the level of irresponsible...

[Radar]

There is more data now on trauma outcomes than at any other time. @363medic may have some insight as well. A lot of trauma implementations pre-hospital (or in the field re: military) you really can't replicate in a double blind study, but that does not mean there is not meaningful data.

A lot of sacred cows are going to the slaughterhouse, thank God. @Radar @NCMedic @phideux @chiefjason

C-collars/LSBs
pre-hospital intubation
crystalloids for fluid resuscitation
bumping up the BP in trauma
TQ use

And in cardiac arrest, every drug that we give (none has shown any efficacy or benefit in outcomes).

Gonna have to agree to disagree on that one. I have seen no real benefit to a suprglotic airway in my personal experience BUT, I have seen pros to intubation. Granted I come from an old school mentality still where we were effectively taught how and when and why to do it in numerous scenarios. Then went to a vet clinic that did spay and neuter on Friday and did like 10 or 12 in on day. Then went to the OR and did some with a CRNA. Once that was done we finally could attempt to take a test and get cleared to do it in the field.

 

[fishgutzy]

Should be 2nd degree murder. Drunk and racing. The football dude driving the other car should be charge with felony murder as it should be in all deaths that result from racing. 124 in a 45 is prima facia evidence of racing.

 

[JohnFreeman]

I'll agree but with an exception. If they presented ID that would pass scrutiny from a "normal" person then the bar isn't responsible. Now if the ID was obviously fake, or the picture doesn't match, then the bar shares the responsibility.

That's not a popular take, but I agree with you. These folks are bouncers and barkeeps, not document examiners. If it's a good fake, it's not their fault.

 

[Chuckman]

Gonna have to agree to disagree on that one. I have seen no real benefit to a suprglotic airway in my personal experience BUT, I have seen pros to intubation. Granted I come from an old school mentality still where we were effectively taught how and when and why to do it in numerous scenarios. Then went to a vet clinic that did spay and neuter on Friday and did like 10 or 12 in on day. Then went to the OR and did some with a CRNA. Once that was done we finally could attempt to take a test and get cleared to do it in the field.

ETI will (hopefully) never go away, but there are a lot more options to manage airways now than there used to be. That's all I meant.

 

[LarrySr.]

Chief
I agree with your post above almost 100%.

With the exception of the very last remark : "Now the survivors have to live the rest of their lives with the very tragic consequences of their actions. And so will this young lady's family."

The family of the young lady definitely had their life changed . But those other kids especially the 3 ball players I think the only thing they are thinking about is getting kicked off the football team. Even more sick is they probably won't be.

 

[chiefjason]

There is more data now on trauma outcomes than at any other time. @363medic may have some insight as well. A lot of trauma implementations pre-hospital (or in the field re: military) you really can't replicate in a double blind study, but that does not mean there is not meaningful data.

A lot of sacred cows are going to the slaughterhouse, thank God. @Radar @NCMedic @phideux @chiefjason

C-collars/LSBs
pre-hospital intubation
crystalloids for fluid resuscitation
bumping up the BP in trauma
TQ use

And in cardiac arrest, every drug that we give (none has shown any efficacy or benefit in outcomes).

IIRC it was a Dr in Afghanistan that told the troops to "stop the bleeding and get them to me warm." What he did and asked for was apparently way out of the norm. But his rate of survival skyrocketed. I think part of it was stop working so much in the field and get them here at all cost. And seems that some of them took a lot of flak at the beginning until the numbers started to come around to their side. But I've listened to so much of that stuff no way I could track it down.

And yeah, no way to study that stuff you just gotta track the outcomes. And separate what the responders are doing from sometimes just blind luck and grit.

 

[Chuckman]

IIRC it was a Dr in Afghanistan that told the troops to "stop the bleeding and get them to me warm." What he did and asked for was apparently way out of the norm. But his rate of survival skyrocketed. I think part of it was stop working so much in the field and get them here at all cost. And seems that some of them took a lot of flak at the beginning until the numbers started to come around to their side. But I've listened to so much of that stuff no way I could track it down.

And yeah, no way to study that stuff you just gotta track the outcomes. And separate what the responders are doing from sometimes just blind luck and grit.

There is something called the Trauma Triad of Death (actually now a diamond): coagulopathy, acidosis, and hypothermia. These are what kills trauma patients. A cold trauma patient is a dead trauma patient. With the diamond, just add hypocalcemia for the fourth 'leg.'

As for this girl, she likely had so much internal injury and neurologic insult, it was never going to be survivable.

 

[RetiredUSNChief]

There is something called the Trauma Triad of Death (actually now a diamond): coagulopathy, acidosis, and hypothermia. These are what kills trauma patients. A cold trauma patient is a dead trauma patient. With the diamond, just add hypocalcemia for the fourth 'leg.'

As for this girl, she likely had so much internal injury and neurologic insult, it was never going to be survivable.

I'm guessing she was in the back seat, not belted in. 124 mph wreck that ended with the car upside down isn't an exceptionally survivable accident under those conditions. And of those who do manage to survive, odds are they're disabled for life.

 

[cubrock]

There is more data now on trauma outcomes than at any other time. @363medic may have some insight as well. A lot of trauma implementations pre-hospital (or in the field re: military) you really can't replicate in a double blind study, but that does not mean there is not meaningful data.

A lot of sacred cows are going to the slaughterhouse, thank God. @Radar @NCMedic @phideux @chiefjason

C-collars/LSBs
pre-hospital intubation
crystalloids for fluid resuscitation
bumping up the BP in trauma
TQ use

And in cardiac arrest, every drug that we give (none has shown any efficacy or benefit in outcomes).

Curious - what about TQ use?

 

[Chuckman]

Curious - what about TQ use?

The data absolutely endorses TQ use. The challenge with a lot of these things is you really can't design double-blind study; he gets a TQ, but that one won't, etc. So you have to look at the data retrospectively. There is lab data to support, with live tissue training and forced bleeding with animal models. There is zero literature to say TQs do not work.

 

[cubrock]

The data absolutely endorses TQ use. The challenge with a lot of these things is you really can't design double-blind study; he gets a TQ, but that one won't, etc. So you have to look at the data retrospectively. There is lab data to support, with live tissue training and forced bleeding with animal models. There is zero literature to say TQs do not work.

Thanks for the explanation.

 

[363medic]

There is more data now on trauma outcomes than at any other time. @363medic may have some insight as well. A lot of trauma implementations pre-hospital (or in the field re: military) you really can't replicate in a double blind study, but that does not mean there is not meaningful data.

A lot of sacred cows are going to the slaughterhouse, thank God. @Radar @NCMedic @phideux @chiefjason

C-collars/LSBs
pre-hospital intubation
crystalloids for fluid resuscitation
bumping up the BP in trauma
TQ use

And in cardiac arrest, every drug that we give (none has shown any efficacy or benefit in outcomes).

My opinion is that over the past several decades we have seen in increase in the protocolization of medicine at all levels, from first responder to physician. This is sort of a double edged sword because on one hand protocols can help standardize care and avoid errors of omission. On the other hand (again, my opinion) they have come at the cost of a significant erosion in clinical decision making, again at all levels. Rather than assessing a constellation of signs and symptoms and developing a treatment plan for a specific patient with a specific presentation, much of the time medical care simply boils down to stupidly simple algorithms: IF PATIENT HAS SYMPTOM “A” THEN YOU AS THE PROVIDER DO TREATMENT “B”. Unfortunately, this is very much apparent in the trauma world, and it has led to me witnessing first hand many unfortunate comedies of error that could likely have been resolved with the simple application of basic clinical decision making, or, barring that, at least a modicum of common sense.

I think we made some incredible advances early on in the GWOT, most evidently with the rise of tourniquet and whole blood use. Unfortunately I think in some ways we became so obsessed with these particular interventions and perseverated over them to the point that it has stifled other innovation. By 2010 the military and much of the civilian trauma world had fully embraced the utility of tourniquets. But in 2015 you still had pillars of the TCCC community devoting their time to journal articles that, I kid you not, assessed whether chopsticks or pencils served as superior windlasses for improvised tourniquets (Wilderness Environ Med 2015 Sep;26(3):401-5. doi: 10.1016/j.wem.2014.12.028.Epub 2015 Mar 12.). As military evacuation times grew longer and longer and prolonged field care became more of a focus, we put all our money on fresh whole blood as the magic bullet. Any discussions of vasopressor use were rapidly shot down based on what was (as far as I can tell) extremely limited retrospective data. I see this as a potentially life saving intervention being sacrificed because, well, its tough to protocolize. Using vasopressors effectively requires some nuance beyond “MAP <65 GIVE NEO”. It would really require us to invest in developing, and ultimately putting faith in our medics, and that seemed to be something the military was moving away from when I got out. Who knows though, its been a minute so maybe things have changed.

 

[Chuckman]

My opinion is that over the past several decades we have seen in increase in the protocolization of medicine at all levels, from first responder to physician. This is sort of a double edged sword because on one hand protocols can help standardize care and avoid errors of omission. On the other hand (again, my opinion) they have come at the cost of a significant erosion in clinical decision making, again at all levels. Rather than assessing a constellation of signs and symptoms and developing a treatment plan for a specific patient with a specific presentation, much of the time medical care simply boils down to stupidly simple algorithms: IF PATIENT HAS SYMPTOM “A” THEN YOU AS THE PROVIDER DO TREATMENT “B”. Unfortunately, this is very much apparent in the trauma world, and it has led to me witnessing first hand many unfortunate comedies of error that could likely have been resolved with the simple application of basic clinical decision making, or, barring that, at least a modicum of common sense.

I think we made some incredible advances early on in the GWOT, most evidently with the rise of tourniquet and whole blood use. Unfortunately I think in some ways we became so obsessed with these particular interventions and perseverated over them to the point that it has stifled other innovation. By 2010 the military and much of the civilian trauma world had fully embraced the utility of tourniquets. But in 2015 you still had pillars of the TCCC community devoting their time to journal articles that, I kid you not, assessed whether chopsticks or pencils served as superior windlasses for improvised tourniquets (Wilderness Environ Med 2015 Sep;26(3):401-5. doi: 10.1016/j.wem.2014.12.028.Epub 2015 Mar 12.). As military evacuation times grew longer and longer and prolonged field care became more of a focus, we put all our money on fresh whole blood as the magic bullet. Any discussions of vasopressor use were rapidly shot down based on what was (as far as I can tell) extremely limited retrospective data. I see this as a potentially life saving intervention being sacrificed because, well, its tough to protocolize. Using vasopressors effectively requires some nuance beyond “MAP <65 GIVE NEO”. It would really require us to invest in developing, and ultimately putting faith in our medics, and that seemed to be something the military was moving away from when I got out. Who knows though, its been a minute so maybe things have changed.

Preach. The military is still the military; it says on one hand "our medics are wondermedics and are independent practitioners," then say "we're going to protocolize everything and make an algorithm for everything and God help you if you deviate." I think, no, I know, part of the military's driving force of protocolizing everything is because of a lack of experience and context. True for the general military, especially true for 18X and street-to-fleet SOIDCs in the navy which uses the firehose-for-education approach.

I do think there are some paradigm shifts in thinking with regard to PFC, so I have not given up hope.