# Trauma.



## NomadicMedic (May 25, 2015)

Let me throw a hypothetical situation out there for you, get some input and then I'll fill in the backstory. 

You're dispatched (AEMT and a Medic) to a 1 car MVA into a tree. 

On arrival you find a patient who has been ambulatory at the scene, with a cop, for the last 10 minutes or so.  This guy was the driver, and after the crash he just opened the drivers door and climbed out. He has a couple of lacs and abrasions, but no other injury or complaint. No drugs or alcohol on board. Remembers the whole event. No LOC. He says they were traveling about 50 mph when he over corrected on a corner and lost control. No driver airbag deployment. He was belted. 

You look to the left and see a vehicle into a stand of trees with significant damage to the vehicle and a patient in the passenger seat. There a couple of first responders in there holding cSpine. She's not injured, but the roof has been deformed and she can't get out without Fire cutting up the car. No pain, no complaints. No LOC. The extrication takes about 20 minutes before she's disentangled. The airbag did deploy on her side. 

There is a community hospital <10 minutes away. The trauma center is about 60 minutes by ground. There is an airship that can be on the ground in 20 minutes. 

What do you want to know? What do you do? Where do you go?


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## Jim37F (May 25, 2015)

Vitals for both patients. I'd do a quick head to toe just to rule out any other injuries may not have noticed.

For the passanger, no injury, no complaints, no head, neck or back pain, no acute neurologic deficits, ambulatory once extricated, etc, we'd clear C-spine. 

Local protocols do dictate 12 inches of passenger space intrusion equals trauma center transport (if no 12 inches, protocol does still highly encourage trauma center for anyone needing extrication). 

But otherwise, if vitals are stable and WNL, sounds like many a patient we've AMA'd here...but transport to the local hospital POC


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## LACoGurneyjockey (May 25, 2015)

Let me get a good physical exam on both of them, with more focus on the passenger. Full set of vitals on both (BP, pulse, respiratory rate and effort/lung sounds, SPO2/etco2, skin, pupils).
Do they want to be transported? If I've got time I'll get a lock on the entrapped passenger.
Without any significant findings in that physical exam or vitals, I'm comfortable taking both code 2 by ground to the nearest ER.
That would be a step 3 trauma activation by my protocols (12" passenger space intrusion, and the extrication time), but those go to the local community hospital regularly.
Did anyone witness the crash? Does PD/FD have any relevant to tell me if I asked?
And CAOx4 with no complaint, clear c-spine on both. 
Or what Jim said before I could post...


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## NomadicMedic (May 25, 2015)

Nobody saw it. Cops arrived after the fact.

Head to toe on driver is unremarkable aside from small lac on arm, abrasion on right shin and left hand. HR 90, 126/70, resp 20.

Passenger extricated to LSB and collar. Head to toe unremarkable aside from some soreness in her head and neck from the position she was in. She said her pain is. 2 out of 10. Nothing acute on palpation. Abd soft/non tender. Pelvis intact. No obvious fx, deformity or external bleeding. HR 94, 130/80 resp 18.

Again, here's the choices:

Level 1 Trauma center is about an hour down the highway, community hospital with a doc, X-rays and CT 10 minutes away or get a helo on the ground in 18 minutes that'll fly to the same level I it'll take you an hour to drive to. 

Does the trauma transport tool come into play here?


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## DesertMedic66 (May 25, 2015)

For my area we would most likely be going to the trauma center. I would do a call in and talk to the doc and make sure they don't want me to transport to the community ED. As of right now I am not seeing a reason to call a bird out and have the patient charged $20,000+


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## NomadicMedic (May 25, 2015)

Why is this a trauma center transport?


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## LACoGurneyjockey (May 25, 2015)

Because of 12" passenger space intrusion (I assume) and >20 min extrication time it would be a step 3 trauma activation where I'm at. I'd get a consult with the trauma center and push hard to transport to the community hospital, and I wouldn't expect them to disagree. I can't find anything wrong wrong with either patient.
This almost feels too straight forward for you to be posting it as a scenario.


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## TRSpeed (May 25, 2015)

Step 3 for us. Which means you CAN do a trauma consult you don't have to though. And can transport to a local ED.


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## RocketMedic (May 25, 2015)

Is this even a transport?


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## Ewok Jerky (May 26, 2015)

50 mph into a tree? No airbag on the driver? 20 minute extrication? I would not be excited about AMAing.

As for transport decision, I would base solely on trauma protocols. Given the vitals and PE I would be comfortable transporting to local ED.


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## zzyzx (May 26, 2015)

This is a bit of a grey area, so like the other posters, you could make an argument for either a trauma center or a community hospital.

Cars have become so much safer, and they continue to improve. This factors into our thinking about mechanism of injury, which is of course one of the things we consider when we consider trauma criteria, such as in this scenario. A 1970s or 80s sedan with major front end damage, for example, would lead you to be suspicious for the patient having possibly suffered injuries related to sudden deceleration, whereas the same damage on a brand new car tells you that the car did what it was designed to do--absorb the energy of the impact. Likewise, rollover protection has gone from non-existent in the 1970s to quite advanced today, and that has changed our thinking about trauma criteria as well. Not to mention air bags, side-impact protection, and so on.


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## NomadicMedic (May 26, 2015)

local community hospital declined to accept these patients based solely on mechanism.


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## Carlos Danger (May 26, 2015)

DEmedic said:


> local community hospital declined to accept these patients based solely on mechanism.



"Holy CRAP Johnson come here! Did you see this mechanism of injury!?"


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## Flying (May 26, 2015)

> community hospital with a *doc, X-rays and CT 10 minutes away*





DEmedic said:


> local community hospital declined to accept these patients based solely on mechanism.








Am I missing something here?


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## Tigger (May 26, 2015)

DEmedic said:


> local community hospital declined to accept these patients based solely on mechanism.


Hah I deal with this all the time, and was going to write a post about it. 

But yea, sucks.


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## Jim37F (May 27, 2015)

Luckily for me, if base contact was made vs. just BLS it and the MICN at base insisted on going to the Level I Trauma Center, it's only about 20 min away lol (As they did the one time we had an auto vs bicycle, where the car was making a right turn and knocked the guy on the bike in the crosswalk to the ground, about 5-10mph max, getting ready to BLS to the local hospital 2 min away, the base hospital had us go to said Level 1 that for us is as far away as the community hospital in the OP scenario, but oh well lol)


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## COmedic17 (May 27, 2015)

We can call two types of "trauma alerts". 

First type - "Limited Trauma".
This means there was a significant mechanism of injury, but the patient is stable. It's pretty much a "cover my butt" kind of thing. It pretty much tells the hospital that they were in a pretty gnarly accident, or whatever the mechanism was, but the patient is fine. Most hospitals can and will accept a limited trauma if they have some/any form of trauma accreditation and/or doctor willing to accept. 

Second type "Full trauma Activation". 
This is for a patient that actually needs a trauma activation. They go to legit trauma center.


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## chaz90 (May 27, 2015)

^I very much miss this about Colorado.


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## phideux (May 27, 2015)

COmedic17 said:


> We can call two types of "trauma alerts".
> 
> First type - "Limited Trauma".
> This means there was a significant mechanism of injury, but the patient is stable. It's pretty much a "cover my butt" kind of thing. It pretty much tells the hospital that they were in a pretty gnarly accident, or whatever the mechanism was, but the patient is fine. Most hospitals can and will accept a limited trauma if they have some/any form of trauma accreditation and/or doctor willing to accept.
> ...




I work in 2 places, both have 2 trauma levels. 
In one we have Level 1 and Level 2, in the other is an 811 or 911.
One is based on MOI, the other is based on the actual patient condition.


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## COmedic17 (May 27, 2015)

chaz90 said:


> ^I very much miss this about Colorado.


Its convenient lol


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## gotbeerz001 (May 27, 2015)

COmedic17 said:


> First type - "Limited Trauma".


We call this "Code 2 Trauma". This is for the pt that met criteria for several possible reasons but my index of suspicion is low for significant injury. In these cases, the pt preferred hospital usually happens to also be the trauma center, anyways. 

If they meet criteria based solely on mechanism with no pertinent findings, I can make base to bring in as a regular pt or go to pt choice (non-trauma center).


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## NomadicMedic (May 28, 2015)

The patients wanted the community hospital, neither was injured beyond minor cuts and bumps, but the community hospital refused the patients, saying, "we don't take high mechanism trauma here. Take them to the trauma center."  

I was going write a long diatribe about how I believe the the trauma triage tool is blah blah blah... But what's the use. The hospital where they should have gone wouldn't take them. End of story.


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## Summit (May 28, 2015)

It would have been poetic if the pt AMA'd and then POV'd to the community hospital.


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## Tigger (May 28, 2015)

DEmedic said:


> The patients wanted the community hospital, neither was injured beyond minor cuts and bumps, but the community hospital refused the patients, saying, "we don't take high mechanism trauma here. Take them to the trauma center."
> 
> I was going write a long diatribe about how I believe the the trauma triage tool is blah blah blah... But what's the use. The hospital where they should have gone wouldn't take them. End of story.



What sort of punishment do you anticipate if you brought the patients to that hospital anyway?



Summit said:


> It would have been poetic if the pt AMA'd and then POV'd to the community hospital.



It's happened...


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## Brandon O (May 30, 2015)

You mean declined over the phone/radio? Or in person?


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## NomadicMedic (May 30, 2015)

Via telephone.


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## Brandon O (May 30, 2015)

Sounds like a preference, not a mandate.


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## NomadicMedic (May 30, 2015)

Oh no. Most decidedly a mandate.


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## Brandon O (May 30, 2015)

Not much they can do if you bring them there; that's EMTALA. No ED can actually refuse a patient.


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## chaz90 (May 30, 2015)

Brandon O said:


> Not much they can do if you bring them there; that's EMTALA. No ED can actually refuse a patient.


Yeah...I've been met at a local band aid station with a doctor in the parking lot trying to shoo my ambulance away. I think this particular hospital has been fined for EMTALA violations in the past and just accepts them as an occasional cost of business.


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## Tigger (May 30, 2015)

THis is what I run into. They say they will not take the patient, but we all know that's an idle threat. If the patient wants to go that facility, they are welcome to do so.


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## NomadicMedic (May 30, 2015)

Well, I work for a hospital based service. If I took a patient there and they had told me no, it would most likely be the end of my employment.


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## Tigger (May 30, 2015)

That would be a problem. We rely on our local hospital for too much revenue (they will transfer literally anything), so if they don't want the patient I will try very hard to convince the patient as such. But if the patient will only go to the local hospital and they need to go, I will still bring them in rather than just leaving them, as I am sure most of us would.


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## NomadicMedic (May 30, 2015)

Tigger said:


> That would be a problem. We rely on our local hospital for too much revenue (they will transfer literally anything), so if they don't want the patient I will try very hard to convince the patient as such. But if the patient will only go to the local hospital and they need to go, I will still bring them in rather than just leaving them, as I am sure most of us would.



Both went to the level I, non emergent, traveled an hour and got a nice bill.


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## DesertMedic66 (May 30, 2015)

We have a hospital that will refuse transport of generally any trauma patients. The Doc/MICN will actually use the term refuse. 

Our hospitals are now able to refuse patients based on our ambulance redirect protocol. Pretty much if we have too many units on bed delay at that hospital no other transports of stable patients will be allowed even if the patient requests transport to that facility. The patient is given the choice of transport to a different hospital or they have to sign out AMA.


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