Dead is…unfortunately, dead. It doesn’t matter if the patient dies two minutes after you arrive on scene or two hours later or two weeks later. Dead is still dead.
With that in mind, it’s worth considering how we might shift our ideas about trauma care to a more global perspective. When you look at the mortality time curve in traumatic injuries you see that patients tend to die in three time windows.
Put simply, when people experience significant trauma, they tend to die in about two minutes. If they don’t die in two minutes, they tend to die about two hours later. In most urban settings this means that they die on a trauma surgeons table in the middle of damage control type cut-and-run surgery. If the patient is fortunate enough to survive the surgery, then they tend to die about two weeks later. Two minutes, or two hours or two weeks.
Here’s the big get it. In each of the mortality time windows, the patient dies for different reasons. But…
- The stuff we do on scene, in the first two minutes, effects all three time windows.
- First: Control the Airway (2 minutes)
- Second: Let Them Breathe (2 minutes)
- Third: Stop the Bleeding (2 minutes and 2 hours)
- Fourth: Keep it Clean
The stuff we do on scene, in the first two minutes, effects all three time windows.
Wrap your brain around that for a minute. We do stuff on scene that effects the patients mortality in the first two minutes. This is what we often think about the most when we think about our trauma care. Crash medicine. Down and dirty airways, immobilization, rapid transport. But what we do also effects the two hour survivability significantly. And, believe it or not, we can have a huge impact on the two week survivability as well.
To be able to treat the patient in all three windows, we need to know what kills trauma patients in two minutes, two hours and two weeks.
I was first introduced to the concept of addressing trauma care from the 2/2/2 perspective by a fantastic trauma and burn surgeon named Dr. Bradley Philips who practices at Swedish Medical Center in Denver Colorado. Here’s Dr. Philips analysis of why trauma patient’s die in each of our three time windows.
- Patient’s die in two minutes from: Airway and breathing compromise and hypovolemic shock.
- Patient’s die in two hours from: Hypovolemic shock.
- Patient’s die in two weeks from: Septic shock.
Often, we run our trauma calls from the two minute perspective and we don’t really consider the other two time frames. Perhaps, we’ve been taught that our job is to simply get the patient to the trauma team alive and everything else is their problem. It’s easy to think that way. Once the patient is out of our hands, who are we to be concerned about their long term survival? Isn’t that some doctor’s job?
As is the case with many questions in medicine, yes…and no. If the patient dies on the operating table because they were given so much saline in the prehospital setting that they were unable to coagulate their blood, we played a significant role in their death. If we let a trauma patient get cold and that hypothermia contributes to their abnormal coagulopathy and hypovolemia, our care played a significant role in their death. If the pseudomonas bacteria on our gloves is transferred to the patient’s wound while we are packing it and the patient dies two weeks later from a pseudomonas infection, our care played a role in the patient’s death.
I understand that this is a less comfortable way to look at trauma care. The get-them-there-and-forget-them strategy is more comfortable. It relieves us of our responsibility to be concerned about the patient’s survival after they have left our direct presence. And it keeps the game on our playing field. Let’s face it, getting trauma patient’s to survive the first two minutes is easier than getting them to walk out of the hospital. However, for the patient and their loved ones, dead is still dead.
What’s an EMT to do? When you walk into your next trauma scene, ask yourself, “What will kill this patient in the next two minutes?” Then ask yourself, “What’s going to kill them in the next two hours?” and then ask yourself, “What’s going to kill them in the next two weeks?” Here are some more specific guidelines.
First: Control the Airway (2 minutes)
The first big killer immediately following a major traumatic event is airway compromise. Get in there and get aggressive. Use those BLS airway adjuncts early to improve your efforts to assist ventilation. You were trained to use them for a reason. Use them. If the patient can take an OPA without gagging, they need a more definitive airway. Get out your king tube or Combitube or whatever more advanced airway you have and use it.
If you have the ability to intubate and the skill to do it quickly, do it. Be honest with yourself about that second part. I know you think you’re fast when it counts, but very few of us really are fast enough to not bog down a trauma scene with our intubation attempt. If your intubation attempt delays the transport of the patient one second, it wasn’t worth it. You should have stuck with the BLS airway.
Second: Let Them Breathe (2 minutes)
Pay attention to the patient’s lung sounds and, if you suspect they have a pneumothorax, vent the chest. If pleural decompression isn’t in your scope of practice, get that patient to someone who can vent their chest. It’s a horrible thing to watch someone suffocate in from of you. It’s even worse to let them suffocate and not recognize that you could have saved them with a simple procedure. Figure out a way to get the chest decompressed.
Also make sure that you stabilize any paradoxical motion of the chest wall and keep the breathing patient on high flow oxygen. Think carefully about how yo utilize interventions that impinge upon breathing like shock position and the Kendrick extrication device. These interventions have a role, but we need to consider effective breathing first.
Third: Stop the Bleeding (2 minutes and 2 hours)
This is relatively easy and we suck at it. Often times we let people bleed to death. Fear of tourniquets is part of the problem. Not being aggressive enough with out direct pressure is another part of the problem. There are three things we can do to prevent our patient’s death from hypovolemic shock.
1) Be really aggressive about bleeding control.
That means pack wounds with dressings, Gauze, Kerlix, whatever you have and then put real pressure on it. If you see someone assigned to bleeding control gently holding a dressing on a wound while blood oozes from underneath put your hand over their hand a squeeze like you mean it. Also put their free hand on the closest pressure point and squeeze there as well. If it doesn’t work, start thinking about a tourniquet.
2) Keep the patient warm.
We let most of our trauma patients get hypothermic and we rarely pay close attention to this detail. The good news is that we’re exposing people appropriately. The bad news is that even a small drop in core temperature can significantly impair the patient’s clotting ability through three different mechanisms. If they are going to survive surgery, we need to keep them warm. Cover them when your done with your assessment and kick the heater on high.
3) Go easy on the IV fluids.
It’s time to move away from the mindset that more fluid is better. Permissive hypotension is the new name of the game. To much saline impairs the patient’s ability to clot. If the patient’s is oriented and their systolic pressure is above 90, you probably aren’t doing them a favor by dumping more saline into them. Do them a favor and back off on the big fluid challenges.
Fourth: Keep it Clean
Sterile gloves are the most underused piece of equipment on the ambulance. Those sterile gloves are for more than delivering babies. If you’re working on open wounds, burns on invasive procedures, you should be pulling on those sterile gloves. It’s not a big production. Just pull a pair over your non-sterile gloves.
If you’re packing and working with a significant wound, you may need to layer up several sterile gloves while you work. Using sterile dressings isn’t enough. To many of our patients end up with extended hospital stays and increased mortality due to the infections we give them in the field.
If you don’t think that using sterile techniques is important, you’re not paying enough attention to sepsis mortality rates. The patient might not die in your care, but dead is still dead.
What do you think?: Should we treat trauma patients with the 2/2/2 mindset? Leave a comment and tell everyone what you think.