Pneumothroax Transport Destination

[JPINFV]

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.

...but we're discussing a case where the patient doesn't necessarily meet trauma center criteria and whether it's appropriate to drive 20-30 minutes further for a trauma center (time between hospitals is the only thing that matters in this, not total transport time). We're discussing a procedure that any board certified emergency physician should be able to perform.

 

[abckidsmom]

...but we're discussing a case where the patient doesn't necessarily meet trauma center criteria and whether it's appropriate to drive 20-30 minutes further for a trauma center (time between hospitals is the only thing that matters in this, not total transport time). We're discussing a procedure that any board certified emergency physician should be able to perform.

But the ER is not the end of the patient's stay. The podunk community hospital is not going to have experience with a trauma patient with a chest tube. The nurses on the floor are going to have to dig deep to remember the last patient they ambulated with a chest tube. They are going to be impressed with the pain the patient has and potentially let him stay in bed, increasing his risk for darn near everything.

Pain control will be managed differently in a facility where this is not normal and routine, and the patient may suffer.

Every patient's strongest desire should be to be just another day at the office for the medical staff, and nothing special. This guy on a regular surgical or trauma floor is no big deal. In a small community hospital, he could easily be the first patient with a chest tube that floor has seen all year.

It makes a big difference, and it's worth the ride.

The value added in the trauma center experience is that the whole hospital is equipped and experienced with trauma, and it's not just something that happens in the ER.

 

[DrankTheKoolaid]

Yeah that is true JP, but if the Paramedic knows what he is doing the patient can be stabilized with a needle decompression and not prolong arrival to definitive care.

Re-reading the OP's 2 options at bottom of his post, both are poor unacceptable options. Air is not indicated and I stand by my statement doubting that air is going to be faster then a C2 drive unless the helo is close and already in the air. Start talking 1 hour+ ground transport and then air is more of an appropriate decision as long as it is immedietly available.

A competent Paramedic should be able to handle a pneumo and recognize when it needs to be treated VS monitored. So bypassing to the closest ED really isnt indicated and will only prolong transfer to definitive care at least an hour if the rules are followed by EMTALA standards.

 

[AeroClinician]

So bypassing to the closest ED really isnt indicated and will only prolong transfer to definitive care at least an hour if the rules are followed by EMTALA standards.

But if the local hospital is able to handle the pt. then why would they transfer the pt. out?

 

[DrankTheKoolaid]

Any ED is capable of handling a simple pneumo. The real questions you have to ask are what is the bed status on Med-surg?

What aquity level will the small community hospital keep upstairs? If it is like some of the locals im used to, much more then the sniffles or abnormal lab values that need tweaking and observation get shipped. Any actual treatment needed and that patient is getting transferred or denied admission to the floor to begin with.

We have no level 1 anywhere close to us and our trauma center is a level 2, so the patient really doesnt need a level 1 anyway you look at it.

 

[AeroClinician]

Any ED is capable of handling a simple pneumo. The real questions you have to ask are what is the bed status on Med-surg?

What aquity level will the small community hospital keep upstairs? If it is like some of the locals im used to, much more then the sniffles or abnormal lab values that need tweaking and observation get shipped. Any actual treatment needed and that patient is getting transferred or denied admission to the floor to begin with.

We have no level 1 anywhere close to us and our trauma center is a level 2, so the patient really doesnt need a level 1 anyway you look at it.

And when contact with the ER Doc is made about the pt., he should be able to take bed status into account.
It sounds like the locals in your area are not the same as central FL locals I am used to. Most of the locals can and do treat serious patients, I only know of 1 in my area that is like the locals in your area.

 

[FLdoc2011]

But the ER is not the end of the patient's stay. The podunk community hospital is not going to have experience with a trauma patient with a chest tube. The nurses on the floor are going to have to dig deep to remember the last patient they ambulated with a chest tube. They are going to be impressed with the pain the patient has and potentially let him stay in bed, increasing his risk for darn near everything.

Again, this is highly subjective and not sure what you're definition of a "Podunk community hospital" is, may be different from mine. A lot of our community hospitals around here routinely do open hearts and complicated neurosurgery cases, not to mention have full service ICU's so a chest tube is nothing. In a super rural area where the hospital may or may not even have a functional ICU then you may have a valid point but I don't think that's what he's dealing with.

 

[usalsfyre]

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

Bingo.

But it is ENTIRELY possible to be a level II. There are two LIIs in podunk East Texas. I've worked for and around both of them. They (and most LIIs) are extremely capable of handling this type of patient. Trauma designations are about ensuring appropriate resources and expertise is available. Yes Podunk (or not so Podunk) general may be able to deal with a trauma patient on a Wednesday. What about Saturday of a holiday weekend when half the medical staff is out of town or half in the bag?

Trauma is poorly reimbursed and expensive. That also helps keep volumes high, which is important for outcomes.

 

[DrankTheKoolaid]

And when contact with the ER Doc is made about the pt., he should be able to take bed status into account.
It sounds like the locals in your area are not the same as central FL locals I am used to. Most of the locals can and do treat serious patients, I only know of 1 in my area that is like the locals in your area.

Yeah I am in a rural area where the local podunk is a level 4 at best, but they dont keep up with accurate trauma reporting so they dont even have that status, and the med surg nursing staff is almost all new grad so patient severity that is admitted is extremely low. Something else I notice repeated by you is talking with the ED Doc. That happens extremely rarely here as our autonomy on destination if not guided by hard protocols is left to the individual medic to decide based on patient presentation. Only contact we ever need to make ( not to the local podunk, but our base which is 1 hour plus away ) is for the rare med, other wise they just get a report if we bring them to them before arrival.

 

[JPINFV]

Bingo.

But it is ENTIRELY possible to be a level II. There are two LIIs in podunk East Texas. I've worked for and around both of them. They (and most LIIs) are extremely capable of handling this type of patient. Trauma designations are about ensuring appropriate resources and expertise is available. Yes Podunk (or not so Podunk) general may be able to deal with a trauma patient on a Wednesday. What about Saturday of a holiday weekend when half the medical staff is out of town or half in the bag?

Trauma is poorly reimbursed and expensive. That also helps keep volumes high, which is important for outcomes.

Considering that the major difference between level I and level II was the presence of research and a residency program, I'm surprised that anyplace makes a distinction between a level 1 and a level 2 trauma center. It's the lower levels where you start running into the issue of specialists either not being their or being on call at home.

 

[med51fl]

I would transport to the local ED. Based on what you gave in your scenario there would be no real indication for me to do otherwise.

Now, with that being said there is always that pesky "gut feeling" about patients. If that is what had you second guessing yourself, then throw down the paramedic judgement card for trauma criteria and send them to the level 1. If that is the case then don't bother calling the local ED to try and have the doc talk you out of your decision.

Myself, I call the ED doc in two cases. 1. request to stop resuscitation 2. for orders that exceed my standing orders

 

[Veneficus]

...but we're discussing a case where the patient doesn't necessarily meet trauma center criteria and whether it's appropriate to drive 20-30 minutes further for a trauma center (time between hospitals is the only thing that matters in this, not total transport time). We're discussing a procedure that any board certified emergency physician should be able to perform.

I think this is the key.

But you first have to have the EM.

Many community hospitals I have been to in the US do not staff EMs. They staff whatever they can get.

While it is true that prior to EM many "dedicated" ED docs who wanted to be in the ED we actually IM, and there are still a few of these older and highly capable docs floating around, even in major EDs, when you go to a community facility, You simply don't know what you are getting.

Then there is the question of resources?

Does the community hospital actually have the equipment or can it dedicate staff to specific procedures?

I agree with JWK there is a lot of money and politics that revolve around trauma.

Probably more so than many other forms of medical service.

But I disagree that other hospitals can be just as capable. If they had such a dedication, they would be advertizing as more capable for trauma, which if they actually want to make money is probably not a good idea.

There is an argument by some in the EM community that since they handle a lot of minor trauma they should be considered more than capable trauma experts.

But my opinion is is you can only handle part of the case load, then how can you be an expert?

What service does EM admit their trauma patients to?

 

[JPINFV]

What service does EM admit their trauma patients to?

Well, there was a patient at my current rotation (for some reason, the students on psych still have to pull inpatient call. It's a family practice and traditional rotating internship program, so I refuse to call it IM), the guy who went over his handle bars on his bike and ended up with 2 broken ribs, a broken thumb, and a broken clavicle was admitted to medicine with an ortho consult. Not saying it's the best, but it is what it is.

 

[Veneficus]

Well, there was a patient at my current rotation (for some reason, the students on psych still have to pull inpatient call. It's a family practice and traditional rotating internship program, so I refuse to call it IM), the guy who went over his handle bars on his bike and ended up with 2 broken ribs, a broken thumb, and a broken clavicle was admitted to medicine with an ortho consult. Not saying it's the best, but it is what it is.

But was he admitted by the ED physician or by IM?

 

[JPINFV]

But was he admitted by the ED physician or by IM?

EM I believe, but I'm not 100% sure about how the departmental politics run at this hospital.