps you from placing in the abdominal visceral take-offs from the aorta, which is zone two. And then zone three is defined as infrarenal. And this is to help control pelvic bleeding. So the balloon catheter was advanced. A chest X-ray was obtained to identify the catheter was above the diaphragm in zone one. And it was insufflated. At this time, the balloon catheter can be transduced on an A-line as well to assess a response in your blood pressure. And then you check for femoral pulses to ensure adequate occlusion of your aorta. I'll take that, just that, thank you. All right, so after the balloon was inflated, systolic improved to about 110, and he maintained at that, and his heart rate improved to the 70s. The decision was made to transport him to CT to identify additional injuries. The balloon was deflated during his chest abdomen pelvis with contrast, and he remained hemodynamically stable after deflating that balloon. While in the CT scanner, it was identified that he did have a right common iliac artery injury. IR, interventional radiology, was called from inside the CT scanner. And the patient was taken back to the trauma bay while the plan of care was being decided. At that time, the balloon was, Roboa was repositioned to zone three, remained deflated, but in the event that he were to deteriorate again, we could inflate that balloon. And then he was transported to IR at 1625. All right, he was in IR, I'm sorry, these are the list of his CT results. As you can see, numerous pelvic fractures, the right common iliac injury, the grade two spleen lack, some hemoperitoneum as well, no suspected mesenteric injury or anything. And then had some displaced fractures of some transverse process fractures. And then the edema and contusion of the pelvis and contusions of the posterior left chest wall without other traumatic findings of the chest. So he went to IR, and let's see if this, go ahead. There we go. So this is whenever he was in the IR suite. This is the first arteriogram that they shot. And what you can actually see here is it's a right internal iliac. It does not feel all the way down the length of the internal iliac. And then here's, it's showing the extravasation of contrast from that internal iliac. So they placed coils to embolize this, and then their post-procedure arteriogram is seen here. As you can see, there is no longer any extravasation from that internal iliac, and there's adequate perfusion down the external iliac. So the procedure was completed at 1800. He did well during the IR procedure and required only minimal resuscitation during that procedure. I had the privilege of meeting this gentleman as I came on shift that night around 1900. And on my exam, he developed peritoneal signs as the abdomen was very tended, almost rigid. And I was concerned for a bladder injury given his CT scan findings of all the pelvic fractures. He had some irregularity to his bladder as well, and the reported blood edema on his arrival. So I took him to the OR. Knife time was at 1930. He was found to have an eight centimeter rupture of his bladder. This was repaired in two layers. And I left internal and external drainage. Post-operatively, he had a CT cystogram five days after his procedure on 11-2, which showed a leak, or sorry, did not show a leak. That was a typo. Did not show a leak. The foley was removed, and he was able to avoid independently. He had the drain removed a few days later and was discharged home. So like we said, we named this lecture Synergy. The interaction or cooperation of two or more organizations, substances, or other agents to produce a combined effect greater than the sum of their separate effects. If EMS had worked isolated and just did what they did, the patient wouldn't have done as well as he did. If the rural facility was left out of the equation and wasn't part of the conversation, part of the care, the outcome wouldn't have been the same. If Lifestyle wasn't part of the equation, we wouldn't be where we are today. And if we didn't have the processes in place at UT and our trauma center for Roboa CT mass transfusion protocol, the patient wouldn't be where he is today. And fortunately, that patient is now back to work, living with his family, has quite a few little kids, and is enjoying life every day. It's important for us as trauma centers to remember that not only is our purpose to work with our own facility, to increase our processes, smooth our processes, and provide better patient outcomes, but we can't do it by ourselves. It takes all of us. So for those of you who work in education, outreach, PI, invest in your EMS, invest in your rural facilities, look at the challenges that they face. We heard a lecture earlier from Alaska. I had no idea they had those kind of challenges. Makes our rural area look really not rural. Um, we highly appreciate what you guys do. But every area has its own unique challenges and its own specific needs. So immerse yourself in it. I challenge you that if you've only worked in a hospital, go jump on a truck. If you've only worked in your ER, go to a small ER. Ask them what resources they have. See how it's different. I've had the pleasure of getting to do that. And a little personal story with that is I'll never forget the first time I ran my first EMS call. I had been a nurse first before I came into EMT, and my husband, who is a flight paramedic, has been a medic for years. We ran the call together. It's 11 o'clock at night. It's dark, it's stormy, it's rainy. And we know that this truck has flipped over on its top. Well, I think I'm good to go. I've done trauma for 10 years. I know what to do. So I get my little trauma bag. I think I'm cute and cool. And I'm walking down this little embankment to go to the patient. There's no one in the truck. And I said, I have to find my patient? I'm used to them coming in on a long spine board. No. OK, how many people were in this truck? I have to figure out how many, too. So I'm literally searching in trees and bushes for my patient. And I find him up under the hood of the car with only his torso up sticking out. And unfortunately, he had already died. But my husband and I, on the way back to the station, had the conversation of what would we have done if he had a pulse. And I said, would we have started IVs and fluid? And would you have intubated him while we were right there? And he looked at me like, duh. And he said, that's our job. And I said, this is not the same. This is different. I would have gotten that exact same trauma patient in my trauma bag. But my care for them would have still followed airway, breathing, circulation, disability, exposure, environment. But it looked a lot different. If that patient showed up in the ER where I work part time, it would not have looked the same. I don't have the same blood products. I don't have warming mechanisms. I don't have the same number of doctors. It's different. So get out there. Find out what your areas have. See what they need so that your education tailors it to be practical and not just textbook education. Because for patients like this gentleman right here, it made a difference. Our area does this thing called the Star of Life. And it's where EMS providers are nominated for going above and beyond the scope of care to help patients survive and have a functional outcome. Not just did they survive, but did they have a functional outcome? And we nominated this case, and they won. And this is when the flight crew, dispatch, even some of the police officers got to meet with this patient and his family. And he got to tell them thank you and see some of them for the first time in person since he was on their stretcher telling them, I'm gonna die. Tell my wife, goodbye, I'm gonna die. And it was a really, really unique moment for these people to get to come together. And we talked about it taking everyone. I did leave out one group that was important for this, which was law enforcement. They actually provided police escorts from the scene to the rural facility and from the rural facility to the LZ so that they could expedite care for this patient even more. So even our partners that are outside the medical field make a difference in these patients' outcomes. So having those relationships is really important. Does anybody have any questions? We've got a little bit of time for some. Why not explore them? What was that? Why not explore them? You mean whenever he's in the trauma bay, making the decision to go up to the OR? So can't speak on the clinical decision-making prior to my arrival there. But I think that getting him, getting the robo up and identifying that bleeding on the CT scan kept him from having to have massive bleeding in the OR because the amount of blood loss he would have with an open repair for that iliac injury would have been more catastrophic for him. But you would have found the bladder injury. Yes, we still took care of it. Yeah. Thank you very much.

trauma case

EMS collaboration

TXA administration

blood transfusion

REBOA procedure

interventional radiology