# Pneumothroax Transport Destination



## AeroClinician (Aug 25, 2012)

Here is the situation, you have a pt. that was involved in a motorcycle accident and your pt. only complains of back pain. Still has helmet on. A/Ox4, GCS 15, PERRL, Neuro exam and Stroke Exam Normal, denied loss of counciouness. HR, B/P Normal, EKG Sinus Rhythm. While your backboarding the pt. he states that he is not sure if he is having some difficulty breathing. L/S present with clr left lung and a clr right but your unsure if the right sounds more diminished than the left. SpO2 reads 96%. You have a Lvl 1 trauma center 40mins away going emergency and a primary reciving hospital 15 mins away going emergency. 

Now, you have a suspected to be possible pneumothorax, and if that is what it is it is in its early stages of onset. And as a result you are not going to decompress this pt. unless the pt. gets worse. 

You need to decide to either fly this pt. to the trauma center or call the priamary facility and check if they are capable of handling a pneumothorax then transporting code 3. What is the more adventagious route?


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## DrankTheKoolaid (Aug 25, 2012)

Ground transport to whichever facility is approved to receive trauma that is closest would be most appropriate, unless protocols dictate otherwise.  Patient is stable and no reason for Code 3 transport.  What you do need to consider is this patient may become more short of breath and if on a backboard then what.  May want to consider. KED and leave him sitting upright on the gurney.  Plenty of people live with pneumos that are simply reabsorbed as long as they do not cause any other problems.


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## Hockey (Aug 25, 2012)

Trauma center.


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## AeroClinician (Aug 25, 2012)

Corky said:


> Ground transport to whichever facility is approved to receive trauma would be most appropriate.  If it



The primary reciving hospital is a community hospital and can recieve trauma pt.s, but it is just not a FL state approved lvl 1 trauma center. Can handle long bone fractures, not facial fractures.

If you call the primary hosp. and they have chest tube capability it would make sense to go there instead?


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## AeroClinician (Aug 25, 2012)

By the way, if you go to the lvl 1 trauma center you must fly due to greater than 30mins trasport time. Weather is good.


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## DrankTheKoolaid (Aug 25, 2012)

You would have to fall back onto your protocols then.  But a simple pneumo doesnt need a level 1, hell a tension doesnt either once a chest tube is in.   

Im going to assume your protocol reads if X criteria is met then direct transport to X trauma facility unless there is uncontrolled bleeding, or a failed airway. In those cases divert to closest ED


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## AeroClinician (Aug 25, 2012)

Corky said:


> Patient is stable and no reason for Code 3 transport.  QUOTE]
> 
> Reason for code 3 transport is because if it is a pneumo then it could potentualy get worse and turn into a tension pnemo.
> 
> Is that a plausible reason for code 3?


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## Medic Tim (Aug 25, 2012)

Firehazmedic said:


> Corky said:
> 
> 
> > Patient is stable and no reason for Code 3 transport.
> ...



If the pt is stable there is no need to go ls. Many ppl do but that doesn't mean it is needed or right.


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## STXmedic (Aug 25, 2012)

Firehazmedic said:


> Reason for code 3 transport is because if it is a pneumo then it could potentualy get worse and turn into a tension pnemo.
> 
> Is that a plausible reason for code 3?


Are you a paramedic? If so, do you have the capability to mitigate a tension pneumo?


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## JakeEMTP (Aug 25, 2012)

With back pain and difficulty breathing a spinal injury can not be excluded. Innervation to the diaphragm could be impaired with paralysis on just one side which could give the presentation of diminished breath sounds. 


If it was just a pneumothorax, just about any ER can hand that. 

The local hospital could probably stabilize a SCI with intubation and prepare to transport by the most appropriate team although that might take several hours to arrange.


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## DrankTheKoolaid (Aug 25, 2012)

No.  He gets worse you needle his chest and the world is all good again and you continue on your merry way.  Still no reason for C3 unless he remains unstable.

30 minutes....... And what if air isnt available or on another run?  Are you just going to sit there with your patient and shoot the breeze?  What if they are delayed enough to make the time difference a wash?  

I noticed you said "must". Is this a hard protocol for you for some reason?


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## AeroClinician (Aug 25, 2012)

Corky said:


> Im going to assume your protocol reads if X criteria is met then direct transport to X trauma facility unless there is uncontrolled bleeding, or a failed airway. In those cases divert to closest ED



This pt. wouldnt meet those direct criteria, and the transport to lvl 1 would then only happen if the pt. still needed the care of the lvl 1 cntr. despite not meeting trauma critera and would be a paramedic judgement situation.


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## AeroClinician (Aug 25, 2012)

Corky said:


> No.  He gets worse you needle his chest and the world is all good again and you continue on your merry way.  Still no reason for C3 unless he remains unstable.
> 
> 30 minutes....... And what if air isnt available or on another run?  Are you just going to sit there with your patient and shoot the breeze?  What if they are delayed enough to make the time difference a wash?
> 
> I noticed you said "must". Is this a hard protocol for you for some reason?



Sorry, I shouldnt of said "MUST",  yes if it is a wash due to delays or if weather is bad and they cant fly then you just go ground.


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## AeroClinician (Aug 25, 2012)

Corky said:


> No.  He gets worse you needle his chest and the world is all good again and you continue on your merry way.  Still no reason for C3 unless he remains unstable.



One of the definiate critera for lvl 1 transport is "Airway assistance beyond Oxygen Administration". Would'nt you consider decompressing a lung as beyond O2 admin.?


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## JPINFV (Aug 25, 2012)

Firehazmedic said:


> One of the definiate critera for lvl 1 transport is "Airway assistance beyond Oxygen Administration". Would'nt you consider decompressing a lung as beyond O2 admin.?




No... because it's not an airway issue. Additionally, the ED better be able to do a thoracostomy regardless of whether it's a trauma center.


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## Veneficus (Aug 25, 2012)

*If I could offer a perspective.*

Go to the trauma center.

You described a pt who "might" have a pneumo. 

Not every pneumo requires a chest tube. I have worked in centers that will not put in a chest tube if the pneumo self limits with less than 16% lung involvement unilaterally.

Despite the fact most people don't "need" a level I trauma center, do you think that this patient has only an isolated injury involving his lung?


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## usalsfyre (Aug 25, 2012)

Go to the trauma center. The patient needs an evaluation by a trauma team. What they DON'T need is air or emergent transport. Trying to justify any other option hiding behind protocol is honestly, weak sauce.


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## d_miracle36 (Aug 25, 2012)

If you could transport to a trauma center via ground I might go that route. If not I would go to local hospital unless patient had other injuries. Air medical services are utilized way too much. The patient appears stable fro
 The report and if he did have a pneumo then the local er should easily able to put in a chest tube then transport if needed. I don't think patients should be sent via air based solely on moi unless there are other injuries.


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## AeroClinician (Aug 25, 2012)

usalsfyre said:


> Go to the trauma center. The patient needs an evaluation by a trauma team. What they DON'T need is air or emergent transport. Trying to justify any other option hiding behind protocol is honestly, weak sauce.



So you would drive the pt non emergency past the local hospital to the trauma center. If this pt needs evaluation by a trauma team instead of a local hospital Eval then wouldn't that warrant code 3 transport? If he is stable enough to be taken non emergency, then does he really need to go to the trauma center? Can't a local hospital check for other injuries and internal bleeding just as well?

I'm thinking this would best be managed by contacting medical controll and getting the doctors input from the local hospital.


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## Aidey (Aug 25, 2012)

Just because someone needs a specialist doesn't mean they need lights and sirens. Specialists have been proven to help, lights and sirens have not. 

And am I the only one who sees a problem with flying a possible pnuemo in an unpressurized aircraft?


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## Veneficus (Aug 25, 2012)

Firehazmedic said:


> So you would drive the pt non emergency past the local hospital to the trauma center. If this pt needs evaluation by a trauma team instead of a local hospital Eval then wouldn't that warrant code 3 transport? If he is stable enough to be taken non emergency, then does he really need to go to the trauma center? Can't a local hospital check for other injuries and internal bleeding just as well?
> 
> I'm thinking this would best be managed by contacting medical controll and getting the doctors input from the local hospital.



Yes I would drive the pt past the local hospital in a non emergent manner. Mostly because I understand that the meager amounts of time saed doesn't make a difference in most cases and the risk of an accident is at least 300x greater according to the insurance bodies that provide coverage.

All emergency departments are not the same. All doctors are not equal. All facilities are not equal. 

The very reason that trauma systems exist and are encoded in legislation is because we don't want people trying to handle things over their head. We don't want doctors who comparitively manage less trauma, less serious trauma, less often, give it a go when somebody who eats drinks and breaths trauma is just a few minutes down the road.

It seems obvious to me that you are simply not comfortable with this type of patients. That is not a bad thing. It is a realization of the limits of expertise and ability. 

But you do not solve your problems by dumping the patient on somebody who may be in a similar situation. Worse, may know what to do and not be able to do it because of the confines of equipment or staff.

You do not have to endager the lives of flight crew because you are uncomfortable. 

From the medical standpoint, there are all kinds of occult injuries. There are injuries that develop over time. (like a pneumo) None of us want to see a patient dropped off at a community hospital who thinks they have things in hand to find out later (usually when the patient is decompensating) that they are in way over their head. At that point, even stabilizing the patient can be impossible. 

We take heart patients to cardiac centers.
We take stroke patients to neurocenters.
We take cancer patients to cancer centers. 
We take trauma to trauma centers. 

Community hospitals are designed to care for common community needs which require inpatient care. They are not designed nor expected to act as specialty centers for every patient who comes in the door.

I recently met an internal medicine specialist who hasn't sutured a wound since early residency. 

What if the doc at the community ED you go to hasn't put in a chest tube since then either?

What if he doesn't know the shadow on the aorta that appears on most chest CTs is a limited of the technology and not a forming clot.

What if that shadow is mistaken for a clot forming on an aortic rupture?

What if it actually is?

I am not picking on the poster personally, but this demonstrates exactly why EMS providers are not considered professional or taken seriously by a multitude of healthcare providers.

Taking the trauma patient to the trauma center should be a no-brainer.

But if it was a no brainer, like I said, there wouldn't need to be laws to tell people to do it.


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## bahnrokt (Aug 25, 2012)

Firehazmedic said:


> So you would drive the pt non emergency past the local hospital to the trauma center. If this pt needs evaluation by a trauma team instead of a local hospital Eval then wouldn't that warrant code 3 transport? If he is stable enough to be taken non emergency, then does he really need to go to the trauma center? Can't a local hospital check for other injuries and internal bleeding just as well?
> 
> I'm thinking this would best be managed by contacting medical controll and getting the doctors input from the local hospital.



The decision on which facility fits the pts needs and how to transport them there are two distinct decisions.  

I drive past 2 hospitals on the 45 min ride to the nearest Lvl1 trauma. I also never go there l&s and only once have flown someone.


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## JPINFV (Aug 25, 2012)

Veneficus said:


> The very reason that trauma systems exist and are encoded in legislation is because we don't want people trying to handle things over their head. We don't want doctors who comparitively manage less trauma, less serious trauma, less often, give it a go when somebody who eats drinks and breaths trauma is just a few minutes down the  road.


I'm note quite sure I'd qualify 25 minutes further as "just down the road." If anything, it's right on the edge of that qualification. As described, I'm not quite sure that the patient is in a situation where moving heaven and earth in order to get to a specialty center is necessary. 




> From the medical standpoint, there are all kinds of occult injuries. There are injuries that develop over time. (like a pneumo) None of us want to see a patient dropped off at a community hospital who thinks they have things in hand to find out later (usually when the patient is decompensating) that they are in way over their head. At that point, even stabilizing the patient can be impossible.
> 
> We take heart patients to cardiac centers.
> We take stroke patients to neurocenters.
> ...


Yet not every cardiac issue or chest pain goes to a specialty center. 

Not every patient with neurological issues goes to a neurocenter.

Not every cancer patient with a complaint goes to a cancer center (albeit transport to home hospital is important if possible). Cancer isn't going to be suspected prehospitally. 

Not every patient with a mechanism of injury goes to a trauma center. 

If the issue is chest tubes, then shouldn't every patient short of breath also go to a trauma center? What if the patient has a massive effusion of empyema that also requires a chest tube for drainage?

Transporting every patient that meets a broad category to a specialty center, without regards to the history and physical is like consulting a specialty just because it can fit into that category. It's like consulting cardiology for a run of the mill non-ST elevated chest pain prior to running serial EKG/enzymes or consulting ENT for a sore throat. 

If a physician can order a bad consult, then EMS can make a bad specialty center referral.


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## Medic Tim (Aug 25, 2012)

In my experience ppl who like going code 3 (for stable pts) are usually not comfortable with their assessment, treatment abilities or themselves in general.

We bypass local eds all the time with transport times up to an hour or more.( the local ed was 5-15 away) non lights and siren daily. A smooth ride is better and safer for everyone. I would have taken the pt to the trauma center no ls.


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## Veneficus (Aug 25, 2012)

I would consider even an hour to a specialty center a reasonabl ride. 

I have taken serious trauma to non trauma centers out of need. Just as I have taken nonserious trauma to a nontrauma center.



JPINFV said:


> Not every patient with a mechanism of injury goes to a trauma center.



I am not suggesting they should. However, in this scenario, there is an actual injury suspected, not simply a mechanism. 




JPINFV said:


> If the issue is chest tubes, then shouldn't every patient short of breath also go to a trauma center? What if the patient has a massive effusion of empyema that also requires a chest tube for drainage?



Not quite exactly. However, I would suggest that a patient who requires a chest tube might more likely find such a treatment at a higher grade trauma center by virtue of in house surgery.

Just the other day I was reading 2 articles (for disclosure in a surgery publication)

The first was a study showing that immediate operation of acute appendicitis has less post surgical complications then patients who are medically managed until the next morning. 

It was suggested in the same article that any acute surgical pathology (by extension suspicion of such) might benefit from being taken to a trauma center in many cases simply because it is likely the only hospital with in house surgery.

It was not a part of the article, but I would personally stipulate that emergent reoperations or patients with a surgical history should still go to the center of origin of the surgery if feasable.

(there was also a follow on article talking the benefit of medically managing low grade appendicitis)

There was also another study talking about trauma centers as a center for all acute surgery. For many reasons, but the one that stood out in my mind was comfort of operating on patients who are not preselected and with open techniques. 



JPINFV said:


> Transporting every patient that meets a broad category to a specialty center, without regards to the history and physical is like consulting a specialty just because it can fit into that category. It's like consulting cardiology for a run of the mill non-ST elevated chest pain prior to running serial EKG/enzymes or consulting ENT for a sore throat..



I agree. But we are talking about a patient who has a chief complaint relating to trauma, as well as physical findings suspect of traumatic injury in this case. 



JPINFV said:


> If a physician can order a bad consult, then EMS can make a bad specialty center referral.



Very true.

But outside of this scenario what would you like to wager on?

A specialty center specific pathology that goes to a community hospital or a condition not requiring a specialty center that goes to one?

Both have a multitude of problems associated with them.


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## abckidsmom (Aug 25, 2012)

I would take this patient to the trauma center.

Another important thing to consider is just what the hospital is capable of.  We have a couple of hospitals that are like really nice clinics with rooms, and a couple more that are cardiac and neuro resource centers but they divert trauma to the trauma centers.

In one of our destination cities, the choice is between that small, slow hospital that I'd go to for stitches in my leg and a university medical center that's 10 minutes farther away.

We're already driving 40-50 minutes to the hospital, so what's 10 more minutes?

I rarely transport lights and sirens, and very rarely for the entire 50 minute transport.


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## FLdoc2011 (Aug 25, 2012)

Honestly without knowing more about the hospital capabilities I would err on the side of going to the trauma center.   Yea, it may be a needless extra 30min transport, but it may save a potential transfer later on anyway if the closer hospital finds something they can't handle and has to transfer anyway. 

It's also going to vary on your location and the capabilities of that closer hospital.   If it happened in my area here it certainly wouldn't be reasonable to go a nontrauama facility as from it looks like now this of technically may not meet state trauma code criteria.   And it least I know at my facility we can handle whatever services this pt may need surgically or medically even though we're not a trauma center.   I don't even get surgery involved for a pneumo unless I need a VATS or open pleurodesis.  Usually managed by Pulm/critical care.

So without knowing more about your area or specifics on the pt it's a little hard to give a concrete answer.


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## Doczilla (Aug 25, 2012)

Aidey said:


> Just because someone needs a specialist doesn't mean they need lights and sirens. Specialists have been proven to help, lights and sirens have not.
> 
> And am I the only one who sees a problem with flying a possible pnuemo in an unpressurized aircraft?



In most places in the CONUS, rotor wing aircraft don't get high enough for that to be an issue.


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## GaMedic (Aug 25, 2012)

Depends on your state. In Georgia the pt could meet trauma triage criteria. How fast was he traveling on the motorcycle? Does the scene indicate a significant mechanism of injury? For trauma triage criteria for mechanism in Georgia regarding motorcycle accidents is greater than 20 MPH. Now does that mean we fly every poor sap that falls over on his motorcycle? No but you can look at the scene and formulate an idea of what kind of force was involved and get an idea of what destination is appropriate. Hope that helps


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## jwk (Aug 25, 2012)

FLdoc2011 said:


> Honestly without knowing more about the hospital capabilities I would err on the side of going to the trauma center.   Yea, it may be a needless extra 30min transport, but it may save a potential transfer later on anyway if the closer hospital finds something they can't handle and has to transfer anyway.
> 
> It's also going to vary on your location and the capabilities of that closer hospital.   If it happened in my area here it certainly wouldn't be reasonable to go a nontrauama facility as from it looks like now this of technically may not meet state trauma code criteria.   And it least I know at my facility we can handle whatever services this pt may need surgically or medically even though we're not a trauma center.   I don't even get surgery involved for a pneumo unless I need a VATS or open pleurodesis.  Usually managed by Pulm/critical care.
> 
> So without knowing more about your area or specifics on the pt it's a little hard to give a concrete answer.



"Know your hospitals" is always good advice.  There are designated trauma centers, and then there are perfectly good hospitals that have made a choice NOT to be a trauma center (for economic or political reasons, etc.) but have really good ER's and available specialty services.  None of the three hospitals where I'm on staff are trauma centers, yet all three, from a 50 bed rural hospital to the 500 bed tertiary referral center, would be capable of handling this particular case described by the OP.


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## AeroClinician (Aug 25, 2012)

jwk said:


> "Know your hospitals" is always good advice.  There are designated trauma centers, and then there are perfectly good hospitals that have made a choice NOT to be a trauma center (for economic or political reasons, etc.) but have really good ER's and available specialty services.  None of the three hospitals where I'm on staff are trauma centers, yet all three, from a 50 bed rural hospital to the 500 bed tertiary referral center, would be capable of handling this particular case described by the OP.



I agree with this statement, and a good subsitute to knowing your ERs would be a consult with the ER doc while onscene.


This pt. does not meet the trauma critera for Florida.
It looks like this scenerio in particular appears to be debateable and I would imagine that if you had a room of 50 doctors, some would disagree with each other. And as a result, it appears that the most adventagous route would be to contact the ER doc at the local hosp. over the radio or phone and run the situation past him and get his input on transport destination based on the resources that he may or may not have to his disposal and if he believes that he can manage this pt.

Seriously if the local ER doc says that he can manage this pt. over the phone, why drive an extra 30 mins to the Lvl 1 center?

Really if you show up at the local ER and the doc ends up not being able to manage the pt. and has to transfer the pt. then you really cant be blamed. It puts it off on him. Why do I see no problem with this? Every trauma doenst need to go to the lvl 1 trauma center. I think that we are smarter than that.


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## usalsfyre (Aug 25, 2012)

Firehazmedic said:


> Seriously if the local ER doc says that he can manage this pt. over the phone, why drive an extra 30 mins to the Lvl 1 center?


Because if they can't you've delayed definitive care an average of 3 hours simply so you didn't "have to drive the extra 30 min. 



Firehazmedic said:


> Really if you show up at the local ER and the doc ends up not being able to manage the pt. and has to transfer the pt. then you really cant be blamed. It puts it off on him. Why do I see no problem with this? Every trauma doenst need to go to the lvl 1 trauma center. I think that we are smarter than that.


Its a crap way of looking at patient care. It's not about blame, it's about the patient. Your looking for excuses to get out of doing the right thing and dump your patient on someone else. If you can come up with a reason for not going a little out of the way that centers on the patient I MIGHT start to listen. Until then it's typical EMS asshattery.


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## AeroClinician (Aug 25, 2012)

usalsfyre said:


> Its a crap way of looking at patient care. It's not about blame, it's about the patient. Your looking for excuses to get out of doing the right thing and dump your patient on someone else. If you can come up with a reason for not going a little out of the way that centers on the patient I MIGHT start to listen. Until then it's typical EMS asshattery.




So at what point are we suppost to know when, and when not to trust medical direction from a MD at the ER while on scene? 

Its not about looking for the easiest route to "dump" the pt. on someone. Instead, its about not jumping the gun and going overboard. And being smart by utilizing a closer facility that the MD at the ER has confirmed is able and willing to accept and treat the pt.

And when it comes to, who is to "blame" for "xyz" or who is most "liable", that is what lawyers are all about. As a result it makes sense to me to be vigilant and mindfull of liablity matters when dealing with pt. care. 

What ever happened to "if possible" starting out with lesser invasive and working up to most invasive in regards to treatments prehospitaly. For instance a pt. with hypotension, using lesser invasive means of managing by positioning the pt., and then working up to most invasive with Dopamine.

This is similar from the perspective of considering, and consulting with closer facilites prior to just taking to the farther away trauma center.


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## Baele11 (Aug 25, 2012)

Veneficus could you link the surgical articles you are referencing? Or give the name and issue? I would be quite interested in reading them. Thanks!


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## usalsfyre (Aug 25, 2012)

Firehazmedic said:


> So at what point are we suppost to know when, and when not to trust medical direction from a MD at the ER while on scene?


If they want to play with trauma patients they can go get the designation, or he can go work in a trauma center. 



Firehazmedic said:


> Its not about looking for the easiest route to "dump" the pt. on someone. Instead, its about not jumping the gun and going overboard. And being smart by utilizing a closer facility that the MD at the ER has confirmed is able and willing to accept and treat the pt.


How is a non-emergent transport that's 30min further away jumping the gun? I'm still not seeing how this is a patient centered decision.



Firehazmedic said:


> And when it comes to, who is to "blame" for "xyz" or who is most "liable", that is what lawyers are all about. As a result it makes sense to me to be vigilant mindfull of liablity matters when dealing with pt. care.


If you took them to the trauma center you wouldn't be playing this game. Generally if you err on the side of the patient your liability is pretty low. It's when you start playing the "convient for me" game you get into trouble.



Firehazmedic said:


> What ever happened to "if possible" starting out with lesser invasive and working up to most invasive in regards to treatments prehospitaly. For instance a pt. with hypotension, using lesser invasive means of managing by positioning the pt., and then working up to most invasive with Dopamine.


Strawman argument. Transporting a bit further away is not invasive. Your trying to justify something that's somewhat questionable medically by comparing it to a wholly different situation. 



Firehazmedic said:


> This is similar from the perspective of considering, and consulting with closer facilites prior to just taking to the farther away trauma center.


If you thought about a trauma center, why are you trying to get out of going?


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## AeroClinician (Aug 25, 2012)

usalsfyre said:


> If they want to play with trauma patients they can go get the designation, or he can go work in a trauma center.



Do you take any trauma pt.s to local hospitals or are you of the belief that everything more severe than cuts and bruses need trauma center transport?




usalsfyre said:


> How is a non-emergent transport that's 30min further away jumping the gun? I'm still not seeing how this is a patient centered decision.


Its jumping the gun because if the local hospital has said they are capaible then they are an acceptable desitantion and can handle. As well the pt. doesnt even meet "trauma alert criteria". To me its like taking a chest pain w/ no S-T elevation to a cardiac center instead of the closer non-cardiac center local hospital.



usalsfyre said:


> If you took them to the trauma center you wouldn't be playing this game. Generally if you err on the side of the patient your liability is pretty low. It's when you start playing the "convient for me" game you get into trouble.



Yes of course going to the trauma center would ensure that the pt. would get the highest level of care and treatment availiable without a doubt. And taking a pt. with a single forearm bone fracture to the trauma center would as well, but its a matter of when do you take to local vs. trauma center when they dont meet trauma alert critera. And I would say the determinating factor at that point would be if they are capible of handling the pt. at the closer local hospital or not.



usalsfyre said:


> Strawman argument. Transporting a bit further away is not invasive. Your trying to justify something that's somewhat questionable medically by comparing it to a wholly different situation.



Of course it is not invasive to transport further, I would submit to you the question of if a particular treatment is able to be exicuted with the least involvment with acceptable positive results, that it would be more adventagious over using a treatment with a greater intensity of invasiveness/involvment that also produces a positive result. The same can be compaired to the situation of going to a closer/quicker to get to local facilty that can handle and produces a positive outcome vs. a farther/slower to get to superior facility that also produces a positive result.   See what I am saying?



usalsfyre said:


> If you thought about a trauma center, why are you trying to get out of going
> 
> ?






The idea of a trauma center may cross your mind when you have a single tib/fib fracture in a MVA, but you dont have to, "try to get out of going" per say, you know that the pt. doesnt meet trauma alert critera and you know that the pt. can be handled with a positive outcome at the closer/local hospital. So I doint see how I would be trying to get out of anything.


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## jwk (Aug 25, 2012)

usalsfyre said:


> If they want to play with trauma patients they can go get the designation, or he can go work in a trauma center.



I'm curious - do you have ANY idea what is involved with being a designated trauma center?  Any idea of the requirements, costs involved, personnel requirements involved, and what the different levels represent, etc.? 

It's a political and economic game as much as anything.  For example - there are two Level 1 trauma centers in Atlanta, not counting the children's hospitals.  Both are smack in the middle of downtown, in or next to the worst part of town, and both are teaching hospitals.  

It is near impossible for a non-teaching hospital to be a level 1 trauma center, because trauma is a money-loser and most hospitals don't want to pay the extraordinary costs involved for staff and care that all too frequently is not reimbursed well.  Keeping 24/7 in-house surgical specialists in particular is terribly expensive, and many surgeons, in an era of decreasing reimbursement and high medicolegal liability, simply will not work in a trauma center.

However, there are at least a dozen hospitals around town that do a fine job with trauma, but don't have a trauma center designation, including two that are in the top 5 ER volumes in the state.  Just because they don't want to be known as a trauma center doesn't mean they're not every bit as capable.


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## DrankTheKoolaid (Aug 25, 2012)

And unfortunately as long as Paramedics have to work under protocols designed to the lowest common denominator what you say about non designated hospitals means nothing.  If patient meets the TTC then they need to be transported to the designated center, unless there is a failed airway or uncontrolled bleeding, then and only then can they be transported to the closest ED capable of stabilization.


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## Merck (Aug 25, 2012)

For the case mentioned the local hospital is fine for the presentation mentioned.  The thing to remember is that we work in a dynamic environment.  The pt sounds ok right now.  If things change, re-evaluate.

If the speed was 140 km/h or something you can make a better case for heading to the trauma centre but 40 minutes is a long drive.  A helicopter response would appropriate.


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## DrankTheKoolaid (Aug 25, 2012)

Well 40 minutes is a bad example as I disagree.  Unless the helo is already in the air, ground transport will be as fast if not faster.  It also will not put the flight crew at risk if you go by ground.


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## JPINFV (Aug 25, 2012)

Corky said:


> And unfortunately as long as Paramedics have to work under protocols designed to the lowest common denominator what you say about non designated hospitals means nothing.  If patient meets the TTC then they need to be transported to the designated center, unless there is a failed airway or uncontrolled bleeding, then and only then can they be transported to the closest ED capable of stabilization.




...but we're discussing a case where the patient doesn't necessarily meet trauma center criteria and whether it's appropriate to drive 20-30 minutes further for a trauma center (time between hospitals is the only thing that matters in this, not total transport time). We're discussing a procedure that any board certified emergency physician should be able to perform.


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## abckidsmom (Aug 25, 2012)

JPINFV said:


> ...but we're discussing a case where the patient doesn't necessarily meet trauma center criteria and whether it's appropriate to drive 20-30 minutes further for a trauma center (time between hospitals is the only thing that matters in this, not total transport time). We're discussing a procedure that any board certified emergency physician should be able to perform.



But the ER is not the end of the patient's stay.  The podunk community hospital is not going to have experience with a trauma patient with a chest tube.  The nurses on the floor are going to have to dig deep to remember the last patient they ambulated with a chest tube.  They are going to be impressed with the pain the patient has and potentially let him stay in bed, increasing his risk for darn near everything.

Pain control will be managed differently in a facility where this is not normal and routine, and the patient may suffer.

Every patient's strongest desire should be to be just another day at the office for the medical staff, and nothing special.  This guy on a regular surgical or trauma floor is no big deal.  In a small community hospital, he could easily be the first patient with a chest tube that floor has seen all year.  

It makes a big difference, and it's worth the ride.

The value added in the trauma center experience is that the whole hospital is equipped and experienced with trauma, and it's not just something that happens in the ER.


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## DrankTheKoolaid (Aug 25, 2012)

Yeah that is true JP, but if the Paramedic knows what he is doing the patient can be stabilized with a needle decompression and not prolong arrival to definitive care.

Re-reading the OP's 2 options at bottom of his post, both are poor unacceptable options.  Air is not indicated and I stand by my statement doubting that air is going to be faster then a C2 drive unless the helo is close and already in the air.  Start talking 1 hour+ ground transport and then air is more of an appropriate decision as long as it is immedietly available. 

A competent Paramedic should be able to handle a pneumo and recognize when it needs to be treated VS monitored.  So bypassing to the closest ED really isnt indicated and will only prolong transfer to definitive care at least an hour if the rules are followed by EMTALA standards.


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## AeroClinician (Aug 25, 2012)

Corky said:


> So bypassing to the closest ED really isnt indicated and will only prolong transfer to definitive care at least an hour if the rules are followed by EMTALA standards.



But if the local hospital is able to handle the pt. then why would they transfer the pt. out?


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## DrankTheKoolaid (Aug 25, 2012)

Any ED is capable of handling a simple pneumo.  The real questions you have to ask are what is the bed status on Med-surg? 

What aquity level will the small community hospital keep upstairs? If it is like some of the locals im used to, much more then the sniffles or abnormal lab values that need tweaking and observation get shipped.   Any actual treatment needed and that patient is getting transferred or denied admission to the floor to begin with. 

We have no level 1 anywhere close to us and our trauma center is a level 2, so the patient really doesnt need a level 1 anyway you look at it.


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## AeroClinician (Aug 25, 2012)

Corky said:


> Any ED is capable of handling a simple pneumo.  The real questions you have to ask are what is the bed status on Med-surg?
> 
> What aquity level will the small community hospital keep upstairs? If it is like some of the locals im used to, much more then the sniffles or abnormal lab values that need tweaking and observation get shipped.   Any actual treatment needed and that patient is getting transferred or denied admission to the floor to begin with.
> 
> We have no level 1 anywhere close to us and our trauma center is a level 2, so the patient really doesnt need a level 1 anyway you look at it.



And when contact with the ER Doc is made about the pt., he should be able to take bed status into account.
It sounds like the locals in your area are not the same as central FL locals I am used to. Most of the locals can and do treat serious patients, I only know of 1 in my area that is like the locals in your area.


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## FLdoc2011 (Aug 25, 2012)

abckidsmom said:


> But the ER is not the end of the patient's stay.  The podunk community hospital is not going to have experience with a trauma patient with a chest tube.  The nurses on the floor are going to have to dig deep to remember the last patient they ambulated with a chest tube.  They are going to be impressed with the pain the patient has and potentially let him stay in bed, increasing his risk for darn near everything.



Again, this is highly subjective and not sure what you're definition of a "Podunk community hospital" is, may be different from mine.   A lot of our community hospitals around here routinely do open hearts and complicated neurosurgery cases, not to mention have full service ICU's so a chest tube is nothing.   In a super rural area where the hospital may or may not even have a functional ICU then you may have a valid point but I don't think that's what he's dealing with.


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## usalsfyre (Aug 25, 2012)

jwk said:


> It is near impossible for a non-teaching hospital to be a level 1 trauma center, because trauma is a money-loser and most hospitals don't want to pay


Bingo. 

But it is ENTIRELY possible to be a level II. There are two LIIs in podunk East Texas. I've worked for and around both of them. They (and most LIIs) are extremely capable of handling this type of patient. Trauma designations are about ensuring appropriate resources and expertise is available. Yes Podunk (or not so Podunk) general may be able to deal with a trauma patient on a Wednesday. What about Saturday of a holiday weekend when half the medical staff is out of town or half in the bag? 

Trauma is poorly reimbursed and expensive. That also helps keep volumes high, which is important for outcomes.


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## DrankTheKoolaid (Aug 25, 2012)

Firehazmedic said:


> And when contact with the ER Doc is made about the pt., he should be able to take bed status into account.
> It sounds like the locals in your area are not the same as central FL locals I am used to. Most of the locals can and do treat serious patients, I only know of 1 in my area that is like the locals in your area.



Yeah I am in a rural area where the local podunk is a level 4 at best, but they dont keep up with accurate trauma reporting so they dont even have that status, and the med surg nursing staff is almost all new grad so patient severity that is admitted is extremely low.  Something else I notice repeated by you is talking with the ED Doc.  That happens extremely rarely here as our autonomy on destination if not guided by hard protocols is left to the individual medic to decide based on patient presentation.  Only contact we ever need to make ( not to the local podunk, but our base which is 1 hour plus away ) is for the rare med, other wise they just get a report if we bring them to them before arrival.


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## JPINFV (Aug 25, 2012)

usalsfyre said:


> Bingo.
> 
> But it is ENTIRELY possible to be a level II. There are two LIIs in podunk East Texas. I've worked for and around both of them. They (and most LIIs) are extremely capable of handling this type of patient. Trauma designations are about ensuring appropriate resources and expertise is available. Yes Podunk (or not so Podunk) general may be able to deal with a trauma patient on a Wednesday. What about Saturday of a holiday weekend when half the medical staff is out of town or half in the bag?
> 
> Trauma is poorly reimbursed and expensive. That also helps keep volumes high, which is important for outcomes.



Considering that the major difference between level I and level II was the presence of research and a residency program, I'm surprised that anyplace makes a distinction between a level 1 and a level 2 trauma center. It's the lower levels where you start running into the issue of specialists either not being their or being on call at home.


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## med51fl (Aug 26, 2012)

I would transport to the local ED.  Based on what you gave in your scenario there would be no real indication for me to do otherwise.  

Now, with that being said there is always that pesky "gut feeling" about patients.  If that is what had you second guessing yourself, then throw down the paramedic judgement card for trauma criteria and send them to the level 1.  If that is the case then don't bother calling the local ED to try and have the doc talk you out of your decision.

Myself, I call the ED doc in two cases. 1. request to stop resuscitation 2. for orders that exceed my standing orders


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## Veneficus (Aug 26, 2012)

JPINFV said:


> ...but we're discussing a case where the patient doesn't necessarily meet trauma center criteria and whether it's appropriate to drive 20-30 minutes further for a trauma center (time between hospitals is the only thing that matters in this, not total transport time). *We're discussing a procedure that any board certified emergency physician should be able to perform*.



I think this is the key.

But you first have to have the EM.

Many community hospitals I have been to in the US do not staff EMs. They staff whatever they can get.

While it is true that prior to EM many "dedicated" ED docs who wanted to be in the ED we actually IM, and there are still a few of these older and highly capable docs floating around, even in major EDs, when you go to a community facility, You simply don't know what you are getting. 

Then there is the question of resources?

Does the community hospital actually have the equipment or can it dedicate staff to specific procedures? 

I agree with JWK there is a lot of money and politics that revolve around trauma. 

Probably more so than many other forms of medical service.

But I disagree that other hospitals can be just as capable. If they had such a dedication, they would be advertizing as more capable for trauma, which if they actually want to make money is probably not a good idea. 

There is an argument by some in the EM community that since they handle a lot of minor trauma they should be considered more than capable trauma experts.

But my opinion is is you can only handle part of the case load, then how can you be an expert?

What service does EM admit their trauma patients to?


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## JPINFV (Aug 26, 2012)

Veneficus said:


> What service does EM admit their trauma patients to?



Well, there was a patient at my current rotation (for some reason, the students on psych still have to pull inpatient call. It's a family practice and traditional rotating internship program, so I refuse to call it IM), the guy who went over his handle bars on his bike and ended up with 2 broken ribs, a broken thumb, and a broken clavicle was admitted to medicine with an ortho consult. Not saying it's the best, but it is what it is.


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## Veneficus (Aug 26, 2012)

JPINFV said:


> Well, there was a patient at my current rotation (for some reason, the students on psych still have to pull inpatient call. It's a family practice and traditional rotating internship program, so I refuse to call it IM), the guy who went over his handle bars on his bike and ended up with 2 broken ribs, a broken thumb, and a broken clavicle was admitted to medicine with an ortho consult. Not saying it's the best, but it is what it is.



But was he admitted by the ED physician or by IM?


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## JPINFV (Aug 26, 2012)

Veneficus said:


> But was he admitted by the ED physician or by IM?




EM I believe, but I'm not 100% sure about how the departmental politics run at this hospital.


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