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Part II
Trauma Team Design
Out-of-Hospital Care fromParamedical
toNon-medical Personnel
RyanShelton andMatthewBrock
17
Origination
Prehospital care has progressed signicantly since the rst
documented ambulance services, organized by Napoleon’s
chief military physician, Jean Dominique Larrey. Just as
EMS began in the military, today’s latest lessons learned in
trauma remain revolutionized by the military. In recent years,
the United States Military has put a signicant emphasis on
advancing higher levels of care to the point of injury. The
goal of all medical treatment is early effective point-of-injury
care, transport/extraction, and surgical stabilization at denitive care. For the traumatized patient, this often means a
Level 1 Trauma Center. The role of EMS is much more than
transport. Appropriate point-of-injury care completed correctly does not lead to a delay in reaching denitive care.
What My Trauma Doctors Need toAppreciate
The complete trauma team dynamics concept, or “One
Team,” as the Colonel Jim Barren of the United States Army
team eloquently understood, translates to the medical arena
by incorporating key fundamental accomplished objectives
to stabilize every trauma patient. The totality of care in a
vibrant healthcare system has the entire system of trauma
care providing competent care at each level of certication
Matt Brock has been a professional reghter and a paramedic for over
20 years. Over his career, he has been a part of multiple special teams,
including USAR, ARFF, HAZMAT, Peer Support, and Pipes and
Drums. Matt has been a primary instructor for an EMT-B course for
over a decade and remains passionate about not only developing skills
but also building resiliency.
R. Shelton (*)
University of Colorado Hospital, Anschutz, CO, USA
e-mail: ryan.shelton@uchealth.org
M. Brock
South Metro Fire Rescue, Centennial, CO, USA
e-mail: Matt.brock@southmetro.org
and licensure. This can only be done through a sustained
relationship of education and preventative upkeep in the
form of continuing education (CE) from the surgeon to the
prehospital providers, which includes rst responders, emergency medical technicians (EMT), and paramedics.
Paramedics will act quickly in trauma crisis, adapt to lessthan- ideal conditions, and operate effectively on critical
trauma patients with limited personnel and resources to
depend on. Their prehospital environment is heinous at times
with challenges of weather, hazardous materials, patient
access, extrication complications, and extended patient
transport times with hemodynamically unstable patients, and
they must consistently operate with comfort in an uncontrolled environment with difculties of crowds, including
violent rapidly erupting scenes. It is important that hospital
providers understand prehospital protocols and their limitations with protocols and equipment, while appreciating the
environmental constraints they perform their skills in. Many
EMS have elevated levels of training in high-performance
teams and can manage septic patient in ARDS necessitating
9 IV infusions, vasopressors, chemical sedation, and
advanced airway control with two crew in the small quarters
of a helicopter or xed wing, usually staffed by one paramedic and a ight nurse. Cutting-edge prehospital agencies
have progressed to utilizing point-of-care-ultrasound
(POCUS) to determine termination of resuscitation (TOR),
tension pneumothorax conrmation, guided pericardiocentesis, resuscitative endovascular balloon occlusion of aorta
(REBOA) zone conrmation, evaluation of inferior vena
cava for congestive heart failure, and FAST exams to determine the most appropriate trauma destination. In addition to
a widening scope into midlevel knowledge, skills, and abilities (KSA), the prehospital environment continues to evolve.
Take the SWAT Paramedic that is staged at a peaceful protest, suddenly turning violent, creating a single gunshot to a
patient’s mandible necessitating an immediate cricothyrotomy. No hesitation and seconds away security protocols are
executed followed by immediate advanced patient care by
the SWAT paramedic. What rst responders and paramedics
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_17
121
122
R. Shelton and M. Brock
do with bleeding control, airway management, or patient
temperature management all affect the viability of the
patient. Their care can determine whether enough time has
been preserved to reach the operating table. The evolution of
agencies across the nation is using metrics that capture continuous competency for each paramedic through generated
reports and quality assurance programs. Highly functioning
Emergency Medical Services (EMS) systems track the rst
pass success and total intubation rate for each paramedic and
system-wide success. In most cases, because our education
is not proportionate to our responsibilities and the autonomy
related to patient care, a heavy emphasis is placed on capturing procedural statistics and performance metrics for patient
protection. The paramedic provider will continue to take on
more midlevel scope of practice by necessity of our healthcare system. Cultivating professional relationships of mentoring and education with the prehospital providers of trauma
care is imperative. EMS agencies are evolving to becoming
evidence-based in their care, like the rest of the eld of medicine and appropriately so. A high-performance trauma team
has no metaphoric walls, and it is inappropriate to operate in
silos. It is a choreographed, trained, and performance-driven
team responsible for performing within the standard of care
maximizing trauma patient survival from the moment the
rst trained provider is at the patient’s side until recovery.
Some medical directors adopt the recommendation from
national or state regulatory bodies, while other physicians
approve protocols that are either more progressive or more
conservative. For these reasons, it is unrealistic to rely on one
training curriculum to dene the expected standard of care
for an EMS system. Instead, the trauma system should look
at the evidence-based treatments for trauma patients and
determine what can effectively be implemented by the local
EMS agencies based on their level of training and equipment
carried.
The medical director sets protocols. There are two forms
of protocol orders: direct and standing orders. A direct order
is obtained directly from the agency afliation hospital of the
medical director by any staffed ED physician. They can
approve the requested procedure or medication after receiving a patient report and requested order by an EMT or
Paramedic. All procedures and medications that receive
approval from the base must be within the scope of practice
for that level of provider or have a waiver in good standing.
A standing order is an ongoing automatic protocol that
allows the paramedic or EMT to provide care within those
specic protocol conditions with complete autonomy.
Certication or Licensure
United States Prehospital System Legal Structure
Each state has regulatory power to dene a scope of practice
for each level of certication that was developed by the
National Highway Trafc Safety Administration (NHTSA)
standard curriculum. Through the extension of a medical
director’s licensure, he or she may delegate authority from
the state’s approved scope of practice list, which includes
specied pharmacology, procedures, and protocols within
the medical director’s local jurisdiction. There are special
circumstances where the medical director may petition the
state for a “waiver” if a procedure or medication is not on the
state’s list of acts allowed as a specially approved practice
for Paramedics. In that case, the designated state oversight
body will allow or reject the waivered request and, if
approved, will allow the agency to perform the procedure or
medication administration for a specied amount of time.
This provides the state with gross oversight and the ability to
evaluate trends that may need to be incorporated into the
future acts’ allowed list, control the complexity and frequency in which a higher skill beyond core curriculum education is performed, and data collection with appropriate
reporting to ensure patient safety for skills typically falling
outside the acts. Each agency is required to have a medical
director who is responsible for the agency-specic protocols.
The certication process for First Responders/Emergency
Medical Responder, Emergency Medical Technicians
(EMT), Advanced EMT, EMT Intermediate, Paramedics,
Community Paramedics, and Critical Care Paramedics represent a minimum competency for certication but do not
accurately reect the expectations or capabilities of that
same provider once they begin working for an agency. As
you can see, there are six levels of prehospital medical providers. These levels of practitioners are complicated and
widely variant by state, predominately based on land area
make-up (urban, rural) and cost feasibility for the providers.
The most functional information is to demonstrate the variance from the lowest level of certication/licensure to the
highest level by comparing their scope of practice. The rst
segment will cover acts allowed for a First Responder or
Emergency Medical Responder, which remain mostly in
rural volunteer settings and have minimal training, followed
immediately by a Critical Care Paramedics scope.
Emergency Medical Responder/First Responder Scope of
Practice:
1. Perform initial, focused, and ongoing assessment
2. Provide respiratory assistance utilizing oral and nasal
airways, and oxygen delivery system components
3. Apply suctioning techniques to clear airways
4. Apply dressings and bandages for wound care
5. Apply splints and immobilization devices
17 Out-of-Hospital Care fromParamedical toNon-medical Personnel
123
6. Apply spinal immobilization devices
7. Provide care for obstetrical emergencies including
assisting in childbirth
8. Provide ordinary reasonable care for ill and/or injured
persons in accordance with established regional
protocols
9. Utilize automated debrillators in accordance with
established regional
protocols
10. May serve as attendant-in-charge on an EMS VehicleClass A
11. May serve as vehicle operator
Critical Care Paramedic Scope of Practice:
1. Video and direct oral laryngoscopy rapid sequence
induction (RSI)
2. Supraglottic device insertion (e.g., LMA or KING
airway)
3. Needle and surgical cricothyroidotomy
4. Chest/lung compromise needle, simple, and tube thoracostomy with drainage system initiation and
management
5. Mechanical ventilation initiation and management of all
modes of ventilation; to include but not limited to: high
frequency oscillating; volume, pressure, and dual-mode
ventilation; non-invasive positive pressure ventilation
6. Cardiovascular management of ventricular assist device
(VAD): including but not limited to: percutaneous or
central LVAD, RVAD, and BiVAD
7. Management of extracorporeal membrane oxygenation
(ECMO) with or without heater/cooler capability
8. Intra-aortic balloon pump (IABP) counter pulsation
9. Perform and interpret 12 Lead ECGs with catheterization lab activation capabilities
10. Intraosseous access (e.g., EZ-IO or FAST1)
11. Indwelling port access (e.g., Hickman, Port-a-Cath, etc.)
12. Transcutaneous, transvenous, and epicardial wire pacemaker capabilities
13. Pericardiocentesis
14. Invasive hemodynamic monitoring (e.g., CVP, pulmonary artery pressures, abdominal pressures, arterial pressures, intracranial pressures)
15. Blood/uid warming devices and blood product administration (e.g., whole blood, PRBCs, plasma, platelets)
16. Operation of single and multi-channel infusion pump(s),
including but not limited to Intravascular, intraosseous,
intrathecal, and intra-arterial routes
17. Cardiovascular Doppler/ultrasound monitoring
18. Arterial cannulation, radial and/or femoral
19. Central venous cannulation, femoral, subclavian, and
internal jugular
20. Wound closure including but not limited to: suturing,
stapling, skinglue
21. Laboratory sampling, point-of-care testing, result interpretation, and treatment
22. Non-invasive tissue oxygenation monitoring
23. Hemorrhage control including but not limited to: tourniquet use, chemical clotting agents
24. Asherman chest seal
25. Tranexamic acid (TXA) and plasma administration
26. Gastric tube placement and management
27. Urinary catheter initiation and management
28. Ability to calculate and independently administer medications applicable to the critical care environment and
covered in protocols, guidelines, or standing orders:
(a) Vasoactive agents, paralytics, anxiolytics, anti-
inammatory, anticonvulsant, narcotics, anesthetics, thrombolytics
(b) Inhaled gases: Heliox, nitrous oxide, nitric oxide,
anesthesia gases
(c) Nebulized medications
(d) Antiemetic, antibiotics
(e) ACLS medications: Epinephrine, lidocaine, atro-
pine, anti-arrhythmic
(f) Electrolytes: Potassium, magnesium, calcium
(g) Prostaglandin
(h) Surfactant blood and blood products
(i) Tranexamic acid (TXA)
29. Radiographic interpretation
30. Perform and interpret ultrasound imaging including
utilization for placement of medical devices, i.e.,
REBOA
31. Ability to manage and transport any indwelling medical
device
32. Invasive and non-invasive temperature monitoring
33. Initiation and management of non-invasive and invasive
thermoregulation device
34. Thoracic and extremity escharotomy and fasciotomy
35. Fetal heart/uterine monitoring
36. Umbilical vein/artery cannulation
37. Surfactant administration
38. Esophageal compression tubes
39. Peri-mortem cesarean section
40. Suprapubic cystostomy
41. Esophageal cooling tubes
Association of Critical Care Transport—Critical Care
Transport Standards—Version 1.0 ©2016 [1]. The CCT provider may be required to perform skills not otherwise listed
in this document via direct or video remote medical oversight. Based on the CCTA’s patient population, the need for
these skills should be anticipated and included in training
and competency assessment.
124
R. Shelton and M. Brock
Paramedic Structure inCanada
Paramedics in Canada are certied as either a primary care
paramedic (PCP), a critical care paramedic (CCP), or the
advanced care paramedic (ACP). In order to become a para-
medic, the applicant needs to successfully complete a course
of training which can vary in different provinces.
Levels ofParamedics inCanada
• Primary Care Paramedic
The PCP is at the entry level of the paramedic profession,
with duties that include providing basic medical care, the
administration of oxygen, administering IV, cardiac monitoring, semi-automated external debrillation, administering
medications such as aspirin, epinephrine, nitroglycerine, and
more for emergency conditions, as well as performing
trauma immobilization. If the PCP receives additional training, he or she is authorized to provide medical care on the
level of the Advanced Care Paramedic, or ACP.
To become a PCP, the prospective paramedic must take
the two-year Primary Care Paramedic Program of training
and pass the provincial PCP exam, after which the successful
graduate can obtain employment at an ambulance company
or a medical institution, rst obtaining the approval of the
local medical director.
• Advanced Care Paramedic
Although jurisdictions and provinces such as New
Brunswick and Quebec don’t have ACPs, Advance Care
Paramedics are greatly in demand in Canada’s health professions. ACPs are qualied to carry twenty different medications, although those medications may differ signicantly
from region to region. ACPs are also trained to perform intubation and intravenous therapy, place external jugular IV lines,
perform needle thoracotomy and obstetrical assessment, and
administer pain relief. An innovation in Canada that has had a
profound effect on patient survival rates allows ACPS discretionary direct 24-h access to cardiac catheterization labs labs,
bypassing the hospital emergency departments.
Before becoming an ACP, the paramedic must work as a
PCP between 6 and 24months. The applicant needs to complete the 1200-h ACP training program, passing all required
exams and certication programs as required by the Canadian
province in which the paramedic is employed.
• Critical Care Paramedics
CCPs have prior experience working with ambulances
and responding to 911 emergency calls. A CCPs expertise is
focused on the critical and intensive unit level care, stabilizing, and transporting patients in hospitals with limited
resources to programs that can provide a higher, and in many
cases, lifesaving, level of care. A CCP provides care that
would otherwise be administered by a physician or nurse. In
addition to providing the care levels that are administered by
PCPS and ACPs, the CCP is trained to administer medication
infusion pumps, mechanical ventilation, and monitor arterial
lines.
To be eligible forthe CCP program, which takes a year to
complete, the applicant must have worked for one year as an
ACP, be certied in basic trauma life support and advanced
cardiac life support and have aeromedical certication.
As you can see there is a chasm of disparity between the
protocols at each level, all grounded by the providers’ education, training, knowledge, skills, and abilities. It is up to system administrators to know their local prehospital care
limitations.
Science Behind Prehospital Injury Patterns
Largely accepted is the concept of irreversible death in the
“immediate” time frame after injury, usually occurring prior
to EMS arrival or very shortly thereafter. This is followed by
the second peak in the trimodal distribution known asearly
trauma deaths. This mortality is generally estimated to be
around 20-30% [2, 3]. This is where well-choreographed and
high-performance prehospital team trauma care can have the
greatest impact and is the greatest reversable cause of death
post-traumatic injury.
With chest and head injuries leading in patient presentation, providers must be competent with both endotracheal
intubation and chest decompression or nger thoracotomy.
These are statistically where training will have the most
impact on patient outcomes. Unfortunately, many areas
struggle with intubation successes, both endotracheal and/or
nasal. In business classes, they teach to measure what matters. Here, success in intubation matters so training programs
that better identify the airway challenges of every patient
encountered and translate that into more successful intubations are preferred. Although volume for skills is down per
provider within the 911 system, with evolving technology
there is the ability to create life-like task trainers, life-like
human-worn simulators for immersion training, 3D-printed
anatomy models for skills drills, and both embalmed and
ash-frozen cadavers for realistic sequencing and experience
training (Fig. 17.1). Each serves a purpose and needs to
progress the following route to achieve competency:
We will discuss making an impact reecting where the
data dictates. For trauma patients younger than 65 years,
there are nine prehospital deaths for every in-hospital mortality. One estimate suggests that in 2014 alone, 30,000 of
147,000 trauma deaths may have been avoided with timely
17 Out-of-Hospital Care fromParamedical toNon-medical Personnel
125
•Individual skill
•Demonstrate correct sequence of skill
•Demonstrate fundamental understanding of goal with
the skill
•Low stress on the provider
•Can only be used as a foundaonal means of training
•Appropriate Modes: Task trainers, low to mid fidelity
manequins, and cadavers
•Ability to perform under pressure with individual paent
•Totality of care prioroized based on paent presentaon
•Mild exeron of stress on provider
•Allows for coreograph of a team of providers for effecient care
•Verificaon of sequencing with individual skill while correctly
placing skill into sequence of total paent care
•Will idenfy equipment incompatabilies
•Appropriate Modes: standardized paents medical or trauma
if conscious, trauma if unconscious, mid or high fidelity for
medical unconsciuos, and worn tainers on standardized
paents conscious or unconscious
Drills
Fig. 17.1 Skills and stress progression corollary. Marks the progressions from static skill mastery under minimal stress to complex deployment of knowledge, skills, and experience for uent intervention of
hemorrhage control [4]. Timely hemorrhage control is a
medical intervention that can be performed by both paramedical and non-medical personnel alike. Direct pressure,
elevation, and appropriate tourniquet placement are skills
taught within basic life support and advanced life support
training. These simple interventions can and should be performed long before the patient arrives at the trauma center. In
trauma protocols worldwide, control of massive hemorrhage
is listed as the rst action to be considered and performed if
necessary. In the International Trauma Life Support for
Emergency Providers, this is laid out using the acronym
C-ABC (control bleeding, airway, breathing, circulation). In
Tactical Combat Casualty Care Training, this is emphasized
using the MARCH acronym (Massive Hemorrhage, Airway,
Respirations, Circulation, Hypo/hyperthermia). Paramedical
and non-medical personnel play a very large role in external
hemorrhage control. External hemorrhage is the easiest to
recognize, as the bleeding is both signicant and visible.
Concepts inParamedic Education
Team Synergy vs Rock Star Player
This is an interesting concept for team dynamics and likens
to the nature vs nurture debate. In our environment which is
most important: a rock star paramedic that can do any skill
and catch any abnormal patient presentation or a team with
synergy that as individuals intelligence, skill level, and experience is simply average? I have spent thousands of hours
Scenario
Training
•Ability to show mastery of
resources on scene while managing mulple
paents and mulple skills through idenfying the
correct sequence of crical needs
•Exerts a high level of stress on the provider equal to
the environment expected to perform in
•Will always have mulple vicms
•Hollywood style scene to mimic sight, smell, hearing,
touch, and kinec movement
• Will unmask providers weaknesses
•
Measures teams crical errors
•Will idenfy system errors in protocol or operaonal
deployment eneffeciencies
•Appropriate intervenons with appropriate trigger
me performance met
all skills and coreograph
Immersion
Training
critical factors that maximizing stabilization increasing survivability in
the most challenging environment with multiple patients in a truly
dynamic environment. (Source: Shelton 2024)
teaching thousands of initial certications for EMT through
paramedic and continued education for all prehospital ranks.
I can tell you it is impressive to watch a rock star train and do
nearly everything by him or herself hitting every benchmark
along the way; however, human error increases outside of
group dynamics, and the time to critical skills is also much
slower for accomplishment. Team synergy is the most important aspect in trauma resuscitation.
Double Checking Is aSign ofRespect
As we talk about this concept, I originally heard it from
Steve Markham, 23 years Navy, 19 as Reconnaissance
Corpsman with the Marine Corps. It is simple and utilizes
the trust and verify concept. The concept comes from a wellintended process to be at the core of any highly functioning
team. On all critical tasks, this should be performed. It is
preventative in nature, not in the heat of battle. Double check
each other with equipment checks, procedural drills, protocol quizzes, and competency scenario performance. The success of the team depends on your preparation.
Medical Errors
In 2016, an article in the British Medical Journal written by
Martin Makary and Micheal Daniel, titled “Medical Error:
The Third Leading Cause of Death in the US,” it estimated
251,000 deaths per year were at the hands of medical
professionals. This number has been likened to a 737-plane
crashing every day, but the math works out to metaphorically
crashing over four 737 aircraft with total human life lost
126
R. Shelton and M. Brock
every day in the USA.The reason it is frequently compared
to the aviation industry is because at one point the aviation
industry struggled with increasing examples of human error,
climbing crash rates and unacceptable fatality totals. The
expert analysts and statisticians for the industry extrapolated
that at current growth rate of the aviation industry compared
to the amount of human error, there would be one plane crash
per month. It was decided within the aviation industry that
the projected rates for catastrophic human loss were too
great and that aggressive steps needed to be taken to make air
travel the safest means to travel. This gave birth to concepts
of human error reduction, critical check lists, subservient
cultural training, communication training, protocol development, annual competency evaluations, and mentored coights. The Guardian published that forty commercial
passenger planes crashed in 2020 for a .27 fatal accident per
million ghts. To accomplish such a safety record, the airline
industry moved to a risk-based decision-making model with
strong regulatory oversight and an incredibly active safety
culture within the industry. DeLine Box and Display of
Denver has a 2–5% variance with paper material. This allows
for human error, humidity, and temperature differences as it
reacts with the paper products all to nish with a product
within 1/16 of an inch variable. It is important to know your
error rates and is a measured standard in nearly every other
industry except healthcare, from making packaging to safety
in ight. Measuring error is a fundamental principle in highperformance team dynamics and plays a critical role in the
reduction of human error. In Hyper-realistic, Team-Centered
Fleet Surgical Team Training Provides Sustained
Improvements in Performance, authored by Tuan Hoang, two
critical discoveries were made studying team dynamics: 1.
Time for skills performance decreased from 11min±3min
to 3min±1min and 2. Error rates drastically dropped from
4 errors ±1 to 1 error±1 error. This was directly attributed
to a formalized course showing value in improving “teamwork and communication skills of participants” [4]. This
course was completely immersive, and every skill had to be
performed in realistic conditions. The medical eld must follow an example set by the airline industry with a purist safety
culture where our performance is measured and trended.
Controversy What Should Our System Implement
resources in personnel and equipment can lead to scene
departure delays. The identied need for hemostasis or airway/ventilation maintenance should take priority. However,
these processes do take time, which is at a premium in the
traumatized patient. One of the more time-consuming steps
is patient extrication and packaging. Removing an injured
patient from a vehicle involved in a collision is inherently
time consuming and takes signicant personnel and energy.
Current rescue dogma is no longer “removing the patient
from the vehicle,” but rather “removing the vehicle from the
patient.” This is confounded with an environment of inclement weather, poor lighting, and patient and/or bystander distress. Much of the principles prehospital practitioners follow
in managing the trauma scene, and patient is outlined in
established curricula in courses like International Trauma
Life Support (ITLS) or the American program Prehospital
Trauma Life Support (PHTLS). Historically, prehospital
care has evolved into paramedical personnel that perform
many of life-saving procedures once only employed in hospitals. Procedures like intravenous volume resuscitation or
better yet whole blood, needle decompression, and endotracheal intubation can be utilized in the eld and delivered to
the traumatized patient at the point of injury. Many innovative EMS systems adopted and trained their personnel in
these skills and encouraged their use. As evidence-based
evaluation of practice migrated to the prehospital world and
greater scrutiny was employed, EMS medical directors and
practitioners have had to change their standards of practice.
With the evolution and increasing sophistication of EMS
systems, medical evidence has weighed in on prehospital
care management strategies in trauma. The ongoing debate
of “load and go” versus “stay and play” is moot. A strategy
of “scoop and treat” is preferred. In the United Kingdom and
parts of Europe, physicians can be part of the EMS response.
However, even in these systems, where advanced therapeutics and procedures are possible due to the physician present,
all practitioners will appreciate that patients need to be transported rapidly from the scene onto a trauma center for denitive care as soon as possible. There will be inherent delays in
patient extrication and packaging. Skilled and rapid clinical
assessment and patient care should be performed enroute
with minimal scene time as the goal. Procedures to optimize
the airway, breathing and circulation should be accomplished
with minimal delay in transport.
“Scoop andRun” Versus “Stay andPlay”
The out-of-hospital environment is austere which poses
many challenges to initial responders. While principles like
“load and go,” which minimize scene time and rapid transport to denitive care, are strived for, the reality is the trauma
scene is chaotic with multiple competing interests. Limited
Airway Management Controversy
withParamedics
Conicting evidence has weighed in on prehospital airway
management, which since inception has been the hallmark of
the paramedic. There is some evidence showing higher mortality with prehospital intubation of traumatic head injuries
17 Out-of-Hospital Care fromParamedical toNon-medical Personnel
127
[5]. As a result, there has been a push by some within the
medical oversight community to deemphasize airway capture utilizing rapid sequence intubation strategies in the prehospital environment [6]. Furthermore, a recent prospective,
randomized, controlled trial showed that prehospital rapid
sequence intubation by paramedics increases the rate of
favorable neurologic outcome at 6 months compared with
intubation in the hospital [7]. It is outside the scope of this
text to discuss what a specic agency’s protocols should be.
This conicting data allows assessment of not only the paramedic providers but also their role within the entire trauma
team. However, these two conicting studies illustrate a crucial point. The skills, protocols, and effectiveness of EMS
systems are variable. As a member of a trauma team, it is
crucial to know the protocols and capabilities of the specic
EMS systems within that trauma team. With the increase in
professionalism and competencies at many prehospital re
departments and EMS agencies, intubation can safely be
done in trauma patient care while maintaining prociency of
the skill via tracking of current global agency system success, as well as individual intubation success. This is done
through metrics of quality management knowing the systems
performance compared to its benchmark for the following
criteria: rst-time pass, successful intubation acquisition,
and second-by-second tracking for capnography during intubation. The system average then gives a direct reection on
your training modality performance. This assures the safest
known intubation training, standards, and performance of
intubation on our most critical patients of trauma.
It is imperative that the research surrounding a procedure
is critically evaluated with the capacity’s providers in mind.
Common arguments against prehospital advanced airway
management include potential delay in transport, studies
showing an increase in morbidity or mortality, the belief that
EMS providers should wait for the procedure to be done by
emergency physicians due to their expertise. Within certain
trauma systems, these concerns are valid. However, prehospital advanced airway management can be performed in the
prehospital setting without delaying transfer to a trauma center [8, 9]. When performed by skilled emergency medical
services (EMS) providers, advanced airway management is
associated with a signicant decrease in mortality [9, 10].
While it is possible for EMS to wait for the emergency physicians to perform the intubation, in the hospital setting,
delayed intubation is associated with increased mortality in
non-critically injured trauma patients [11].
The Eastern Association for the Surgery of Trauma
(EAST) practice guidelines on Endotracheal Intubation
(ETI) immediately following trauma address this contradictory evidence by saying, “No conclusion could be reached
regarding prehospital intubation for patients with traumatic
brain injury, with or without RSI [rapid sequence intubation]. Diversity of patient population, differing airway algo-
rithms, various experience among emergency medical
service personnel in ETI, and differing reporting make consensus difcult” [12].
From the above discussion, we learn that when implemented correctly, advanced airway procedures can be a lifesaving and morbidity-reducing procedure. For this reason,
endotracheal intubation is the standard of care for denitive
airway management in hospitals. When not effectively
implemented, advanced airway procedures can end up doing
more harm than good by prolonging hypoxia and delaying
transport to denitive treatment. There is no indication that
the prehospital intubation under the same training and verication procedures is any less impactful. Depending on
national, state, and local protocols, a traumatized patient
may be received by the trauma team with a wide variety of
treatments performed. The Trauma Team should compare
the literature with an honest introspective look into the
trauma team’s capabilities proved by hard numbers of success and failure. The goal of this conversation should be to
maximize the efcient treatment, transport, and denitive
management of each patient. This involves specic patientcentered protocols based on the capabilities of the EMS system, the local hospitals, and the distance from scene to a
trauma center. In one area, a trauma team may receive a
patient from the eld who has undergone Rapid Sequence
Induction followed by being placed on a portable ventilator
for a head injury. Another trauma team may receive a traumatized patient directly from the eld with only bag valve
mask ventilation, the use of supraglottic airway devices, or
patients with decreased level of consciousness (GCS< 8)
with only supplemental oxygen. Regardless of how the
patient arrives, obtaining or conrming denitive airway
management, including endotracheal intubation, by receiving trauma teams will need to be a priority.
To Fly or Not toFly
There are only three circumstances that helicopter transport
benet patients using evidence-based assessment: (1) when
time out of physician care is crucial to either patient stabilization efforts or patient survival; (2) if patient access is not
available by other means in a timely fashion and the patient
is unstable; and (3) if a helicopter has performed a cold landing at a predetermined rendezvous point between the transporting ambulance and trauma center with the load time
factored and determined shorter than the ambulance to continue ambulance transport (trafc, time of day, construction).
Helicopters are a valuable tool in a trauma system, but it is
one of the most misunderstood tools when we look at
evidence- based support. Helicopters are most useful for a
rural population for the transport of critically ill patients to a
larger center [13].
128
R. Shelton and M. Brock
Training Quality
In the book, Outliers by Malcom Gladwell, there is a themed
concept of the 10,000-h rule as a benchmark for mastery.
This was a false conclusion that Gladwell drew from Anders
Ericsson’s research published in The Role of Deliberate
Practice in the Acquisition of Expert Performance. Not only
was this a misinterpretation of the most important part of the
conclusion, but it also took what was a fractionalized concept of hours to aid in expert performance and made it the
sole contributor to achieving expert performance. Ericsson’s
conclusion hinged on a concept of the high quality of instruction and the transferability from the training environment to
the expected execution environment with striking similarities as the greatest contributor to mastery. Hours to mastery
were discussed at length, but there was no basis for 10,000h
as the actual hour calculations varied from 4000h to 7000h
without repeated correlation within the research subjects.
What matters is simple, as a Paramedic you are expected to
do complex tasks in all environments, with varied critical
physiological patient presentations, unfavorable weather
conditions, and under challenging circumstances. Why do
your task trainers exist on a table in a room set at 70 degrees
under great lighting? Why do we ever have an intubation
mannequin on the table? We should not, it does not represent
the expected environment we perform in. Your training has
set you up for failure if it is not realistic. Human error can be
minimized with as realistic as possible training. Each standardized patient must be physiologically modeled after real
patients.
Case Study ofEective Trauma System
Training: Before theNeed
The call came in as a possible shooting in a school in our
district. The number of units that were called seemed neverending. The immediate rush of adrenaline as I heard the
tones and information on the radio was nauseating. This was
not another training. My mind rushed to make sense of the
information and began to create a mental list of what needed
to be accomplished. I looked at the MDT to see who was
responding, where would I be in the list of units, what might
I be assigned to accomplish?
Information that there may be multiple victims and multiple shooters. The rst police ofcers arrived within 2min
and immediately broke into contact teams seeking the shooters. Within 3min, ofcers made contact with the shooters
and were already providing aid to multiple gunshot victims.
Dispatch was getting multiple callers and attempted to make
sense of the deluge of information to assist responding units.
Students were eeing the scene, some injured victims, and
were desperately seeking safety on this tragic day.
While I drove emergent cars with worried parents followed me as if I was towing them, no doubt trying to make it
to help their children. A father myself, with school-age children at a different school not more than a mile away, I understood and felt their pain as I pulled onto the scene. Police
were stopping the parents to keep them from going any
closer and I could see them screaming at the ofcer in my
rear-view mirror. I parked out of the way to maintain egress
for the likely transports to come. As I donned my bulletproof
vest and tactical helmet, I could hear screaming parents begging to be allowed to come into the school to nd their children. I will never forget the sound of desperation I heard that
afternoon.
The sheer number of people and responding vehicles
that were at this call was overwhelming. It was difcult to
make my way to command to do a face-to-face and get my
assignment. Multiple re engines and trucks were parked
well away with the crews already making their way to the
scene. Ambulances were staged so that they could take any
patients being extracted from the building. Police vehicles
were parked near the school, but clear of the road to allow
for transporting ambulances to get through. Students were
being evacuated in groups, hands in the air, escorted by
police in tactical gear. The injured were starting to be
extracted from the building to the Casualty Collection
Points (CCP).
It was 24min from the initial 911 call until the last injured
patient was transported from the scene, which had ed from
the building seeking safety. The 911 call to the rst Fire/
EMS Rescue Task Force entering the building was 11min
with a transport time from Fire/EMS arrival of 4min and
32s for the rst two critical patients. Four South Metro Fire
Rescue Paramedic Ambulances transported all patients
within 13min of Fire/EMS arrival. Enroute, the victims were
treated with skill and precision that helped ensure the best
outcome. The hospitals that received these patients were
ready and triaged immediately upon activation of the
Emergency Management Systems linking prehospital patient
needs to hospital resource availability. Each victim, regardless of the hospital, was treated quickly and effectively prevented any further loss of life.
The entire time the radio never stopped buzzing with trafc as command skillfully brought the call rst to incident
stabilization with no further loss of life, then to an end. With
all the victims at the hospitals and the shooters arrested, the
rst phase of the scene came to a close and all those involved
began to process what they experienced. Parents began to be
reunited with their children down the street at a nearby
church.
Tragically, one student was killed instantly on scene,
Kendrick Ray Castillo, after he attempted to stop one of the
shooters. His actions allowed other students to disarm the
shooter and undoubtably saved multiple lives.
17 Out-of-Hospital Care fromParamedical toNon-medical Personnel
129
It was no accident or luck that allowed this call to be mitigated with the success that is did. Unfortunately, Colorado
has had more than its fair share of school shootings, so experience played a role. We also knew it was only a matter of
time before we would have another school shooting, and we
needed to prepare for it. We created a large-scale training
that included every agency that would be involved, including
police, reghters, EMTs, nurses, and doctors, including
surgeons from resident to seasoned. It included a realistic
scenario with live victims, from point of injury, extraction,
prehospital care, transport, emergency room, and nally
ended at the surgical suite in several of our Level I and Level
II trauma centers. It was this recent drill that gave us the ability to take command and unify the responders of multiple
agencies and disciplines, to work as one unied team to
accomplish the one thing that mattered that day in Colorado—
saving the kids that were shot.
Active Killer
Realistic Training
At the end of 2018, our re department decided to break free
from the traditional mode of training and bridge to hyperrealistic training. We had created some large-scale trainings
that included elaborate scenarios in the past, but we only
trained our own people. We realized that we were only one
small piece of the puzzle for a patient from injury to discharge from the hospital. We needed to include each element
of a patient’s success to survive a traumatic injury by truly
understanding all the players involved. Dissolve the established silos. We created a training that brought in multiple
agencies and disciplines and created “one team” to work
synergistically choreographed at accomplishing the missions’ objectives to save as many people as possible. It was
the ultimate in team dynamics for our community.
It was the multiple mass shootings that were committed in
schools, movie theaters, campuses, and on the streets that
forced us to look at our response to these events after signicant response issues occurred repeatedly across the country.
At each event we learned how to do it better and forced us to
realize our department’s short comings. Despite having this
knowledge, it made no difference if all the responders, from
law enforcement, Fire/EMS, and hospital staff were trained,
a system wide global breakdown occurred with isolation of
agencies and hospitals, individualized response plans, and a
lack of large scenarios to test the systems process errors. In
the end the system errors always outnumbered the individual
human errors. Issues with blook bank protocol, like having a
nurse check it out for verication who was much more valuable in the ED where the injured were, equipment compatibility, or simply chest tube trays in quantity readily available
for the number of patients that these scenes generate. With
the help of multiple agencies, we were able to begin piecing
together effective training to improve the outcome of these
patients using the concepts previously discussed.
This allowed for the creation of Standard Operation
Guidelines (SOGs) that were widely accepted over judicial
precincts incorporating multiple law enforcement, and Fire/
EMS agencies—creating one plan for unied command,
dening terminology, declaring tactics that allow for all
agencies to work together to complete the mission and
assigning responsibilities for every critical factor and objective necessary to stabilize an incident.
Lessons Learned
Again, without breaking from our traditional trainings, we
would not have learned so many valuable lessons. Even
though we made great strides in working with the police if
we had stopped there and had people simply read the new
SOGs, we would not have seen such dramatic changes in our
operations. A mass scale exercise (not of patients of quality,
realism, and follow-through of services) completed with
complete emersion and a seamless transition through the
entire trauma system from point-of-injury to stabilization in
the operation room created a platform for a cultural competency reecting a shift to a one team philosophy.
Response
We have seen a shift in how we respond to the active shooter
incident over the past several years. The Hartford Consensus
by the American College of Surgeons implemented the
THREAT acronym in 2013 as response to nearly 7000 lessons learned from over a decade of combat studies and the
evaluation of over 250 civilian casualties in active shooter
events since Columbine in 1999 [14].
• Threat suppression
• Hemorrhage control
• Rapid Extrication to safety
• Assessment by medical providers
• Transport to denitive care
Knowing thatin an active shooter environment that hemorrhage has always been the single greatest preventable
cause of death to our patients. We will irt with mortality in
approximately ve minutes post injury and our access to the
patients is too slow using our old methodologies of “scene
safe,” law enforcement brings them to us, or any other outdated practice. If you take 15–23min trigger time to reach
your rst patient, you will fail to have any impact on positive