When I was hired as the EMS coordinator at the hospital there wasn’t much mention about one small part of my job – that of being the hospital’s trauma data collector.
All of the hospitals in our state, like those in most states, are required to participate in their state’s trauma data registry. The trauma data registry collects information about all victims of trauma who are either admitted to the hospital, die in the ED or are transferred from the ED to another acute care hospital.
The collected information includes: patient demographics (age, race, zip code, etc), type of injury, mechanism of injury, and when injury occurred, method of arrival (ambulance, private vehicle, police, etc.), prehospital information (times, vitals, interventions),* ED treatment (times, interventions, vitals), and hospital treatment (length of stay, procedures performed, and discharge status (alive, dead, level of functioning).
*This is the reason why in our state, EMS is required by law to leave a copy of their prehospital run form for a trauma patient before leaving the hospital.
While the hospital specific information collected by the state is kept privileged, some general information is released to the public and researchers can apply for access to the data.
Since we are not a trauma center, I only have to input a basic set of information. Trauma center data collectors have a much more intensive number of data points to enter.
The inputting itself is extremely tedious. Fortunately, our medical records are now computerized so I can access them from my desk rather than dragging my laptop down to the medical records office and then having to page through thick binders for the information I am looking for as I did when I first started the job. Still, it can make for a long day (although some days I don’t mind having mindless work to do).
Think about it: if you arrived on scene at 11:54, I have to type in 11:54. If the BP was really 140 systolic, but you wrote down 142, I have to type in 142. If you c-spined a patient, I check that the patient was c-spined. If you didn’t, I don’t check it. If you didn’t describe how the accident happened, then I have to hope it is described in the Ed chart or else I have to type in unknown. And if you didn’t leave a run form and I can’t track it down, I have to check run form unavailable. Then I have to check the ED chart to see if they listed your interventions. I would get another job if this was all my job was about. Fortunately, it is just 20% of my job.
Once a year the data I collect is downloaded to the state, which means I could theoretically ignore my inputting for months at a time, but believe me, if you delay, you pay for it later. I try to keep up. Sometimes I get caught up, and then the next thing I know two months have gone by and I am behind again. I would like to manage my time so I do it weekly.
This past week, with my monthly CME presentation done and out of the way, I devoted two full days to catching up.
The experience, as it always does, left me frustrated and upset.
80% of all our trauma patients are fall victims, 70% are falls of less than 3 feet. The average age of our all of our trauma patients is in the high 60’s. We see many hip fractures, mostly in patients in their 80’s.
As many of you may have heard, hip fractures have a 15-20% mortality rate within a year of injury. I see this all the time. Occasionally a patient will come in with a hip fracture, and expire in the hospital from other medical causes. But more often, in reviewing EMS run forms throughout the year I will see familiar names. The medics bring in a patient with pneumonia. The patient had a hip fracture three months earlier. The medics bring in someone with sepsis. Hip fracture two months before. They presume someone on scene. A familiar name. Entered her as a hip fracture six months before. Hip fractures are tough on old people. They don’t heal well, fear limits their mobility, immobility makes them susceptible to illness. While some recover to lead full engaged lives, for others, a hip fracture is the beginning of the end. Farewell to independent living, hello skilled nursing facility, hello dark and lonely descent to death.
Most of our hip fractures are females, maybe 35% are men. While I stay fit which lowers my risk factors for an eventual hip fracture, I am of tall stature, which is a risk factor. I’m only 51, but it still worries me. It will be just my luck thirty years from now, another bored trauma collector will be typing in my demographic information and reading another paramedic’s run form about how they treated me on scene.
Here are two things that bother me:
One is the never-ending nature of the hip fractures. Every month, there are sure to be seven of eight new patients to enter into the data base just with hip fractures alone. I wish I had their names in advance, so I could warn them. Please be careful.
The other thing that bothers me is reading the patient’s EMS run forms. Here is what I see. Pain scale 10 of 10. Patient cries when ambulance hits bump. BLS transport. It really bothers me in a deep personal way. I get upset about Wall Street and the banks screwing the little guy. I get upset about all the chemicals and pollutants in our air and water and food. And I get upset about the way we treat hip fractures in EMS.
While pain scales are not recorded in the trauma data base, I have been keeping my separate Excell spread sheets on pain. I am tracking everything, compiling the data.
Here are some of the nuggets I can release:
1 out of 10 hip fractures gets prehospital analgesia. While this is horrible, statewide only 1 out of 20 gets it. Almost 90% of these patients will get analgesia in the ED.
When medics give pain meds they give it an average of 15 minutes into the call. This also works out to be 22 minutes before arrival at hospital triage.
While I am not at liberty to give out our hospital’s time to medication, it is better than national studies and we are working to improve it. But it is fair to say time to hospital triage is rarely time to immediate pain relief.
A paramedic on scene can medicate a patient far quicker than a nurse can medicate a patient rolling into the ED. At least in the ED, they get a more comfortable bed and an end to the jostling of potholes on the road.
While I would like to see a greater improvement in prehospital pain management – like 100% for patients with 4 or more on the pain scale and no contraindications, there are numerous problems that need to be overcome.
Our area is not one EMS system, but virtually a different system in each town. Consequently the hip fracture treatment rates vary widely from town to town. My statistics show towns that have all medic ambulances provide more pain relief than towns that have BLS ambulances and medic flycars. The reasons for this are that medics are not dispatched for low falls, basic EMTs are reluctant to call for pain management for hip fractures and when they do, fly medics are reluctant to commit themselves to riding in on a hip fracture when it means they are leaving their town without medic coverage (they might be missing a “more serious” call).
While there are benefits to both systems, I don’t want my grandmother living in a town that will not treat her hip fracture with analgesia. I don’t want her living in a town that will strap her unmedicated soul to a board and bounce her over the bleeding roads to the hospital. No sir.
So today, I am still depressed after two days of reading through run forms of seeing patients in pain, and seeing their pain go untreated.
I continue to collect my data, continue to build my case.
In the meantime, frail old people, be careful.
It’s a mean world out there.