What Does it take to overwhelm your trauma service?

[emtcsmith]

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As a paramedic student I've seen trauma teams work in Hahnemann my first year of school and now Crozer for my second year. The busiest I've ever seen was something like eight trauma cases strait. Often we'll bring in from accidents, assaults, shootings we'll have mutiple trauma patients. Obviously it depends on your staffing levels and the critical nature of each patient. But at what level does your hospital have to say "enough is enough" and go on divert?

 

[Jeff698]

But at what level does your hospital have to say "enough is enough" and go on divert?

What is this divert you speak of?

Sadly, we have no place to divert to. And our institutional answer to any transfer request is "bring 'em, we're happy to help".

Take care,
Jeff

 

[GeneralVeers]

We can go on divert for everything EXCEPT trauma. We're the only trauma center for all of South Texas, so it's simply not an option.

 

[USCDiver]

The only time we ever came close to diversion (as far as I know), was when all of the hospital ventilators except for one were in use already.

 

[emtcsmith]

I guess a better question would be what is the average staffing of a trauma service? The amount of residents, attendings, and nurses along with size of your facility easily dictate the amount of work you can under take.

 

[Seaglass]

At the hospital where I trained there was no such thing as divert. When the trauma team is overwhelmed we pick up the slack until they can catch up.

 

[Flopotomist]

The criteria for diversion status varies by county, and is legislated (carefully) by EMTALA. Staffing levels would seem to be a logical basis for making these determinations, however are not actually allowed to be a consideration normally. Hospitals generally only go on diversion if there is a facilities issue (eg there are no more ventilators) or there is an internal disaster.

Some counties will allow short term diversion status for a hospital (~4 hours) if the department is saturated with patients with the theory being that this time can be used to start dispo'ing some patients out. However, this can only be used if there is another appropriate facility able to handle pts.

 

[bulgethetwine]

The only time we ever came close to diversion (as far as I know), was when all of the hospital ventilators except for one were in use already.

Answer: Call in more med students. It's not that tough to squeeze an ambubag ... 😉

 

[USCDiver]

Answer: Call in more med students. It's not that tough to squeeze an ambubag ... 😉

Pfft, medical students can't count to 12.

 

[Tiger26]

Pfft, medical students can't count to 12.

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 . . . . . ? ($hit, what comes after 11)

 

[El Cheba]

We will divert only if we are out of blood products and that divert is for outside this county only. The next closest trauma centers are ~hr and a half by ground away. We are also the only public hospital in the county.

 

[PharmDFisher]

We will divert only if we are out of blood products and that divert is for outside this county only. The next closest trauma centers are ~hr and a half by ground away. We are also the only public hospital in the county.

dont know too much about diversion, not really a med student or attending but i was in world trade center tower 1 before it collapsed, i was like 13 at the time and they were bringing trauma patients in and i watch them turn away cases because they couldnt fit anymore people in the hospital and they started putting up tents in the grass and concrete outside, but until then they sent them away

 

[FoughtFyr]

But at what level does your hospital have to say "enough is enough" and go on divert?

I once cleared my ED by literally admitting nearly everyone to continue their work-up because we were told we'd be receiving 15+ level ones and 10 level twos from the high school band bus versus semi crash. Ended up with two DOA and three level ones, but we were ready for the 25 patients.

- H

 

[Jeff698]

I once cleared my ED by literally admitting nearly everyone to continue their work-up because we were told we'd be receiving 15+ level ones and 10 level twos from the high school band bus versus semi crash.

Now see, here's the thing...

This is EXACTLY the reason low bed capacity (aka ED overcrowding) is a such a HUGE problem for our disaster preparedness (i.e. Homeland Security). You were at what I'd guess is one of the few places around that had the bed capacity to do what you just described.

We run our inpatient beds close to capacity every day. As a result, we frequently have patients backed up in the ED even without a disaster.

Should an MCI come in with a large patient load, we'd have no place to go with our current ED patients except the hallways. Granted, we now have huge hallways, but that's not exactly what I meant when I said bed capacity.

Lord knows how we (or, I'm guessing, most facilities) would handle a large bolus of patients (50+) from a terrorist event. And that, as we've seen in other parts of the world, can be a pretty limited terrorist attack.

I don't mean to complain about my place because, from what I hear, we're actually not all that bad off, relative to the rest of the nation.

How about other places? Do y'all have the capacity to pull off what FF described on a typical day?

Take care,
Jeff

 

[crewmaster1]

In June there was a 1.5 hr window in which U. Cincinnati received 11 gunshot victims! I wasn't working that night and I'm not sure how many were level 1 traumas, but I'm guessing it was a crazy few hours.

 

[deleted77919]

When we had the steam pipe explosion (Lex and 42nd I believe) we instituted our mass casualty incident protocol (since we didn't know at the time how many patients to expect). This meant we power admitted just about everyone else who was in the ED at the time. It took about 30 minutes to make about 20 patients disappear.

We can usually get regular floor beds, it's tele beds and sometimes the CCU that usually fill up.

 

[GeneralVeers]

When we had the steam pipe explode we instituted our mass casualty incident protocol (since we didn't know at the time how many patients to expect). This meant we power admitted just about everyone else who was in the ED at the time. It took about 30 minutes to make about 20 patients disappear.

We can usually get regular floor beds, it's tele beds and sometimes the CCU that can fill up.

What would you do if there were no available hospital beds? We've had several days in the past week where the hospital has had every bed filled, and the ED has been saturated with admitted and critical patients. How could you get these people out of your ED to make room for trauma patients?

 

[deleted77919]

To be honest I am not familiar with all of our MCI protocols, I only saw this one implementation of it, so I can only guess. My assumption is they get sent up anyway, if they are going to sit in hallways they might as well be on a floor and out of the way (so long as they are stable).

 

[Seaglass]

When I was training we were occasionally in the position that Veers describes - every single bed in the hospital occupied for days. Not good.

 

[Jeff698]

What would you do if there were no available hospital beds? We've had several days in the past week where the hospital has had every bed filled, and the ED has been saturated with admitted and critical patients.

My point exactly. Surely this isn't just a Texas thing. The papers I've read on this seem to indicate it is occuring all over the country.

Anyone else seeing this?

Take care,
Jeff

 

[Apollyon]

My point exactly. Surely this isn't just a Texas thing. The papers I've read on this seem to indicate it is occuring all over the country.

Anyone else seeing this?

Take care,
Jeff

Had it happen more than a few times at Duke, and have had it several times here in Greenville SC - the good thing here is, though, that we have several community hospitals that can absorb overflow (as there are no residents at the outside hospitals, so the hospitalists move a lot more efficiently).

 

[emtcsmith]

Beyond the obvious cost, logistically speaking how hard would it be to create a "reserve" supply of beds, monitors, 02, fluids to handle a 50-100 patient surge? I know that to some degree stock piles, mobile hospitals and other local and gov't resources exists across the country. But we all know that we must depend on ourselves for at least three days before the feds can arrive to help.

 

[GeneralVeers]

Beyond the obvious cost, logistically speaking how hard would it be to create a "reserve" supply of beds, monitors, 02, fluids to handle a 50-100 patient surge? I know that to some degree stock piles, mobile hospitals and other local and gov't resources exists across the country. But we all know that we must depend on ourselves for at least three days before the feds can arrive to help.

The issue is not supplies, but rather a shortage of nursing. Our nursing shortage is so bad here, that I doubt we could deal with a 10-20 patient surge, much less a mass casualty event.

 

[Jeff698]

The issue is not supplies, but rather a shortage of nursing. Our nursing shortage is so bad here, that I doubt we could deal with a 10-20 patient surge, much less a mass casualty event.

Damn, General, you beat me to it.

Nursing is exactly the issue. Our ICU has 75+ beds. We're currently using around 50 of them. You have to walk past all these brand new, fully stocked, ready to go ICU rooms (complete with flat screen HDTV screens for all the intubated patients...go figure) that are empty because we can't staff them with nurses.

Take care,
Jeff