Destination for trauma patients?

[RedAirplane]

In a couple months I'll be moving from my current role as a volunteer event medic to a volunteer on a "real" 911 ambulance.

One of the biggest things I'm nervous about is trauma -- most people seem to think medical is harder, and perhaps it is at the ALS level, but for me at the BLS level, I feel much more in control of medical emergencies than trauma emergencies. I can talk, hand hold, reassure, and solve the problem by asking really good questions, as opposed to having to deal with blood, bandages, and backboards. I also really enjoy taking patient history and asking about their previous medical complaints, which is not something you get to do if it's an unconscious patient, or if the patient is so severe that you're focused narrowly on ABCs.

Some people had highly recommended the PHTLS course, and since I don't see much trauma on the event side, I thought it would be a good idea for me to brush up on that side of things, so I'll be taking a PHTLS course next month.

I've started reading the first few chapters so far, mostly about the trauma system. It highlights the need for transport to a trauma center because at an "ordinary" hospital the delay to get all the specialists into the ER and then activate the OR would be super lengthy.

However, I have a question about my particular case. I live 30-45 minutes by ground from a trauma center with no helipad and no suitable LZ nearby. Alternatively, there is a further trauma center about 45-60 minutes by ground or 25 minutes by air. However, I live across the street from a pretty big hospital, that, while it isn't a trauma center, has every other specialty under the sun--including STEMI/PCI, referral center for CVA, etc.

Suppose my primary complaint was a head injury and that I was entrapped beneath something for 30-45 minutes. Protocol would dictate I get transported to the trauma center. However, if the nearby hospital has the specialties needed for my case, and in the time I was entrapped could page all of those doctors and free up the facilities needed, why wouldn't the protocol be to have that happen and take me there? If that could be coordinated, wouldn't it save me time?

(This is hypothetical, I am not actually expecting to become entrapped with head injury any time soon).

Thank you.

 

[DesertMedic66]

While the closer facility may have all the other specialties they do not have trauma which means they do not have a trauma team, trauma surgeons, trauma ICU with trauma trained staff, or the appropriate equipment for trauma patients.

What will save you time is to have the airship already landed before the patient is freed up. Is your closest trauma center a level 1, 2, 3?

Are you a pedi patient who should be seen at a pedi trauma facility?

 

[gotbeerz001]

If you can truly solve the medical problem simply by asking questions, the person is not actually sick.


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[EpiEMS]

First, don't worry - you'll be just fine! And PHTLS will be a nice refresher.

However, I have a question about my particular case. I live 30-45 minutes by ground from a trauma center with no helipad and no suitable LZ nearby. Alternatively, there is a further trauma center about 45-60 minutes by ground or 25 minutes by air. However, I live across the street from a pretty big hospital, that, while it isn't a trauma center, has every other specialty under the sun--including STEMI/PCI, referral center for CVA, etc.

Suppose my primary complaint was a head injury and that I was entrapped beneath something for 30-45 minutes. Protocol would dictate I get transported to the trauma center. However, if the nearby hospital has the specialties needed for my case, and in the time I was entrapped could page all of those doctors and free up the facilities needed, why wouldn't the protocol be to have that happen and take me there? If that could be coordinated, wouldn't it save me time?

A couple of quick notes that are important:

In reference to the facility 30-45min from you, is it ACS designated as a trauma center (and if so, what level)? Also, the ACS criteria can be found in here, so that can tell you a bit more about what each level should have (unless there's some state designation, etc. that is distinguishing). Note, Level I and II are pretty similar, Level III things start to "drop off" clinically, if you will.

Also, for your reference: CDC Field Triage Guidelines

I can't speak to your regional protocols, specifically, but I would consider a couple of things: The nearby non-trauma facility may have the needed specialties, but it may not have them 24/7. If you can't control the airway, or if there's non-controllable hemorrhage, etc., diverting to the nearest facility is (usually) acceptable, to my knowledge. (However, I'm 10 min from an ACS Level II trauma center, so I'm feeling pretty lucky...)

To your theoretical question, those are big "ifs". "If" they could get the surgeon, "if" they had an anesthesiologist," if" they had a neurosurgeon - I don't think it's reasonable to expect those to be met. Even if they are, the nearest hospital may even have to transfer you after arrival - for all too many "ifs" - or they may not have the capability to hold a critical patient post-operatively...

There are many protocols that are silly, and many that are nutty. This one could be - possibly - reasonable.

 

[VentMonkey]

Op, first tell me what "reall 911" is to you. Second, it's a trauma patient, take them to a trauma center with trauma capabilities assuming they aren't "in extremis", and even then you can still work around things.

Like @gotshirtz001 mentioned that isn't a true "scratch my head at this" medical patient, though it is the majority of our calls, that's ok. A true medical case leaves you thinking "I wonder what was wrong", or "what could I have done better".

Trauma patients---> ABC's, good and early bleeding control, safe and efficient transport to the appropriate facility.

Again, I ask what's a "reall 911" service?...

 

[gotbeerz001]

Are you a pedi patient who should be seen at a pedi trauma facility?

I **** you not, I was working with a new medic and he asked me,

"So if we get a pediatric trauma activation here (30 minutes to either of 3 pedi trauma centers), where should we go?"

I look at him like "WTF, Oveur*?!... Why are you gonna jinx us like that?"

I had been able to avoid pedi trauma activations for nearly 3 years... 3 hours later we get a 5yo hit by car on MY TECH!"

* a beer to the first person who can tell me who Captain Clarence Oveur is


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[NomadicMedic]

From airplane.

 

[VentMonkey]

I **** you not, I was working with a new medic and he asked me,

"So if we get a pediatric trauma activation here (30 minutes to either of 3 pedi trauma centers), where should we go?"

I look at him like "WTF, Oveur*?!... Why are you gonna jinx us like that?"

I had been able to avoid pedi trauma activations for nearly 3 years... 3 hours later we get a 5yo hit by car on MY TECH!"

* a beer to the first person who can tell me who Captain Clarence Oveur is


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Where's my beer?

 

[VentMonkey]

From airplane.

I'll split it with you.

 

[gotbeerz001]

View attachment 3185
Where's my beer?

[emoji482] Hit me up when you're out this way!


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[gotbeerz001]

From airplane.

[emoji482] Same offer to you!


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[WolfmanHarris]

Roger Roger, what's my clearance Clarance? (I mourn the death of Leslie Neilsen more than some relatives)

It's going to be entirely system dependent. What has been set up in the area you are, how much discretion you're allowed to exercise for activation in your system and what can your local hospitals handle. The biggest issue I have seen in new providers is not in false activations of a trauma team, but in being hesitant to transport patients to a trauma centre who weren't obvious major, probably going to die, multi-system trauma to regional trauma centres.

Takes a deep breath, don't get distracted by obvious injuries or lack there of and consider what has actually happened to the patient. Good example of the top of my head:

About four months ago responded to an ATV vs dirt bike at about 0400. Two patients lying on a dirt farm driveway, both HBD, collision unwitnessed, timelines unclear as patients only found when other party-goers got concerned. One Pt. obtunded w/ a GCS of 6, posturing, CNS hyperventilation, significant blood loss from scalp and facial avulsion, no helmet, HBD, no drugs. He was a clear case of a patient going to the trauma centre.

Counterpart to the collision was GCS13, HBD, unclear LOC, no obvious significant injuries, event amnesia, repetitive questioning. Minimal marks on him, vitals looked fine. He went to the trauma centre based on an abundance of caution, MOI (which while generally a poor predicator of trauma, he was still hit on an unrestrained vehicle w/ no helmet), the condition of the counterpart to his collision and the decreased LOC. No one at the regional trauma centre batted an eye over him coming in.

They don't need to look all gorey to necessarily be a good candidate for a trauma centre nor are all bloody messes instantly going to a trauma centre.

 

[VentMonkey]

Roger Roger, what's my clearance Clarance? (I mourn the death of Leslie Neilsen more than some relatives

Well, since the ops name has "Airplane" in it, I'm calling this relevant to this thread...

 

[WolfmanHarris]

Well, since the ops name has "Airplane" in it, I'm calling this relevant to this thread...

Thanks! You have no idea how much that improved my mood before bed.

 

[Jim37F]

^Repetitive questioning, loss of consciousness, Knocked Out, unable to remember event, etc is pretty much automatic trauma center transport here. Though I am lucky enough I have both a Level I and a Level II withing 20 min of my station....so it's real easy to say "let's just go to the Trauma Center just in case" even if not deciding to call in a trauma alert.

This is my county's trauma center criteria, yours will almost certainly be different so be sure to get copies of your LEMSA's and agency specific policies/protocols.

 

[Handsome Robb]

^Repetitive questioning, loss of consciousness, Knocked Out, unable to remember event, etc is pretty much automatic trauma center transport here. Though I am lucky enough I have both a Level I and a Level II withing 20 min of my station....so it's real easy to say "let's just go to the Trauma Center just in case" even if not deciding to call in a trauma alert.

This is my county's trauma center criteria, yours will almost certainly be different so be sure to get copies of your LEMSA's and agency specific policies/protocols.

Those are pretty standard. Actually I'd say those are basically the CDCs criteria with a little extra spelled out for you special socal folks

OP if they meet trauma criteria they need to go to the trauma center. A non-trauma hospital isn't going to do emergent surgery on a trauma patient even if they have all the specialists. Even though they have neurosurgery that doesn't mean that surgeon is a trauma neurosurgeon, for example.

We see the simple side of trauma when, in fact, it's a very complex surgical disease process that truly requires specialty services.


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[VentMonkey]

Even though they have neurosurgery that doesn't mean that surgeon is a trauma neurosurgeon, for example.

I think this may have been my thought process when I started a thread in the scenario section of the forum about a relative (atraumatic) ICH.

We see the simple side of trauma when, in fact, it's a very complex surgical disease process that truly requires specialty services.

An excellent point, and hence the emphasis on safe, and rapid transport to the appropriate facility with such patients regardless of your level of certification as a prehospital provider.

Those three words sum up the definitive care required to "save their life" in the face of a truly catastrophic traumatic event/ injur, which by no means is anything two large bores, hi-flow, and driving like a bar out of hell does for anyone (general statement).

 

[Tigger]

Hopefully your protocols include some destination guidelines...

 

[Bullets]

First, dont be scared by trauma. Its boring and theres only like 3 thins you can do. As an ALS provider, that adds like 2 other things.

Second, 30 minutes by ground isnt that long. My one job is that distance and we run there all the time.

Third, follow the CDC guideline. And with the extrication > 20 minutes, there needs to be a caveat there of "the extrication team knows that they are doing". Also, as always, the patients condition should guide you. If it takes them 30 minutes to get the person out but they have a broken ankle, DO NOT call a helicopter because it took them 30 minutes to get them out and cite the 3rd class criteria.

 

[VentMonkey]

Third, follow the CDC guideline. And with the extrication > 20 minutes, there needs to be a caveat there of "the extrication team knows that they are doing". Also, as always, the patients condition should guide you. If it takes them 30 minutes to get the person out but they have a broken ankle, DO NOT call a helicopter because it took them 30 minutes to get them out and cite the 3rd class criteria.

But mechanism defines traumatic injuries?!