Evolution of trauma response education

CarolinaFireJournal - Amar Patel
Amar Patel WakeMed Health and Hospitals
04/29/2011 -
It is 38 degrees outside. Roads are slightly wet. You are dispatched to a motor vehicle accident in a remote area of town, at the intersection of Smith road and Country road at three in the morning. You are the only unit available with an estimated 20-minute time of arrival. It is reported that your patient is unconscious.

As you drive, you mentally prepare to respond to the scene. What questions do you ask yourself? Do you go ahead and alert the helicopter? Do you alert the hospital? Do you have a mutual aid agreement? Could the person who called 911 assist? Are you able to take care of more than one critical patient?

How do you prepare to be the only unit available in what is described as a bad, possibly fatal accident in extreme rural territory? This is a scene that could be a reality in the vast majority of North and South Carolina, and although at the time you feel quite alone, it is important to realize that you have an entire emergency response system at your beck and call. What you do and when you do it can truly make a difference for that patient waiting unconscious behind the wheel of a wrecked vehicle.

Rural emergency response offers some unique challenges. Response times are greater, your patients tend to be sicker before EMS arrives and your transport time to a definitive care facility is longer. You are more likely to handle the most critical patients for longer periods of time by yourself. In comparison, a similar sick patient in Raleigh would likely receive help in 10 minutes or less and EMS providers have the ability to rapidly transport the patient. In those rural areas, more often than not, you will not have help. In the beginning, it may be just you. And it could be just you for an extended period of time. How do you prepare for that?

Unfortunately, this added pressure also makes it much more likely that mistakes will happen. A piece of the process is more likely to be missed, a forgotten Epi here, missed shock there or worse a missed esophageal intubation all because you are under more stress. And, you alone are responsible for handling the patient, managing the family and onlookers and, after a time, updating fellow providers coming in to assist. In any large metropolitan district, you would have someone there to help and you would have more opportunities to practice what to do simply because of increased call volumes.

In rural districts, call volumes are less, but when calls do come in they are more likely to be helping the sickest of the sick. EMS providers have training to handle acute illnesses, but exposure to a critical mass of certain scenarios is necessary to hone your skills for high risk, low yield situations. The saying practice makes perfect — or almost perfect — is true. Repetition is a key to solid performance under pressure.

In the past, preparation for response to scenarios would include classroom-based presentations and discussions where EMS providers walk and talk through the process, often using themselves as mock patients. Teachers would ask questions and students would respond, sharing what they would do in that type of situation. The problem is that in the moment, during a scene response in the real world, if something doesn’t go according to the textbook, providers may not be mentally or physically prepared for what can happen.

Education, practice, and reeducation are critical for emergency responders to become more comfortable and more adept at caring for the sick and critically ill. We all know that technology is changing the way pre-hospital care is delivered, and technology is changing how we learn and teach to include more scenario-based education.

These scenario-based programs often involve the use of computer games or human patient simulators, where you have the opportunity to practice a response or a skill repeatedly in a safe, realistic environment, making your response second nature when you are on the side of the road responding alone to that early morning car crash, delivering a baby in a rural community or managing a cardiac arrest. Advances in simulation education provide this real world experience. Simulation enables you to do and to react in addition to talking through what can happen. Research has proven that training through simulation really does work.

Now, you are likely thinking — training using human patient simulators is a spectacular idea, but in our district we have limited funds and little to no access to training resources, even though my district is more likely to encounter high-risk low-yield situations where EMS providers will frequently have to manage the scene on their own for extended periods of time.

There is good news. There are numerous simulation-based classes and programs developed specifically for rural providers and hospitals. While these widely available classes and training programs are specific to trauma care, more and more medical programs are being released regularly. It is important you ask your training officer for information on simulation based in your area.

Below is a list of trauma classes that include simulation technology.

Rural Trauma Team Development Course (RTTDC) developed by an ad hoc group within the American College of Surgeons to help rural hospitals develop their own trauma teams. RTTDC isn’t only for hospital providers, but for all those involved in the trauma process to include fire and EMS responders. While RTTDC is still new, impacting the processes from all levels helps create a unified trauma process. This one-day course has not only provided education but opened the doors of communication between pre-hospital and hospital personnel. http://facs.org/trauma/rttdc/

Prehospital Trauma Life Support (PHTLS) developed by The American College of Surgeons to provide both basic and advanced trauma care to fire and EMS professionals utilizing the principles created in Advanced Trauma Life Support (ATLS). This two-day simulation based course teaches participants basic and advanced trauma care. Providers are exposed to those high-risk low-yield situations that not only test cognitive knowledge but practical application as well. http://www.naemt.org/education/PHTLS/phtls_a.aspx

International Trauma Life Support (ITLS) developed in the early 1980s as basic trauma life support, ITLS has since grown to become an international standard in trauma care. Now endorsed by the American College of Emergency Physicians, this two-day simulation based course teaches out of hospital providers basic and advanced trauma care. ITLS affords students both classroom and practical skills assessment all while relating them to their own experiences. http://itrauma.org/

Advanced Trauma Life Support (ATLS) developed by the American College of Surgeons for primary care providers working in a hospital environment ATLS provides participants with the fundamental knowledge of caring for a trauma patient in a systematic and organized fashion all while being able to effectively communicate with the trauma team. This two-day simulation based course provides a classroom understanding of trauma care and then reinforces that within a simulation scenario. While the target is hospital personnel, fire and EMS personnel are allowed to audit the course. http://facs.org/trauma/atls/index.html

Trauma Nursing Core Courses (TNCC) developed by the Emergency Nurses Association for emergency nurses working in a hospital environment. This 2-day course provide nurses with not only knowledge of trauma care, but the roles each provider plays in the trauma process and means of effective communication. http://ena.org/coursesandeducation/CATNII-ENPC-TNCC/tncc/Pages/Default.aspx

Vertical Evacuation Simulation Training (VEST) developed by WakeMed Health & Hospitals in 2008 after analyzing and testing data obtained from hurricane stricken areas of the United States, VEST provides both hospital and prehospital providers critical information on how to package and transport a critical patient with limited to no resources when a disaster strikes. This one-day classroom and practical simulation based course discusses not only immediate needs but long-term care and impact on patients and providers. http://wakemed.org/simulation

Participation in these programs helps build communication between fire, rescue, police, EMS professionals, first responders, community, bystanders/civilians, and community emergency response teams (CERT), and can help build a group of civilians that can be called upon to help mitigate the incident in the event of a disaster. When a building blows up, whether in an urban or rural area, it is very beneficial to have civilians equipped with basic training to be able to help in emergency situations. It is also critical for emergency response professionals and hospital personnel to be prepared, so they do not run into an unstable building or pile of debris wearing inappropriate clothing like what happened after the Oklahoma City bombing in 1995. The result was two nurses lost their life primarily because of improper training.

Especially in rural settings, simulation training is important so firefighters, nurses, other medical professionals, police, sheriffs, highway patrol and EMS professionals can benefit from real-life simulated cross-training. Simulation training can help build the lines of communication between agencies that have mutual aid agreements between department and across city limits and county lines. These personal relationships can be built while reacting to and participating in response exercises. The interaction helps individuals, agencies and departments become comfortable with each other, understand individual’s roles, establish guidelines, policies and procedures and strengthen mutual aid agreements.

These training activities can also help identify individual or system process issues, thus identifying needs for additional training programs. Building these relationships also increases your chances of being able to attract training programs to your area and increases your ability to apply for and be awarded grants that fund training exercises.

Repetition is the key to learning, and through the use of medical simulation training and education, health care providers have the opportunity to practice skills in a controlled, yet realistic environment, gain clinical competence and confidence through targeted training exercises, improve and enhance communication between all levels of care providers, gain experience with uncommon clinical conditions and infrequently performed procedures, and review specific cases and scenarios to identify areas of opportunity.

Obstetric emergencies tend to be the most complicated calls for any EMS provider. In my 16 years, I have assisted in only two deliveries, and I have always practiced in major municipal cities. Across the country, EMS providers are encountering more births that are going bad. They are seeing more shoulder dystocias due to environmental factors, increased maternal weight and advanced maternal age. Wouldn’t it be wonderful to practice how to handle a shoulder distortion before you receive that call? And, wouldn’t it be nice to have practiced how to respond alone to that potentially fatal car crash at the corner of Smith Road and Country Road. Training using medical simulation can afford all of these opportunities.

Amar Patel is the Director of the Center for Innovative Learning at WakeMed Health & hospitals. Mr. Patel is responsible for integrating technology based educational programs to include human patient simulation, healthcare gaming, and hybrid education into regional educational programs. As a member of the Center for Patient Safety, Amar strives daily to make changes to processes in healthcare that will directly improve patient and provider safety. The WakeMed Center for Innovative Learning was recently designated a Center of Educational Excellence by Laerdal Medical, one of the world’s leading providers of health care solutions, including products and services for simulation, immobilization, basic and advanced life support, patient care, self-directed learning and medical education. Photos by Julie Macie/WakeMed Health and Hospitals
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