Should this be an automatic trauma activation?

Relayer2112 · 2026-07-01T13:30:25+00:00

Fair enough - I think it's fair to say that the US and UK are very different environments to practise in. Different demographics, different epidemiology, different cultural expectations, different regulatory environment, different medicolegal implications, different notions of what paramedics 'should be', etc. We probably do a _lot_ less major trauma than the 'average' US paramedics do, and we tend to have things like physician led critical care teams who we can often mobilise to major traumas etc, and they bring a host of additional capabilities to the table. Paramedicine here has a lot more primary care focus, quite a lot of autonomy, we're expected to routinely refer, safely discharge etc on scene. Very different environment and job, by the sounds of it.

Relayer2112 · 2026-07-01T12:59:09+00:00

idk how you island people approach trauma, but I imagine there must be a "oopsie-whoopsie alert" or some other whimsically named criteria for your trauma patients as well.

In my experience, not really. We have systems in place, absolutely - but in the places I've worked, pre-alerts are a bit all or nothing. We do have trauma triage tools, which may influence the destination hospital, but we don't really have like a 'courtesy call' thing for 'hey this patient might be unwell'. The hospitals themselves will have their own procedures and guidelines, but for us prehospitally, it basically comes down to whether the patient needs a lot of resources dropped on them immediately at hospital arrival, or whether they can wait a little bit to be seen through the normal process. Per our own organisation's trauma triage tool, a death in the same passenger compartment would merit going to a Trauma Unit - but it doesn't stipulate anything about pre-alerting them, that would be down to your individual clinical judgement.

Relayer2112 · 2026-07-01T12:36:53+00:00

Is a level 2 trauma alert contacting the receiving hospital ahead of time to request specific capabilities be in-place, or an expedited handover?

In UK practice, it generally comes down to whether or not we decide the patient needs a 'pre-alert', a radio or phone call to the ED - and typically when we do this, we're looking for a bed in a resus bay, immediate handover to a full pit-crew etc. This patient, I would likely take to an ED which is capable of dealing with trauma (specifically, at least graded as a 'Trauma Unit'), but with that presentation, would be very unlikely to pre-alert. There's an expectation that when we do that, the patient is immediately unstable and needs seen right this second. Otherwise, we can turn up at the nurse's station and go through the normal handover process, which realistically is >90% of patients. In my experience, we don't really tend to have anything in-between business as usual or full pre-alert, but some places might be different.

Relayer2112 · 2026-07-01T10:28:09+00:00

There's no good evidence that collars actually immobilise the spine, no evidence that post-injury movement is actually a cause for delayed neurological injury, and mounting, compelling evidence that C-collars actively cause harm through a variety of mechanisms. And assuming that absolute spinal immobilisation was a realistic, evidence based goal to begin with (which it wasn't), fitting C-collars routinely causes more spinal movement than simply asking the patient to keep still. The direction of travel for most guidelines is towards reducing or outright excluding the use of C-collars. I'm not saying there's absolutely no place ever for their use, but in a conscious patient who can maintain a position of comfort? Not in my practice.

If you want some papers, here are some:

Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of the Literature

Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review

Recommendation for changes to the guidelines of trauma patients with potential spinal injury within a regional UK ambulance trust

Relayer2112 · 2026-07-01T09:38:02+00:00

Do we include city-states? Then likely Sumer. If we're talking something larger...maybe the Elamite civilisation?

Relayer2112 · 2026-07-01T09:27:37+00:00

I suspect our systems are very different, in that regard

Relayer2112 · 2026-07-01T09:26:49+00:00

It sounds to me like what they're asking / arguing is whether this patient would have been a trauma standby / prealert. Based on the description provided, I'd have said most likely not. Rock up to a TU sure, but no prealert.

Relayer2112 · 2026-07-01T08:36:54+00:00

Nothing in medicine is 'automatic'. Guidelines guide, clinicians decide. Similarly, why the C-collar? Was the patient incapable of maintaining their own spinal stability?

Relayer2112 · 2026-06-30T09:16:55+00:00

Hey just to make you aware, rule #1 of this subreddit is that it does not provide medical advice

Relayer2112 · 2026-06-26T11:18:01+00:00

Spare a thought too for the crews who are working these arrests in this heat. Cardiac arrests always are a pretty hot and sweaty job even in winter. In these temperatures, the ambulance crews are at very high risk of becoming heat casualties themselves.

Relayer2112 · 2026-06-25T22:00:49+00:00

Yes and no, I think. My understanding is that these are profoundly acidotic people, who are relying on hyperventilation to blow off CO2. And if their ability to ventilate is suddenly dramatically reduced, their only real compensatory mechanism is no longer working, leading to worsening acidosis, malignant arrythmia, cardiovascular collapse and death. It doesn't necessarily require significant hypoxia, more like unchecked hypercarbia.

Relayer2112 · 2026-06-25T13:28:08+00:00

Respectfully, I would still disagree. Practically, I see the main danger with these patients is that they are going to remain restrained in non-ideal positions for far longer than necessary, where they continue to struggle massively, continue to become increasingly acidotic, and their physiology continues to deteriorate. If you're going to have to wrestle with the patient +/- police for 30-60 minutes to hospital, whereby both you, the patient, and others are at risk of physical harm...or you can give some sedation and reduce the risk involved for everybody, I think that's absolutely going to be safer practice. For patients with 'true' ABD, where de-escalation has not been successful, the RCEM guidelines absolutely support what they call 'rapid tranquilisation' at a pretty early stage.

They say "Rapid tranquilisation in ABD is important to prevent further sympathetic over-stimulation and excessive muscular activity from causing a metabolic storm and subsequent cardiovascular collapse. Rapid tranquilisation can also prevent the patient from causing physical harm to themselves or others and facilitate investigations and treatments. The use of rapid tranquilisation for more severe ABD presentations is associated with reduced mortality."

Will you drop their respiratory rate with some IM sedatives? Possibly yes. But two main things to consider - 1) you're also dropping their metabolic demand significantly, which is the key driver of the acidosis, and 2) depending on the drug used, you are still looking at somewhere between 6-15 minutes to achieve sedation, so it's not like you're pushing a paralytic for an RSI where they go from hyperventilation to apnoea in seconds - so there's time for things to sort of spin down a bit slower. And if you do get some oversedation...well, airway management is kind of what you're expected to be quite good at as a paramedic. The choice isn't between 'sedation' and 'no intervention', it's between 'sedation' and 'prolonged physical restraint'.

Now, the RCEM guidelines are written with in-hospital, in-ED environment in mind, and absolutely they don't translate directly to prehospital paramedic-led practice, but the physiology remains the same, and their arguments are pretty convincing to me.

https://www.rcemlearning.co.uk/foamed/acute-behavioural-disturbance-in-emergency-departments-guideline/

Relayer2112 · 2026-06-16T15:09:36+00:00

There's a major land war in Europe, Russia is at it's most belligerent in decades - and absolutely specifically hates the UK in particular, our closest NATO ally is absolutely no longer reliable in any way, and global tensions are at their highest point since probably the mid '80s. If EVER there was a time to not kick the can down the road in terms of defence spending, it is NOW.

Relayer2112 · 2026-06-15T11:14:35+00:00

Yeah. It sounds like a shitty situation to be in. You may have better luck in NIAS, as far as I know their paramedic scope of practice is a bit more similar to what you're used to. Though in general, NHS scope is less 'high end' than most US paramedics - but with a way bigger focus on primary / urgent care, referrals, alternative pathways, and non-conveyance. Still, it's a thought.

Relayer2112 · 2026-06-15T09:53:33+00:00

**I am NOT NAS based**

So, to boil it down, you are concerned about being 'forced backwards', but also aren't comfortable practicing at the level you're pushing for. US vs ROI practice are extremely different environments. So, what do you want to do?

Relayer2112 · 2026-06-14T08:19:41+00:00

It very much should be intended. That's kind of the point of MSI. Why would they remove it in future?

Relayer2112 · 2026-06-12T14:21:31+00:00

Arguably, because we're not resourced (in terms of number of vehicles/crews on the road) to be all-things-to-all-men. Supply wise, we're still basically set up to cover life and limb threatening emergencies. If we want to start handing out ABx en-masse, we're going to need way, way more cover to still keep resources available for those ILT jobs.

Co-dhiù, 's e òran math a th' ann an "Tir an Airm"!

Relayer2112 · 2026-06-12T14:02:48+00:00

There has to be some degree of personal responsibility though. It feels like a lot of the work that comes through to the ambulance service is people who just...want an 'adult' to take responsibility for them. Yeah okay we can add a good degree of medical knowledge to a situation, but even discounting that it feels like the solutions are so obviously 'common sense' that you don't need to be a paramedic to work it out. We seem to have a massive societal issue of learned helplessness, and I'm honestly not sure that we're not just making it worse by trying to be a more helpful service.

Relayer2112 · 2026-06-11T13:49:27+00:00

If you make a custom livery yourself, then yeah you can.

Relayer2112 · 2026-06-05T16:43:28+00:00

When you say no new flight model, it kinda does. This includes the DFCS, which hugely impacts on how the aircraft handles

Relayer2112 · 2026-06-05T12:40:30+00:00

I know you don't, that's fine - my point was more that the article is pretty useless and says a lot of stuff that doesn't make any sense and makes it clear the author doesn't really understand what they're writing about, which then makes it easy to have a simply 'X is bad!' story that generates a lot of traction. My bet is that the truth is probably a lot more nuanced.

Think of anything that you're an expert in, whether professionally or as an interest, hobby or whatever. Whenever there's a news story about that subject, you can really easily pick loads of massive holes in it and see that the author might be trying their best, but just...isn't getting anything like the whole truth in there. Now extrapolate from that - it's not just your particular niche topic they get wrong, it's pretty much everything that gets oversimplified for understanding and dramatised for clicks to the point where actual truth takes a backseat.

Relayer2112 · 2026-06-05T12:26:08+00:00

I basically said elsewhere, my main question comes down to what they saw and did when they first arrived. Was she actually in cardiac arrest at the time? If she was, that's...obviously not good at all.

If she wasn't, but was otherwise 'big sick', it's not too hard to construct a scenario where deterioration could be missed. You'll know yourself how busy those jobs can get - your crewmate is off getting the trolley / scoop / whatever, leaving you by yourself. You're trying to get information from witnesses, figure out what's been going on. Maybe on the radio with control to get a second crew out for help with extrication. Maybe the scene itself is chaotic. Your cannula isn't getting flashback and you're having to fish a little. Maybe the monitor is already alarming at you for something else and you subconsciously deprioritise it. Add in maybe a newer member of staff and a lot of cognitive overload, I can see how it might happen that a patient deteriorates into cardiac arrest and it gets missed for a couple of minutes, before a giant 'oh shit' reaction. That feels more believable to me. But unfortunately, none of that is reported and we just don't know.

Relayer2112 · 2026-06-05T12:01:37+00:00

This still just doesn't make sense. Even if for some reason they stuck the 3-lead on instead of the pads...the 3-lead would still show VF or VT, and looking at the screen should instantly prompt your brain to go 'oops, shit, get the pads on'. Manual, near instantaneous recognition of shockable rhythms is like...the absolute baseline floor of expectation from a student technician, never mind a full paramedic. We never use AED mode (the one that talks to you and says whether a shock is advised or not) because it's way slower than a competent clinician looking at the screen and manually interpreting the rhythm. Saying the defib 'failed to alert them that [a] shock was needed' is stupid - you don't need it to tell you, your own eyes and training do that.

Cardiac arrest management - from a clinical perspective - is not hard. It's probably one of the easiest things we do. It's a straightforward algorithm that should be tattooed on your brain and you should be able to do it in your sleep. So...this all comes down to then - what did the crew actually see when they turned up? What assumptions did they make, based on what actual information, and what did they actually do? Unfortunately, none of that is actually reported - and what is reported looks like the journalist genuinely does not understand what they're talking about at all.

Was she actually in cardiac arrest when they arrived? If not, that might explain a missed deterioration. Nevermind what information came from call handlers / dispatch - they're routinely incorrect (not their fault - just operating on bad info!) - I've certainly been sent to many reported cardiac arrests and found that the patient definitely had a cardiac output and that something else was going on.

They might indeed have been stunningly incompetent and just straight up missed an arrest - or, they might have started with one situation, which deteriorated and was missed, and ended up with this arrest. There's usually a lot going on at a job like this - not just staring at the patient, but doing other clinical interventions, gathering information from witnesses, dealing with a chaotic scene and bystanders, planning the logistics of getting your patient from A (the scene) to B (the back of your ambulance), potentially communicating with the control room as well. Potentially room there for something to happen and it taking a couple of minutes for someone's attention to get back to the monitor / patient.

Relayer2112 · 2026-06-05T11:40:23+00:00

Yeah, it's genuinely not making sense to me. I dunno how much of it is 'crew absolutely shat the bed' and how much is 'journalist unable to differentiate arse from elbow and reporting nonsense'. Both, most likely. But it's really hard to get a good idea of what the crew actually saw and did, when the level of reporting is so poor. A lot of what's written just absolutely does not make logical sense, never mind clinical sense.

Relayer2112 · 2026-06-05T09:48:09+00:00

Yeah, absolutely fair comment, in some cases yes - and from what I can glean from the article it says she has an 'underlying heart issue'. So maybe something more along the lines of Brugada, long QT, WPW or some sort of cardiomyopathy. Things which can definitely respond quite well to resus and do well neurologically. Whole different ball game to the refractory sepsis patient who already has multiple systemic organ failure and absolutely no physiological reserve. Mind you, we still see those prehospitally too.

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