Arrest Transport Destination

[WuLabsWuTecH]

So there wan an arrest a few weeks ago that I was not on, and I want to stress that it's obviously easier to look at the situation with hindsight (Monday Morning Quarterbacking if you will) but I'm thinking that the crew on this arrest made the right call.

The arrest happened in an area where our hospital options were a county hospital that is known as being just a "band aid station" that was about 15 minutes away. The Level II trauma center in the closest big city was about 30 minutes away. (The crew chose the latter which had an actual transport time of 27 minutes).

My question is, if you were in the situation, which hospital would you have chosen? I was always taught that with an unstable patient, you go to the closest regardless of what kind of hospital it is. But the crew made the argument on "monday morning" that going to the bandaid station would have done no one any good because all they would have done was the same ACLS we were already doing and they didn't have any more advanced techniques. Also, running fewer arrests in a year than the big city hospital the likelyhood of survival was less. They also made the point that if we got the person back (which we did) the smaller hospital would not have been able to cath the patient and now we just traveled 15 minutes laterally so the patient is still a half hour from a cath lab.

Currently if a patient codes on our doorstep, I take them the 15-17 minutes due south to a (different) county hospital that is very limited in what they can do (8 bed ER, no OB capabilities, no cath lab, etc). I'm starting to wonder if I should opt to go the 30-35 minutes due north to the big city hospital now. Because otherwise, I'm actually taking them 15-17 minutes AWAY from definitive care...

Any thoughts?

 

[Medic Tim]

Was the pt in arrest? Or still alive but unstable? If it was an arrest I would work it on scene then call it after so long unless there was some reason to transport. Not sure if you guys can do that. If the pt was still alive but in bad shape it is usually in the pts best interest to not go to the band aid station.That said.....Without knowing more of the situation and anything about the pt it is hard to say.

 

[Fish]

We do not transport Arrest, not without extenuating cirumstances. And if we do, it is to a hospital that best fits the patient's needs. Unless that hospital is to far away, then we go to the closest. All hospitals are able to stabilize

 

[WuLabsWuTecH]

Was the pt in arrest? Or still alive but unstable? If it was an arrest I would work it on scene then call it after so long unless there was some reason to transport. Not sure if you guys can do that. If the pt was still alive but in bad shape it is usually in the pts best interest to not go to the band aid station.That said.....Without knowing more of the situation and anything about the pt it is hard to say.

It was a witnessed arrest--our protocol requires us to transport all of those. Further, they were able to get pulses back briefly--once again, we are required to transport anyone who had a pulse at any time while we are present. The patient is still in ICU, but they have a good prognosis based on a neuro consult the last I heard.

 

[DesertMedic66]

Closest hospital. They can stabilize the patient and then transport to another hospital if needed.

 

[JPINFV]

What advanced techniques do they want?

 

[DrParasite]

It was a witnessed arrest--our protocol requires us to transport all of those. Further, they were able to get pulses back briefly--once again, we are required to transport anyone who had a pulse at any time while we are present. The patient is still in ICU, but they have a good prognosis based on a neuro consult the last I heard.

If it's a witnessed arrest, there are signs of potential recover (ie, not in PEA, shockable rythym, you get pulses back, young patient with no cause, etc), I try to transport. Stabilize as best you can, if after a predetermined amount of time, start going to the hospital, maybe the ER can do something you can't.

Closest hospital though, any ER should be able to stabilize the patient.

 

[WuLabsWuTecH]

See everyone here keeps saying closest ER, which is exactly what I was taught! But this crew, and a few others have made a good argument for not going to the closest ER, especially if they are taking them away from a tertiary care center.

So let me re-pose the question in a different manner. What do you potentially lose by going 15 minutes further to a more advanced facility?

 

[shfd739]

See everyone here keeps saying closest ER, which is exactly what I was taught! But this crew, and a few others have made a good argument for not going to the closest ER, especially if they are taking them away from a tertiary care center.

So let me re-pose the question in a different manner. What do you potentially lose by going 15 minutes further to a more advanced facility?

I'm in the same position here depending on where I am in our county. One area has a pretty complete hospital in the area but doesnt have an interventional cath lab and usually has full ICUs. If I go there with a resuscitated arrest and they manage to keep them alive the patient will have to be transferred later to a facility with interventional cath lab and open ICU beds.

Or I can go 12 mins further down the road to the more complete facility to begin with doing the same stabilizing procedures the bypassed ER would have done.

Think ill run this by our medical directors/ftos and see their take. To me it's justifiable as makes definitive care happen sooner.

 

[Tigger]

Closest hospital. They can stabilize the patient and then transport to another hospital if needed.

What constitutes stabilizing the patient that an EMS crew cannot do?

 

[VFlutter]

What were the circumstances of the arrest? If the patient had a significant cardiac history with chest pain prior to arrest then I think an argument can be made to transport to a Cath Lab instead of the nearest hospital

 

[JPINFV]

So let me re-pose the question in a different manner. What do you potentially lose by going 15 minutes further to a more advanced facility?

Again, what treatments are you expecting the more advanced facility to perform for a patient still in arrest?

 

[Aprz]

Do you guys have the Lucas device or Zoll Autopulse? If not, that's more time probably doing poorer chest compressions.

You don't ask yourself what do you lose when taking a patient to a facility, you ask what do you gain. That's usually what you have to document in your PCR tok, lol. What did this patient gain that they couldn't from the closer facility? I can only think of a traumatic arrest benefiting from going to a trauma center, but some would say that those patients aren't even worth working up: extremely unlikely to be resuscitated and it takes units out of service burdening the EMS system.

Transporting a patient in cardiac arrest period usually isn't good for the patient, it takes time away from chest compressions moving them to the gurney and into the ambulance, chest compressions are usually poorer, and for the most part, the hospital is gonna follow ACLS unless special circumstances like a pericardial tamponade or penetrating injury.

So I'd like to know why this patient benefited going to the facility further away that was actually useful to this patient for this situation.

 

[DrParasite]

If the patient had a significant cardiac history with chest pain prior to arrest then I think an argument can be made to transport to a Cath Lab instead of the nearest hospital

That was what I was told by a paramedic who is now the clinical coordinator at my former job. Any ER can handle the arrest; but it's the after care that needs to be mitigated.

It's like a traumatic arrest: they can be taken to the closest ER (if you chose to transport). And statistically they have as much of a chance to save the life as a trauma center. But once they do save the life, then what? you need to transfer them from the local ER to the trauma center to deal with all the traumatic injuries and everything post surgery.

If it's less than a 20 minutes difference, than maybe it's worth it. most important thing is to get the heart beating again. but remember, if the hearts not beating, it doesn't matter where you end up transferring them to.

 

[Veneficus]

So there wan an arrest a few weeks ago that I was not on, and I want to stress that it's obviously easier to look at the situation with hindsight (Monday Morning Quarterbacking if you will) but I'm thinking that the crew on this arrest made the right call.

The arrest happened in an area where our hospital options were a county hospital that is known as being just a "band aid station" that was about 15 minutes away. The Level II trauma center in the closest big city was about 30 minutes away. (The crew chose the latter which had an actual transport time of 27 minutes).

My question is, if you were in the situation, which hospital would you have chosen? I was always taught that with an unstable patient, you go to the closest regardless of what kind of hospital it is. But the crew made the argument on "monday morning" that going to the bandaid station would have done no one any good because all they would have done was the same ACLS we were already doing and they didn't have any more advanced techniques. Also, running fewer arrests in a year than the big city hospital the likelyhood of survival was less. They also made the point that if we got the person back (which we did) the smaller hospital would not have been able to cath the patient and now we just traveled 15 minutes laterally so the patient is still a half hour from a cath lab.

Currently if a patient codes on our doorstep, I take them the 15-17 minutes due south to a (different) county hospital that is very limited in what they can do (8 bed ER, no OB capabilities, no cath lab, etc). I'm starting to wonder if I should opt to go the 30-35 minutes due north to the big city hospital now. Because otherwise, I'm actually taking them 15-17 minutes AWAY from definitive care...

Any thoughts?

I think the crew made the right decision.

From my perspective everywhere I have been, if you are really sick, you need the academic facility, not the community hospital. (most of which are band aid stations.)

If it is me or somebody I care about, please bypass any communuty facility.

 

[medicdan]

Did the crew do a 12 lead that indicated an infarct that would respond to PCI? Was their a specific intervention or indication for treatment at the larger hospital?

 

[zmedic]

I think it goes back to protocols. If your protocols say "transport post arrest to the closest hospital," you should call medical control and ask to bypass. If they say yes you are home free.

If that patient is still in arrest you should go to the closest hospital. Mainly because if you haven't been able to get them back on scene they probably aren't coming back. And the ACLS the closest hospital is going to do is the same as the other. And you won't be 30 minutes out of your district for no real reason.

 

[MSDeltaFlt]

According to my company, and I believe AHA & NR, in the absence of a pulse the nearest appropriate facility is the nearest facility period.

 

[Fish]

What constitutes stabilizing the patient that an EMS crew cannot do?

Blood, or an airway that the EMS crew cannot get. With someone who has a pulse.

If we are working a code....... Not much else, not unless your across the street from the cath lab or the trauma facility. Then again there would be no "stabilizing" before sending them out. They would just be attempting to fix the problem right then and there

 

[Handsome Robb]

Like others have said, I don't transport patients except in certain circumstances. Personally, with CPR in progress the patient is going to the nearest facility unless it was witnessed with indications that patient could potentially benefit from specialty services not available at the closest facility. Sure they my be doing "everything we do in the field" but they are doing it in a well lit room, *usually* with more trained hands (even here we will stay and help with really sick patients for a few minutes if they need it, don't see what the EMS crew can't supplement ER staff in this situation) and ultimately an MD.

Sure the bandaid station doc may not run all that many arrests but at the same time those medics that work in a system that the closest facility is said bandaid station probably don't run that many either. By no means am I doubting the capabilities of rural EMS personnel but I just don't think the "that hospital doesn't work enough arrests" is a valid argument.

Why not stop, get a definitive airway (KINGs are our first line in arrests and we can't swap it for an ETT unless it fails) get some labs drawn and start processing them, have an MD, who generally can tell you more then "STEMI or No STEMI" from it, look at the 12-lead, get better vascular access if you need it, orders for pressors, sedation, antibiotics, whatever it may be if you need them then get moving on your way to the more capable facility as an emergent IFT?