Question: Is the stipulation that the patient must be VSA upon arrival to qualify for a Trauma TOR is a SWORBHP deviation from the provincial directives? The protocol does not specifically state witnessed or unwitnessed arrest (as does the Medical TOR protocol). After talking to a couple paramedics under another Base Hospital they have informed me that they can Trauma TOR a witnessed traumatic VSA (for example, the patient goes VSA during extrication and meets all other criteria).

 Great question! The SWORBHP is not deviating from the Provincial Directives since as you state, the directive does not specify witnessed or unwitnessed arrest. The previous Traumatic Arrest Algorithm required the paramedic to establish absent respirations, palpable pulses, papillary reflexes, and spontaneous movements. While these are no longer specified in the current directive, the SWORBHP Medical Council feels that the presence of these "signs of life" could indicate that the PEA you see on the monitor could actually be a perfusing rhythm that is generating a blood pressure that is too low to be obtained or pulses felt. In other words, these could be markers for survival. It would be unusual for a patient to have a suffered a witnessed traumatic arrest upon extrication and have all of these markers absent, that is why our teaching philosophy has been to prefer that these patients with witnessed traumatic arrests be transported.

It would also be unusual for a witnessed traumatic arrest patient's rhythm to immediately be asystole, and within the SWORBHP region, it is often less than 30min drive time to the closest ER thus many of these patients ultimately would require transport regardless.

Remember, TOR is still a patch to the BHP who makes the decision- they don't always agree with pronouncement depending upon the circumstance, and a "witnessed traumatic arrest" may be the case where many BHP would insist upon transport

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