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A picture is worth a thousand words (anonymous)

Every Second Counts

(< 3/100th of an R Adams Cowley's Golden Hour)


Chapter author Dr. Marc T. Zubrow is currently the director of a tele-ICU program that deploys Philips technology.


Emergency medical services (EMS) is called to a roadside motor vehicle collision. EMS personnel are wearing helmet and body cameras, with head-mounted microphones and earphones. EMS notifies the regional telemedicine center EMS/MD that a single passenger in the driver position, belted with front air-bag deployment but no side-window airbags, was “T-boned” from the driver side with about 18 inches intrusion on the driver door. EMS connects the patient to a cellular-enabled vital signs monitor with connectivity to the telemedicine center. The driver is hypotensive, unconscious, and with obvious deformity to the left femur. The EMS doesn’t hear breath sounds on the left chest, and neither does the telemedicine center EMS/MD. The telemedicine center EMS/MD recognizes the risk of tension pneumothorax, splenic rupture, lateral compression fracture of the pelvis, and possible traumatic brain injury. The EMS does a quick on-scene focused assessment with sonography for trauma (FAST) exam as the telemedicine center EMS/MD observes remotely but cannot see sliding pleural lines on the left. Additionally there is fluid in the left upper quadrant (LUQ). The remote physician confirms no sliding pleura and authorizes needle decompression of the left hemithorax and advises 1 liter crystalloids immediately if blood pressure (BP) is no better after needle decompression. The telemedicine center EMS/MD recognizes this patient will need a tertiary trauma center and advises a bypass of local facilities. While the EMS decompresses the left chest and establishes an IV, the telemedicine center contacts aeromedical services to dispatch a medevac helicopter to global positioning system (GPS) coordinates transmitted from the EMS vehicle on scene. Airway patency is a concern in this unconscious critical patient. The paramedic begins a rapid sequence intubation with video laryngoscope and has difficulty. The telemedicine center EMS/MD views remotely and advises on an epiglottis lift with the blade of the scope. Immediately, both the paramedic and telemedicine EMS/MD can see the cords and endotracheal tube inserted. On scene the EMS places the patient in a pelvic binder on a back board after a cervical collar is placed. The medevac helicopter arrives 15 minutes later. The helicopter remains “hot” with rotors turning while the EMS and flight paramedic load the patient. Audio/video connection switches over to the flight paramedic during loading in addition to a portable screen in the aircraft. The patient becomes hypotensive again, and another liter of saline is authorized by the EMS/MD, who also recommends insertion of a left chest tube. The flight paramedic inserts a 32 F chest tube—there is a large gush of air. The helicopter lands on the roof of the trauma center 21 minutes after the crash. The telemedicine center physician follows the ...

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