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Ohio System Wants Paramedics To Have Leeway In Trauma Care Protocols

In 2009, 629 people suffered serious injuries in Franklin County and were taken by ambulance to nontrauma centers, according to a study by the Central Ohio Trauma System.

That's because they didn't meet triage criteria created by the state after a trauma law was enacted more than a decade ago to make sure that severely injured people are taken to the hospitals best equipped the treat them.

The study said many of these patients were later transferred to trauma centers after their symptoms worsened or their trauma injuries became evident. Experts say treating the injuries in the first hour after a crash, fire, fall or fight is the most critical.

Although none of those patients died, the Central Ohio Trauma System said it wants the Ohio Emergency Medical Services board to adjust its rules to allow paramedics to veer from protocols if they think a patient needs trauma care.

"EMS told us (patients) were in bad car wrecks or bad falls, but the state triage says you can't just base the trauma triage on mechanism of injury," said Nancie Bechtel, the local trauma system's executive director.

An example, she said, is a person who is ejected from a car during a crash or has a passenger in that car die, but when paramedics arrive, that person is walking around and says he or she feels fine.

That person doesn't fit the state triage criteria and should go to the closest hospital, which might not be a trauma center. But trauma experts say that what you don't see (internal bleeding, concussion, etc.) can hurt or kill you.

Many EMS agencies keep a laminated copy of the state's trauma triage rules in the back of their ambulances as a reference tool.

"You're relying on physical findings, and some may take longer to present than others," said Robert Bates, assistant chief with the Madison Township Fire Department.

The 629 patients in the study -- 6 percent of Franklin County's trauma patients in 2009 -- looked OK, but their injuries included cervical spine fractures, skull and facial fractures, and injuries to the ribs, sternum and shoulder blade.

Many were transferred to trauma centers two to 12 hours after they were transported to the closest hospital, well after the "golden hour" for treatment. Studies show that outcomes for critically injured patients are worse at nontrauma centers.

"If you're in a life-threatening situation and it's not recognized and you're taken to a nontrauma center, you'll have a nonorganized response to treat that patient's needs," said Dr. Doug Paul, trauma medical director at Grant Medical Center.

"Clearly, people die more often, have more complications and stay in the hospital longer if you go to a nontrauma center and you're a trauma patient."

In 2009, there were 32,193 trauma patients in Ohio. Of those, 1,356 died of their injuries.

And of those patients, 91 died at nontrauma centers. Experts say they would rather have trauma patients die at trauma centers because they are assured that nothing likely could have saved them.

Bechtel recently presented her group's findings and recommendation to the state trauma committee; she also is a member. The committee is seeking input from EMS agencies and hospitals around Ohio before passing it on to the state EMS board.

Dr. Carol Cunningham, medical director for the EMS board, said that despite the Central Ohio Trauma System numbers, there's no need to change the triage criteria.

"I think that's already being practiced in most regions of the state," she said. "Regardless of any protocol you write, there's no substitute for common sense.

"If (EMS workers) know in their gut that it's bad, they go to a trauma center. It's better to have over-triage then under-triage."

Rob Farmer, Delaware EMS chief, agreed: "I would personally think that most EMS providers that I'm familiar with are going to err on the side of patient safety."



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