Arrest Transport Destination

[shfd739]

Going back to the original post.

I ran this scenario past our FTO today and was reminded that our policies/protocols allow us to bypass the closer facility if the closer facility doesn't have a service that may be needed. Cath lab, ICU, trauma care etc. I had forgotten about it since its never been an issue for me.

So for me in this situation I'm going to that further hospital.

 

[WuLabsWuTecH]

Going back to the original post.

I ran this scenario past our FTO today and was reminded that our policies/protocols allow us to bypass the closer facility if the closer facility doesn't have a service that may be needed. Cath lab, ICU, trauma care etc. I had forgotten about it since its never been an issue for me.

So for me in this situation I'm going to that further hospital.

I think most people have this same provision in their protocols as well. But it's a generally accepted rule that unstable ==> closest hospital even when the hospital can't provide definitive care (ex. transporting a burn patient who is unstable to a non-burn center because the person's in respiratory arrest).

So I guess the question is at what point do you choose to go to that closer hospital?

Is there a time cutoff? Or a severity cutoff?

 

[shfd739]

I think most people have this same provision in their protocols as well. But it's a generally accepted rule that unstable ==> closest hospital even when the hospital can't provide definitive care (ex. transporting a burn patient who is unstable to a non-burn center because the person's in respiratory arrest).

So I guess the question is at what point do you choose to go to that closer hospital?

Is there a time cutoff? Or a severity cutoff?

Airway is pretty much our only reason to go to the nearest. Otherwise we are heading for the definitive care facility. 30+ min time differences are the norm some times and acceptable if it means the patient is going to definitive care.

In the case of a resuscitated arrest we can do the same treatments in the unit(for the most) and the patient will be better cared for at the more distant facility- so we are going there.

In the case of an unstable patient it's a medics judgment call on where to go and no has been faulted for their decisions.

 

[cruiseforever]

Our protocols for people that have a ROSC have changed. If the pt. was in V-fib, V-tach, or shocked by an AED we are to transport to a hospital with a cath lab.

It is a very rare event for our system to transport a pt. in cardiac arrest. I have heard the U of M is thinking of doing a study of pts. in refactory v-fib. They want the pts. transported to them and go directly to the cath lab.

Dr.Yannopoulos has been very aggressive in researching cardiac arrests.

http://www.mrc.umn.edu/DYannopoulos/home.html

 

[DesertMedic66]

I think most people have this same provision in their protocols as well. But it's a generally accepted rule that unstable ==> closest hospital even when the hospital can't provide definitive care (ex. transporting a burn patient who is unstable to a non-burn center because the person's in respiratory arrest).

So I guess the question is at what point do you choose to go to that closer hospital?

Is there a time cutoff? Or a severity cutoff?

Burns for us either get transported to our trauma center (not a burn center) or have to be flown out due to the closest burn center being 60-160 miles away depending where we are at in our response area.

If the incident happened close to the trauma center then we will transport there otherwise the patient is flown out.

I've have not ran into an issue like this before as all 3 of our hospitals are STEMI and Stroke centers. If the patient is in full arrest they get transported to the closest facility for us.

 

[leoemt]

I am lucky I don't really have to worry about that. Here in Seattle we have 8 hospitals within the city limits. Some of them are Trauma based (i.e. Harborview) and don't really like cardiac arrest. Others are more medically based and specialize in Cardiac (i.e. Swedish - Cherry Hill). That said every hospital in the region can stabilize. They all have ALCS equipment and drugs. Not all of them have Cath labs though.

The key to EMS is to get them to the Closest MOST APPROPRIATE facility in the least amount of time. What is the difference between the "band aid" station and the other hospital? Does the other hospital have cardiologists on staff? Do they have a cath lab?

To be certified as a hospital I would assume that the "band aid" station would have to be able to stabilize at a minimum. If the arrest was trauma related I would most likely go to the closest "band aid" hospital. However, if the arrest was medical then the bigger hospital would be more appropriate.

A patient with a medically induced cardiac problem needs the specialists that a cardiac facility provides.

I agree with your crew I think they made the right call.

 

[WuLabsWuTecH]

Burns for us either get transported to our trauma center (not a burn center) or have to be flown out due to the closest burn center being 60-160 miles away depending where we are at in our response area.

If the incident happened close to the trauma center then we will transport there otherwise the patient is flown out.

I've have not ran into an issue like this before as all 3 of our hospitals are STEMI and Stroke centers. If the patient is in full arrest they get transported to the closest facility for us.

Yeah I think we are in a bit of a unique situation since our closest hospital (from station, because our district is so large, hospital distances change based on which "zone" we are in) is actually 18 minutes AWAY from the major big city hospitals, and numbers 2 and 3 while not taking the patient farther away, are actually not taking them any closer either. Number 4 is a bit better in terms of getting the patient moving in the right direction, but does not have cath or stroke. Number 5 is a L2 trauma center with cath lab (until 1900), an stroke. Number 6 is a L1 trauma center with cath and stroke, and it isn't until number 7 that we get to a L1 trauma center with cath, stroke, hyperbaric, and burn.

I am lucky I don't really have to worry about that. Here in Seattle we have 8 hospitals within the city limits. Some of them are Trauma based (i.e. Harborview) and don't really like cardiac arrest. Others are more medically based and specialize in Cardiac (i.e. Swedish - Cherry Hill). That said every hospital in the region can stabilize. They all have ALCS equipment and drugs. Not all of them have Cath labs though.

The key to EMS is to get them to the Closest MOST APPROPRIATE facility in the least amount of time. What is the difference between the "band aid" station and the other hospital? Does the other hospital have cardiologists on staff? Do they have a cath lab?

To be certified as a hospital I would assume that the "band aid" station would have to be able to stabilize at a minimum. If the arrest was trauma related I would most likely go to the closest "band aid" hospital. However, if the arrest was medical then the bigger hospital would be more appropriate.

A patient with a medically induced cardiac problem needs the specialists that a cardiac facility provides.

I agree with your crew I think they made the right call.

The "band-aid" stations do not have cardiologists on staff 24/7. Actually, our closest hospital does not even have an OB/Gyn, urology, or dialysis service.

 

[Veneficus]

The "band-aid" stations do not have cardiologists on staff 24/7. Actually, our closest hospital does not even have an OB/Gyn, urology, or dialysis service.

Isn't that a pisser?

 

[mycrofft]

Homework assignment:

Next time you are at the ED, ask them directly what benefit being there versus another ED or the back of the unit is, and their druthers about what is done before the pt's arrive etc. Ask if they really want to receive rolling codes. Ask, if it was their loved one, where they'd want them taken.

 

[Veneficus]

Next time you are at the ED, ask them directly what benefit being there versus another ED or the back of the unit is, and their druthers about what is done before the pt's arrive etc. Ask if they really want to receive rolling codes. Ask, if it was their loved one, where they'd want them taken.

Please take myself or my family to the academic center bypassing any community center along the way unless there is failure to get an airway.

 

[zmedic]

I don't really like the "it doesn't matter if we miss the airway because they are dead" argument. My issue is that if you esophageally intubate and you get ROSC, those pulses aren't going to last very long. Most EMTs don't have the sort of tools that medics carry to confirm tube placement like wave form capnography.

It's also much harder to intubate than you think. I was trained as an EMT to intubate, had probably intubated the airway head 60 times. And I felt "I could do this if my protocols let me, no problem." Now as a resident I intubate all the time and I realize how little I knew. It took at least 15 real tubes before I felt somewhat competent. So I don't agree with letting EMTs do it if they haven't had OR time. And the data isn't holding up intubation as "this is so important we need to get it out in the boonies even if it means EMTs are doing it." Bag them, or throw in a Combi tube.

 

[Veneficus]

So I don't agree with letting EMTs do it if they haven't had OR time. And the data isn't holding up intubation as "this is so important we need to get it out in the boonies even if it means EMTs are doing it." Bag them, or throw in a Combi tube.

Like I said, Ohio is stuffed full of EMS leaders who think the ability to intubate is the one true faith of EMS. Especially Southern Ohio. The fact it may be on the ropes and going down now is a huge step in realing in the many good hearted but "amateur" vol. departments that have way too much power in state EMS.

I have also seen some recent stuff that the SGAs are doing harm in survivors as well.

Despite the huge marketing of device manufacturers, maybe we need to accept both "less is more" and skilled providers over a device to make up for inability?

Radical idea, I know.

 

[mycrofft]

zmedic, ROSC usually doesn't last that long anyway. Like that laptop that stops working, you shake it and it works again even though you didn't do anything tangible to address the root problem.

 

[WuLabsWuTecH]

Please take myself or my family to the academic center bypassing any community center along the way unless there is failure to get an airway.

This has been repeated a lot in our station lately. Meeting with the Medical Director this weekend for all of the crewmembers, and I think it has to to with addressing this issue.

I don't really like the "it doesn't matter if we miss the airway because they are dead" argument. My issue is that if you esophageally intubate and you get ROSC, those pulses aren't going to last very long. Most EMTs don't have the sort of tools that medics carry to confirm tube placement like wave form capnography.

It's also much harder to intubate than you think. I was trained as an EMT to intubate, had probably intubated the airway head 60 times. And I felt "I could do this if my protocols let me, no problem." Now as a resident I intubate all the time and I realize how little I knew. It took at least 15 real tubes before I felt somewhat competent. So I don't agree with letting EMTs do it if they haven't had OR time. And the data isn't holding up intubation as "this is so important we need to get it out in the boonies even if it means EMTs are doing it." Bag them, or throw in a Combi tube.

We do have capnography on board on our monitors. We have to confirm with 2 methods before using it though, so ascultation and the changing color thingy. Though because you've introduced some CO2 into the stomach from bagging and/or the environment, the color change thingy may not always be accurate. Even on a waveform capenography you may get a few breaths with CO2 registering before it stops registering due to the fact that you can introduce CO2 into the stomach.

I'm never going to intubate at the level of a resident until I am a resident, but I feel that it's not a tool we should have taken away. The Scope in Ohio is written as a maximum, so unlike Texas, our medical director is limited by law to the scope. If intubation is something that a MD feels his crew is not ready to do, then don't let them do it. Simple as that, but to not let those of use who have a use for it and whose medical director feels can do it satisfactorily, is taking a tool out of our arsenal. In our general protocols, we do not have RSI for medics, and most basics cannot give drugs off the truck. But for certain people, the MD has approved the RSI protocol and allowed people like me to give drugs off of the truck because he knows that we know what we are doing, and in my case he knows I have the indications and contraindications memorized for each one of the drugs I'm allowed to give.

Like I said, Ohio is stuffed full of EMS leaders who think the ability to intubate is the one true faith of EMS. Especially Southern Ohio. The fact it may be on the ropes and going down now is a huge step in realing in the many good hearted but "amateur" vol. departments that have way too much power in state EMS.

I have also seen some recent stuff that the SGAs are doing harm in survivors as well.

Despite the huge marketing of device manufacturers, maybe we need to accept both "less is more" and skilled providers over a device to make up for inability?

Radical idea, I know.

I agree, but unless you find funding for those skilled providers, this is all we've got. I'm on an ALS department, but that means one paramedic. The rest of us are basics, and if he's already tied up, why can't we, as trained providers use those skills? I agree, there are way to many volunteer departments (some that we run mutual aid or ALS with) that are too cavalier, but we can't keep writing the laws to suit the dumbest person!

My department has 3 med students, 2 pre-meds, and an ER intern on it not to mention numerous other very intelligent people. Why not lest us use our knowledge and skills? We are all very aware of the fact that a well trained monkey can probably perform the skills of a paramedic and treat a patient, but it requires an intelligent person to recognize when to not use those skills to treat a patient.

I've always had an impression that SGAs are not as good a ET tubes, but other than securing it, I can't really enumerate the other reasons as to why right now. I think you're right though in that there is a perception of using technology and equipment to make up for the shortcomings of personnel.

zmedic, ROSC usually doesn't last that long anyway. Like that laptop that stops working, you shake it and it works again even though you didn't do anything tangible to address the root problem.

No, but you can patch it up to keep it running long enough to take it to someone who can fix the root of the problem!

 

[Veneficus]

In his recent frustration, one of my US EM friends posted this on FB.

http://www.youtube.com/watch?v=xskFo75Wdhs

Well played Doc.

 

[NYMedic828]

I don't really like the "it doesn't matter if we miss the airway because they are dead" argument. My issue is that if you esophageally intubate and you get ROSC, those pulses aren't going to last very long. Most EMTs don't have the sort of tools that medics carry to confirm tube placement like wave form capnography.

It's also much harder to intubate than you think. I was trained as an EMT to intubate, had probably intubated the airway head 60 times. And I felt "I could do this if my protocols let me, no problem." Now as a resident I intubate all the time and I realize how little I knew. It took at least 15 real tubes before I felt somewhat competent. So I don't agree with letting EMTs do it if they haven't had OR time. And the data isn't holding up intubation as "this is so important we need to get it out in the boonies even if it means EMTs are doing it." Bag them, or throw in a Combi tube.

As a NYer I presume you are familiar with the "critical care technician" certification we use out on Long Island. The "CC" curriculum does not include any form of live intubation training. As you stated they simply use the airway manikin. On the rare occasion that we respond to a patient requiring intubation and a "CC" does it, they almost always fail. Simply because they have never succeeded, and most never attempted, to intubate real flesh.

 

[18G]

I see the crews point in going to the larger hospital. A strong focus has been placed on post-resuscitation care including hypothermia and immediate cath lab for ROSC arrest patients.

By going to the small "band-aid" station a delay in PCI and hypothermia would result. But on the other hand it's been proven that a resuscitation carried out in the back of a moving ambulance isn't real effective.

I can see the argument from both sides and honestly not sure which would be the better decision. I'm thinking I would go to the small hospital where a quality resuscitation could happen and then standby at the ED so if a ROSC is achieved the patient could be swiftly transferred.

 

[usalsfyre]

In his recent frustration, one of my US EM friends posted this on FB.

http://www.youtube.com/watch?v=xskFo75Wdhs

Well played Doc.

"A big dose of Lasix and some metoprolol"

This kicked over my giggle box.