Pneumothroax Transport Destination

[Veneficus]

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.

 

[bahnrokt]

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.

 

[JPINFV]

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.
We take cancer patients to cancer centers.
We take trauma to trauma centers.

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.

 

[Medic Tim]

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.

 

[Veneficus]

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.

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.

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.

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.

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.

 

[abckidsmom]

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.

 

[FLdoc2011]

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.

 

[Doczilla]

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.

 

[GaMedic]

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

 

[jwk]

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.

 

[AeroClinician]

"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.

 

[usalsfyre]

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.

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.

 

[AeroClinician]

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.

 

[Baele11]

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!

 

[usalsfyre]

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.

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.

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.

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.

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?

 

[AeroClinician]

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?

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.

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.

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?

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.

 

[jwk]

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.

 

[DrankTheKoolaid]

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.

 

[Merck]

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.

 

[DrankTheKoolaid]

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.