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UAB Ophthalmologists Develop Exam Kit to Help EMS Deal with Eye Trauma

Some 2.5 million eye injuries occur in the United States every year, and nearly 1 million of those patients present to emergency rooms or eye trauma centers. Because many eye injuries are first encountered by emergency medical services (EMS) professionals, there is a need for reliable pre-hospital assessment, triage, and initiation of treatment.

UAB ophthalmologists C. Douglas Witherspoon, MD, David Neely, MD, and Kevin Bray, MD, developed a standardized examination system for EMS professionals to conduct on-site emergency evaluations of patients with eye injuries. The system emphasizes quick recognition and practical classification of eye injuries rather than exact diagnoses, and it helps EMS teams make timely decisions that can better prevent overall vision loss and long-term disability.

Dr. Witherspoon, a vitreoretinal and ocular trauma surgeon who was instrumental in securing Callahan Eye Hospital’s Level 1 Ocular Trauma Center designation in 2011, currently co-directs the UAB Vitreoretinal Fellowship Training Program. Drs. Neely and Bray are senior fellows in that program. They recognized an opportunity to improve and standardize the methods EMS professionals use for emergency triage and treatment of eye injuries, drawing upon feedback the doctors received during annual lectures given to regional EMS professionals. Dr. Witherspoon noticed that even experienced EMS professionals commonly experience apprehension when dealing with eye injuries.

“These EMS teams see every kind of severe trauma in the field, and they aren’t afraid of much,” Dr. Witherspoon says. “But the reason that eye trauma causes so much concern is that they are uncertain how to proceed. They would often tell me they would rather deal with a heart attack, bad limb injury, or severe bleeding than treat an eye injury. Hearing that over and over made me suspect that our lectures on ocular trauma, which we have been presenting to EMS professionals for about 10 years now, weren’t having the beneficial effect we had anticipated. So we decided to change the information to focus on the techniques and methods specifically designed for EMS professionals, rather than continue to detail the techniques ophthalmologists employ. We also decided to develop training videos and to make them available online in order to allow for repetition and individually paced selftraining.”

NARROW TREATMENT WINDOW

Dr. Neely notes that the doctors also saw the need for standardization.

“Sometimes a patient might be taken to a general ER that was not appropriate for the level of trauma they had experienced,” Dr. Neely says. “We’re trying to eliminate that because it uses valuable time, since there’s usually a specific window of opportunity to provide effective treatment. On the other hand, if EMS assessment shows that there is no need to visit the eye trauma center, that’s equally useful information. We could see that, with so many cases all being handled differently, standardization would be essential.”

Dr. Bray says a standardized approach is immediately beneficial to patients.

“Patients are understandably frightened whenever they have an eye injury, and that can be a difficult situation to manage in the field,” Dr. Bray says. “Having a standardized way to approach eye problems gives EMS providers the confidence to sort non-emergent injuries from those that need a higher level of care. A standard approach not only allays patient fears, it also saves time and vision.”

Eye trauma often is accompanied by other traumatic injuries and easily can be overlooked, especially in pre-hospital settings where rapid stabilization and transport take priority. Therefore, the most important management principle is to protect the eye from further trauma during transport. Moreover, alerting hospital providers to possible eye injuries prompts them to continue appropriate shielding to prevent further damage and initiate definitive treatment once the patient is at the hospital. Through expert recognition and initiation of pre-hospital treatment, EMS providers can maximize a patient’s recovery from an eye injury.

“An initial evaluation is essential in determining the severity of an eye injury,” Dr. Witherspoon says. “The next step is to provide emergency treatment and stabilization and finally triage to the appropriate fixed treatment facility. Our eye emergency treatment manual includes algorithms we have established to assist in deciding how and when one should go through those steps.”

CONFIDENCE-BUILDER

To that end, Dr. Witherspoon and his team created anorganized and reproducible on-site eye examination system. They produced videos of emergency on-site examinations, wrote a detailed manual, and devised an accessory examination kit, which is an inexpensive, eye-specific set of examination tools that most EMS professionals generally don’t have at their disposal. The video and manual go through an examination sequence explaining exactly how each of the tools should be used.

Such education has not previously been provided to EMS professionals, Dr. Witherspoon says. Now, despite limited opportunities for direct experience and relevant training, EMS personnel can be fully prepared for scenarios that require emergency on-site evaluation of eye injuries.

Dr. Neely also regards the training kit as a confidencebuilder.

“We think we have created a more comprehensive education model that goes beyond traditional classroom lectures,” Dr. Neely says. “The accessory exam kit provides a much more in-depth, hands-on experience. The algorithms we’ve established for assessment and treatment are analogous to the protocols that are now in place for other emergencies such as heart attack or stroke. You get those basic steps down, and from that point treatment gets easier and more effective because, in following a standardized sequence, you have confidence you’re getting it right.”