Taxi vs. 911

eak16 · May 17, 2004

a few weeks ago I saw a woman come in by taxi who had fallen on broken glass and ripped most of the flesh off her forearm :eek: :eek: . Poor thing was new to the area and didn't know that medic one is free.

Its so annoying though to see hear the whines of the frequent flyer who called 911 for a hangnail and is promptly triaged and sent out to the waiting room. "But I was brought in by an ambulance, and it has been hurting for a month now and the ambulance driver brought me in!!!" :rolleyes:

911RN · May 17, 2004

I recently had a 30 something woman who had a live bug in her ear. She called 911 and a taxi. The taxi arrived first, and as the patient was getting in, the ambulance pulled up, so the lady gets out of the taxi, into the ambulance. Talk about unhappy paramedics at 3 am. To top the night off, she stole a good pair of pick-ups, asked for a meal and cab voucher.

Didn't happen.

Havin' A Party!, ASN, RN · May 17, 2004

I recently had a 30 something woman who had a live bug in her ear...

Last month we had a teenager with cockroach in his ear. Said it crawled in while he was sleeping.

Tried irrigating / suctioning it out but we weren't successful.

suzanne4, RN · May 17, 2004

Best treatment for bug in the ear: use a syringe-full of alcohol. The bug will die and float to the surface and can be easily removed. Works much quicker than irrigation and doesn't cause any type of trauma.......

Havin' A Party!, ASN, RN · May 17, 2004

Thanks, S!

Will remember for next time.

Nurse Ratched, RN · May 17, 2004

I flushed a peanut out of someone's ear. But I digress :).

(shudder - roach in your ear - ewwwwww!)

Trauma Columnist · May 17, 2004

I must preface this with "I'm not a bug person". However, we use mineral oil to suffocate the little critter and out it comes!

kc ccurn · May 17, 2004

hmm, having 3 young boys this is definitely good advice for any future bug incidents I might have. YUCK!

RNCENCCRNNREMTP · May 18, 2004

Tonight, in our ER, a man came in with a gunshot wound to the arm via taxi and a three year old came in via ambulance (his parents called 911) because he put a dime in his nose.
Silly, I know.
Just thought I would share.

There was a study not too long ago (Journal of Trauma I think) that compared mortality in major trauma victims who arrived to the ED/Trauma Center via EMS vs Taxi. Those who arrived via EMS fared worse than those who arrived by Taxi. Seems the biggest contributor to mortality was time wasted on scene which EMS did a lot and Taxi drivers did very little. yes, injury severity was comparable in both groups.

susswood · May 18, 2004

Those who arrived via EMS fared worse than those who arrived by Taxi. Seems the biggest contributor to mortality was time wasted on scene which EMS did a lot and Taxi drivers did very little.

That's so crazy....I believe it.

psychomachia · May 18, 2004

There was a study not too long ago (Journal of Trauma I think) that compared mortality in major trauma victims who arrived to the ED/Trauma Center via EMS vs Taxi. Those who arrived via EMS fared worse than those who arrived by Taxi. Seems the biggest contributor to mortality was time wasted on scene which EMS did a lot and Taxi drivers did very little. yes, injury severity was comparable in both groups.

from http://www.jhu.edu/~gazette/2000/apr1000/10trauma.html

In the continuing debate among emergency medical services personnel regarding the best prehospital management for trauma patients, a new study by Johns Hopkins and the University of Southern California raises the bar on the importance of time.

In a study of 103 people, the most critically injured patients transported by private means arrived at Los Angeles County + USC Medical Center, a Level 1 trauma center, in nearly half the time of their counterparts transported by EMS--an average of 15 minutes vs. 28 minutes between time of injury and hospital arrival. Despite this difference, deaths, complications and length of hospital stay were similar between the non-EMS- and the EMS-transported patients. There was, however, a trend toward better outcomes for those who arrived at the trauma center more quickly following injury.

A 1996 retrospective study of 5,782 patients admitted to that center over a two-year period found that trauma patients transported by EMS had death rates twice as high as those transported by private means (28.2 percent vs. 17.9 percent).

Results of the current study--the first to look at the non-EMS group in detail--were published in the March issue of Archives of Surgery.

"One might think that the importance of time is obvious, intuitive and, thus, not worth studying," says Edward E. Cornwell, lead author of the study and chief of trauma at Hopkins. "But just two years ago, we heard reports that Princess Diana was at the scene of the accident for 45 minutes and had a slow transport to the hospital."

About 4 to 15 percent of all major trauma patients arrive at a sampling of large, urban trauma centers by means other than EMS, Cornwell says. These patients represent the purest form of "scoop and run," the philosophy that says EMS should rush patients straight to the hospital rather than first treating them on the scene. Others believe EMS should stay on scene awhile and resuscitate patients with intravenous fluids or other means, then bring them to the hospital, a procedure known as "stay and play."

The best way for EMS to treat patients probably varies with the setting and circumstances of injury, Cornwell says, be it a gunshot wound vs. injuries sustained in an auto crash, for example. Proximity to a trauma center also is a factor.

"Paramedics adhere to pre-established protocols in transporting trauma patients, so our studies showed an amazing consistency in the injury-to-hospital-arrival time interval regardless of the severity of injury," Cornwell says. "By contrast, in the non-EMS group, the more critical the injury, the quicker patients got themselves to the emergency department, almost as if they recognized the severity of their own injuries."

For the current study, patients were enrolled between January and October 1997. Estimated time of injury and outcome for 38 patients who arrived at the center by private means were matched to those of 38 patients of similar ages and injuries who were transported by EMS. Twenty-seven random patients transported by EMS also were studied as a control. The general population was approximately 85 percent male, 80 percent Hispanic and 10 percent African American.

The majority of patients had an injury severity score of 13 or more on a 75-point scale. The ISS is calculated by dividing the body into quadrants and assigning a number to each quadrant based on severity of the injuries in each, then squaring those numbers and adding them together. An example of an ISS of 13 would be a gunshot wound to the chest and abdomen with injuries to the lung and a hemothorax (blood in the chest) and an injury to a peripheral segment of the liver.

Researchers created a model to assess the time of injury in each patient by interviewing the patient and any witnesses or friends and combining their answers with data obtained from police, sheriff and medical examiner reports. No significant differences were observed in the two groups regarding mortality, length of hospital stays, days in the intensive care unit, complications or infections.

Cornwell is continuing his studies of patient injuries, transport time to the hospital and outcomes.

The study was supported by the federal Centers for Disease Control and Prevention in Atlanta.

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and from http://www.trauma.org/archives/scooop.html

Title

Paramedic vs private transportation of trauma patients. Effect on outcome.

Author

Demetriades D; Chan L; Cornwell E; Belzberg H; Berne TV; Asensio J; Chan D; Eckstein M; Alo K

Source

Arch Surg, 131: 2, 1996 Feb, 133-8

Abstract

BACKGROUND: Prehospital emergency medical services (EMS) play a major role in any trauma system. However, there is very little information regarding the role of prehospital emergency care in trauma. To investigate this issue, we compared the outcome of severely injured patients transported by paramedics (EMS group) with the outcome of those transported by friends, relatives, bystanders, or police (non-EMS group). DESIGN: We compared 4856 EMS patients with 926 non-EMS patients. General linear model analysis was performed to test the hypothesis that hospital mortality is the same in EMS and non-EMS cases, controlling for the following confounding factors, which are not affected by mode of transportation: age, gender, mechanism of injury, cause of injury, Injury Severity Score (ISS), and severe head injury. Crude, specific, and adjusted mortality rates and relative risks were also derived for the EMS and non-EMS groups. SETTING: Large, urban, academic level I trauma center. PATIENTS: All patients meeting the criteria for major trauma. RESULTS: The two groups were similar with regard to mechanism of injury and the need for surgery or intensive care unit admission. The crude mortality rate was 9.3% in the EMS group and 4.0% in the non-EMS group (relative risk, 2.32; P

2)

Title

Urban trauma transport of assaulted patients using nonmedical personnel [see comments]

Author

Branas CC; Sing RF; Davidson SJ

Source

Acad Emerg Med, 2: 6, 1995 Jun, 486-93

Abstract

OBJECTIVE: To describe one urban trauma transport system to clarify the impact of transport by nonmedical personnel on patient outcome. METHODS: Retrospective data were assembled over a six-year period through the use of the state trauma registry for an urban county served by seven state-accredited trauma centers. A subset of 4,767 consecutive assaulted patients was analyzed using the TRISS method to estimate survival probability. An unexpected death index (UDI), calculated as the difference between expected (TRISS method) and observed death rates, also was determined. Outcomes for patients transported by fire medics (FMs) vs nonmedical, police personnel (NPs) were compared. RESULTS: FMs transported 2,108 (44%) and NPs transported 1,356 (29%) of the injured assault victims. The FM-transported patients had a lower expected probability of survival than had the NP-transported patients (p

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a few things to conisder:

1. Urban environment close to a level 1 trauma center - I doubt the rural or even semi-rural (>20 min transport time) would have the same outcome.

2. Pt.s were probably able to maintain adequate airway during "private" transport - if you're five minutes away from a level 1 and are not in need of airway management, then the taxi is probably fine.

3. What about the patients who ended up at the "wrong" (no trauma center) hospital?

4. How about a study that includes time to OR between differing trauma centers?? If time is the issue in EMS, lets see what 20 or 30 minutes wasted in the trauma bay does to the mortality rate.

5. If a few minutes difference does make a difference, then let the EMS agencies utilize true "scoop and run" - No c-spine immob, No IV, NO VS, No calling the hospital and having to repeat the story 3 times to the non-listening person on the other end just to be asked at the end, "Does the pt. have an IV started" (man, if I had a dime for every time..) and all the other "time consuming" tasks that the taxi drivers are not required to perform - and then make a comparison between an EMS agency that provides only airway assistance to find out where the emphasis needs to be placed - time vs. procedure.