Closest APPROPRIATE facility

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willtcam

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Hey guys... I just recently became a medic and looking for a little input.

I know all throughout school it's pounded in our heads to transport to the closest appropriate facility so tell me what you guys find more appropriate.

I work in a small community with a small community hospital as well as a flight service in town. Next closest hospital is a level 1 about an hour away by ground. Let's say you have a CVA/STEMI patient, do you fly them straight to the level 1 or transport them to the local hospital for tpa/tnk and let the hospital fly them?
 
This should be explained in your protocols.
Is the local hospital a STEMI or stroke center? Do they have CT, MRI, and/or a cath lab?
 
Not a stemi or stroke center but do have ct and mri no cath lab.
 
Fly them
 
Obviously you have to go by your local protocols, but I would say to go to the Level 1. The local hospital is not going to be able to do much more than you can, except for some meds such as brilinta and heparin. At the rural hospital I work at, EMS keeps the pt on the stretcher until the EKG is complete. If there is a STEMI, they take the pt to the cath lab 45-60 minutes away without the pt coming off of their stretcher. We've had arrival to depart times as low as 6-8 minutes. The rate limiting step is waiting for the accepting cardiologist to call back.
 
Fly. I have worked in an area exactly as you described, and we bypassed the ED on a regular basis to fly patients to a definitive care facility. No point in wasting an hour or more for the community hospital to 'stabilize and transfer' the patient that could already be at definitive care if you had just bypassed the ED
 
Ok so I guess the general consensus is fibrinolytics are not worth the added time to definitive care.
 
willtcam said:
Ok so I guess the general consensus is fibrinolytics are not worth the added time to definitive care.
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I don't think anyone is necessarily saying that. That - and all of this - is your medical director's call and should be guided by your protocols. Everyone knows that the really sick ones go to the big house, but there's a lot of grey area here and paramedics often aren't very aware of what resources do and don't exist at local facilities.

If all of this isn't made clear in your protocols, ask your medical director for clarification.
 
I worked in a similar area as you. we determined fly/drive/local by where we were at in the county.

For Stroke it was what was our time of onset, because our local did have CT / CTA available. now on STEMI it was automatic bypass and a call to the local facility saying hey we got a stemi bypassing you.
 
CVA's go local; but call and warn them so that they can wake up CT tech and look up protocols for TPa.

Ask the Medical director AND the local ED what the local hospital has (is capable of) so that you know these things in advance
 
My non FT service is about an hour and 15 mins by ground to closest PCI/Stroke Center. All suspected CVA and STEMI patients get flown out if possible. In the end both of those patient groups would likely be flown out of the ED anyways, skip the middle man and save time for the patient.
 
In my area we always bypass the closest facility if the patient meets stroke or stemi or trauma center criteria and the closest isn't a designated center for that. For example, we had a full arrest earlier today, after ROSC the rythm was A-Fib with ST Elevation so we had to go to the STEMI Receiving Center, which was twice as far as the local.

Then again were in a built up urban area so that meant a 15 min drive instead lol, bit of a different story than your hour long transports
 
I think this is a really interesting topic. I'm curious as to when (if ever) it's no longer worth it to make a long distance transfer.

At a recent drill I met a paramedic from a rural area. He said that he would often have a 4+ hour drive time from the scene of a trauma to be within radio coverage to call for a helicopter.Yikes! Super rural!

Let's say it was foggy and you finally got to a rural basic hospital with a trauma patient. The trauma center is an additional six hours by ground and the aircraft cannot fly. Is it always best to go to the trauma center, or are there times where the risk/benefit analysis favors staying put and doing whatever you can locally?
 
RedAirplane said:
I think this is a really interesting topic. I'm curious as to when (if ever) it's no longer worth it to make a long distance transfer.

At a recent drill I met a paramedic from a rural area. He said that he would often have a 4+ hour drive time from the scene of a trauma to be within radio coverage to call for a helicopter.Yikes! Super rural!
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4 hour drive time just to get a radio or cell signal? Sounds like a rather large exaggeration. How do they communicate with their dispatch or med control? What if they need PD or FD or another EMS unit? How are they dispatched? How does the public even contact 911 in the first place?

There are lots of times that it's appropriate to go to a much closer facility so that they can evaluate, stabilize, and then arrange IFT, rather than spend hours with a patient who you don't really have the skills and tools to manage for an extended time period. Depends on lots of factors. But I'd say it should be a consideration anytime you have a very long transport to a TC with a patient who is (or is at high risk to become) unstable.

The closest appropriate facility can change depending on factors, both clinical and operational.
 
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Remi said:
4 hour drive time just to get a radio or cell signal? Sounds like a rather large exaggeration. How do they communicate with their dispatch or med control? What if they need PD or FD or another EMS unit? How are they dispatched? How does the public even contact 911 in the first place?

There are lots of times that it's appropriate to go to a much closer facility so that they can evaluate, stabilize, and then arrange IFT, rather than spend hours with a patient who you don't really have the skills and tools to manage for an extended time period. Depends on lots of factors. But I'd say it should be a consideration anytime you have a very long transport to a TC with a patient who is (or is at high risk to become) unstable.

The closest appropriate facility can change depending on factors, both clinical and operational.
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4 hours was his words... But yea it seems a bit odd.
 
I have areas here that we are out of range of hospitals, dispatch etc; due to the mountains, but driving around them gets us within radio range (of dispatch anyway), but that is a pain unless you can send someone else to call for more help. Calling Med control sometimes is tough due to that: We have been told that if you can't get in touch with them do what is needed and document the crap out of it
 
You should always have the patient transported to the closest APPROPRIATE facility. The STEMI should always go to the closest cath lab and the stroke should go to a stroke center if possible.
 
Couple of questions for both OP and the rest of the group.

STEMI; We can confirm this in the field with OLMC and telemetry so i would fly a STEMI patient to a cath lab hospital

Stroke: Where are your primary and comprehensive stroke centers in relation to you? Do they have landing pads? Does your local have the knowledge to even do a stroke work up?

For everyone who is flying a stroke from the field, what guidelines are you using to confirm stroke and prevent flying every AMS patient? LA, Cinncy, MEND?
 
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