Premature Neonate CPR

[Jeffrey_169]

I am obviously not communicating my point effectively. This is apparnet to me. I rest my argument on this issue, and I agree to disagree.

 

[VentMedic]

Jeffery, please take a good NRP class. Keep your own personal, religious and political views to yourself when they interfere with doing patient care. What might be best for you may not be best for the patient and the family. Talk with your medical director about some of the issues you have since they may eventually come into conflict with the protocols he/she has written.

 

[Jeffrey_169]

It is becoming all too obvious to me that my views are not the popular vote here; one would have to be an idiot not to see this. With this in mind, I will no longer discuss this issue here for the simple fact that I am unable to express myself in a manner in which my point is clear.

I will say this, in my own defense. This has been the way I have always practiced, and it was learned by those who trained me. I feel as though my words are valid, but only when displayed in the proper context which I am obviously unable to convey appropriately.

Perhaps if I was a better orator my point would be more clear. I have spoke to my MD on several occasions concerning this issue as this is not the first time it has arisen, and he understands where I am coming from. The fact is that not everyone is going to agree and in all reality I was wrong to engage this issue here. I need to be more aware of this fact in the future.

There are very few things I am passioante about, and this is one of them. I believe, as I tried to state earlier, it is not a job but a calling; its a calling in which not everyone is capable of dealing with. Some jobs anyone can do, others, such as teachers, police officers, etc are not so easily performed by just anyone.

Maybe I am wrong, but life is important to me. I feel we have been intrusted by the public to do right by our patients and sometimes this means giving them the benifit of the doubt, in my opinion.

Perhaps there will come a day when we as medics are educated enough to make such decisions, but I do not believe that day has come yet.

 

[18G]

From the short time I have been posting here, EMTLife can be a harsh little community full of egos and condescending ppl.

I have read some stuff that I do not agree with but I don't try to make the person out to be stupid or tell them what additional education classes to take. Twisting someones words and reading a post way out of context to make your own point isnt cool.

VentMedic, regardless of how much experience you have... chill out! your not the forum police and it sucks to have to read your posts that 99% of the time tell ppl how wrong they are and how your ways are ALWAYS right. You make mistakes and you have areas of weakness but yet, we never, ever hear you talk about em or ask questions.

Didn't you say in one of your post you worked trauma codes? A condition that has less than 1% chance of survival. Why? If your going to extend all your expertise into something such as a trauma code than why not extend it elsewhere? Im not saying its wrong to work a trauma code necessarily its just kinda goes against your stance in this thread and what your saying.

Redcrossemt, Is it really necessary to pick apart the details of someones post?

Medicine is NOT a state of mind. I encourage you to go to your medical director and state, "Medicine to me is not an occupation, but a state of mind. Statistics have no place in my truck." I would be various curious to what he says.

How did you even start to think that Jeffrey_169 was eluding to this? He never said statistics and science are irrelevant. The gist of his post is he is willing to give everything possible so someone can live. Even in what seems like the most futile situations the odds can be defied. And don't read into this which I believe is where the problem is.

And I believe you do have to have a particular "state of mind" in medicine.

Smash,

I'll leave the exercises in futility to those who aren't capable of acting rationally so I can provide appropriate, compassionate care to those who need it.

So you never go out on a limb for a patient? You just casually write em off as non-viable? Where is the compassion in that? Yes, sometimes we are faced with making really tough decisions like to start or not to start. "If I do start resuscitation, will this patient end up brain dead? Quality of life? etc, etc. And nobody has said they ignore this. I think they are just saying lets help patients defy the odds. Especially in children.


Any possibility the forum could get a little friendly and not be so egotistical?

 

[Aidey]

You are speaking of yourself and your own comfort level. I, and I'm guessing a very large number of other people are comfortable with determining if resuscitation is appropriate or not.

It has nothing to do with people being "entitled" to resuscitation. Interventions should NOT be seen as something that everyone deserves, but as things that may help if they are appropriate for the situation and person. Knowing when dead is going to stay dead and not pretending you can do something about it is part of being any healthcare provider.

On cardiac arrests you have to consider the family/friends on scene. Telling them "I'm sorry, it has been too long since their heart stopped beating. We won't be able to get it to start again" can be better for them in the long run than spending 40 minutes sticking tubes and needles in the patient, breaking 1/2 their ribs, making them puke all over, and still not getting anywhere, and then leaving them with all that stuff still attached while you call the coroner.

I would be a heck of a lot more traumatized after seeing that (and possibly getting several thousand dollars worth of bills) than being told from the get go that the person is gone.


Out of curiosity, how do you feel about DNR orders?

 

[18G]

I am not speaking for myself. I am speaking generally. Three or four ppl is not a large number nor representative of a majority.

It has nothing to do with people being "entitled" to resuscitation. Interventions should NOT be seen as something that everyone deserves, but as things that may help if they are appropriate for the situation and person. Knowing when dead is going to stay dead and not pretending you can do something about it is part of being any healthcare provider.

Exactly. I never said anything to the contrary and don't think anyone else has either. However, there are times where a provider will go out on a limb to try even when it may seem futile. Not always, but some situations will present. Unless its obviously obvious, its still not absolutely wrong.

DNR orders are usually a patients informed decision that are present with a terminal illness. So not sure how that ties into the current discussion but I have no problem with them. Why would anyone? A person has the right to determine their own life or death.

 

[Aidey]

Sorry, I wasn't actually directly addressing you, I was addressing Jeffery. I didn't see your post before I posted.

The thing is that Jeffery has stated that statistics don't have any place in his ambulance and that Redcross and I both think not everyone "is entitled" to care.


I am curious what Jeffery thinks of DNRs given his other opinions. Not all people who have DNRs have a terminal illness. My 90 year old grandmother has one, and there isn't anything wrong with her aside from a touch of dementia. She just wants to be allowed to die when it is her time, no matter what causes her death.

 

[Jeffrey_169]

I believe a person who is terminally ill has the right to pass if the decision is informed, and the pt. is of sound mind and body. The Constitution says we have the freedom of choice. In a case where a terminal illness is not present, I will not discuss this because that would be a religious issue to which I feel inapplicable to this discussion. In any event if no DNR order is present then we must assume, as providers, they would want to live. If a DNR is present, it should be respected as their right to chose, but this right is to the individual not to provider.

PS for the record, I got an "A" in my last PALS course.

 

[Veneficus]

I think comfort level has a lot to do with care. At all levels providers who are not comfortable with their own experience or ability defer to other providers. It is definitely not weakness or substandard, it is better for the patient.

Would you want your CABG done by the person who did it 1000 times or the guy who did it 10? Would you admit your own inexperience and defer treatment of a patient with pathology you never saw before to somebody who has experience with it? If you wouldn’t then I would question whether you are acting in the best interest of your patient.

Now in EMS, there is not always the luxury of another provider. You have to make your judgments based on your circumstances.

I think it is important to realize we all didn’t start off as highly experienced providers. It is a journey; some are farther along than others. The idea that simply taking a class will impart the experience and judgment to always do what is best may be a little flawed. Especially since in medicine what is best is a dynamic situation. On any given patient what is “most often” the best decision may no longer be.

Since the very beginning of western medicine, personal value has always been a part of the field. I would like to point out:

The Oath of Hippocrates
I SWEAR by Apollo the physician and AEsculapius, and Hygiea, and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.

This makes a pretty strong point against euthanasia and abortion. Are we to conclude that those physicians providing such are in violation? I doubt it. Instead we just change the oath a little to the modern version which is considerably more value neutral. (I’ll let you find it in the interest of brevity) choosing not to impart a personal value is actually a personal value.

I agree that every effort for more education should be made. But it is very difficult to demand more experience. How do we go about implementing that? Should we close every community hospital and rural provider in the world? How about schools that are not in major population centers?

I encourage people not to let personal belief/emotion be the logic for their decisions. But I doubt anyone can claim perfection in such an endeavor. I agree with Smash, if you are making a large part of your decisions based on emotion or state of panic, then perhaps you should not be the primary decision maker yet. I think Vent also has a very valid point, if you are lacking in knowledge, education is the answer. I also agree with whoever said make sure your medical director (or whoever your superior might be) is ok with your decision making process.

The higher up the ladder you go the more that you have to take into account when making your decisions, items such as cost, psychology, resource management, etc. A paramedic on an ambulance is rarely tasked and in the US certainly not educated to these details. In time these factors do become part of the decision tree of junior providers. Sometimes I think we all lose sight of what it was like to be new. I confess to be guilty of that rather frequently myself, especially in my demands of others. But I do try to remember from time to time. I Guess I do not get my perfection card yet.

 

[Smash]

When did "experience" become an irrational way to practice?

When experience is applied without an appropriate base in science or statistics and without a sound rationale.

You say you are going to perform "compassionate care to those who need it". yet you imply you agree with Aidey in that not everyone is entitled to it. So who are these chosen ones? Who decides who lives and who dies/ Who decide who is worth the effort and who is not? We are not gods, and we practice under the pretense that if they are salvageable then we have a duty to act. Again, if stats and logic is to be applied then no one is worth CPR because only an average of 5% will live anyway, so they are apparently not worth the energy...right?

Everyone is entitled to compassion and care, but that does not mean trying to resurrect the dead. That means caring for those that I am able to help, be it those who have a viable chance at survival, or failing that, those who have to deal with the outcome.

Statistics are of no use when it comes to human life. There is not now, nor will there ever be, room in my truck for it. I will give competent CARE to all my pts, and if I believe they are salvageable then I will do
whatever is within my power to save them....

So what makes you "believe" that someone is salvageable if you don't apply any kind of scientific criteria or logical reasoning?

that is why I practice medicine and not mathematics and statistics. If I wanted to study stats, I would get a degree in accounting; I practice medicine to save lives and leave the stats to the CPA's.

Modern medicine is the application of mathematics, statistics and science, and has been for a very, very long time. I would also suggest that it behooves practitioners of medicine to have a sound grasp on these more than a CPA; they might cost someone some money, we will cost someone their life. Recognizing this and acting appropriately does not remove the compassion or care from what we do, but it allows us to provide the best quality care (in a compassionate, caring manner) for everyone.

 

[Jeffrey_169]

I suppose I should be more clear, and this time I will try to be as clear as I know how.

If a patient is "obviously dead", i.e. decapitated, rigor has set in, they are in an environment that is room temperature and they are cold to the touch, or otherwise apparently no longer in the land of the living, then no I would not attempt resuscitation. There is a difference between just plain foolish and the optimistic, and I am not so diluted as to be blind to this difference. The scenario which was given was an example of optimism, and not a foolish endeavor. I never said the odds of a recovery was in the child's favor, but it is nonetheless possible. As a paramedic I DO believe science and statistics have their place, but when you have a potentially SALVAGEABLE patient they should be worked on to the best of my ability, and at that point stats are not on my mind. In this case the pt was JUST BORN and so there is a chance, although be it not a good one, there is still a chance. In my opinion, as a Paramedic and not a doctor, it is not my call to make this decision and therefore I will work it until a MD tells me to stop. This is in our protocols, and it is my belief as well.

As Veneficus stated, and I agree, I believe more education is needed. A case in point would be in San Antonio TX, which I found out about on this site, where a young girl was found to still be alive after a Paramedic was unable to find a pulse. Upon arrival at the coroner's office, he discovered she was still alive. They followed protocol, and now they have to face the reality that someone is now dead because they made a mistake, but they were following protocol. It not their fault, I agree, but they (the medics and the family) still have to live with the fact that someone died because the system failed. It happens. But then again this is why I say we are Medics not coroners.

I hope this clears up any misconceptions there may be about my point on this issue.

 

[Aidey]

In this case you need to consider WHY the patient was just born, and if they were even born with vital signs or not. This may have been a late term miscarriage because the fetus just wasn't developing right and the mother's body recognized that and the fetus died and the mom is now expelling the tissue. In that case the baby was never viable, even if it was just delivered.


Texas' protocols for declaring death in the field suck. Period. Absence of a palpable pulse? Really? That is just irresponsible. If a proper assessment to determine if vital signs were present had been done that would have never happened.

Jeffery, do you transport every code or will you cease resuscitation on scene?

 

[VentMedic]

As Veneficus stated, and I agree, I believe more education is needed. A case in point would be in San Antonio TX, which I found out about on this site, where a young girl was found to still be alive after a Paramedic was unable to find a pulse. Upon arrival at the coroner's office, he discovered she was still alive. They followed protocol, and now they have to face the reality that someone is now dead because they made a mistake, but they were following protocol. It not their fault, I agree, but they (the medics and the family) still have to live with the fact that someone died because the system failed. It happens. But then again this is why I say we are Medics not coroners.

The girl was found to have a pulse while still at scene. The Paramedics were found not to have followed protocols. It is the same FD that was again under scrutiny and in another thread you just commented on in their favor. This was after the protocols were changed stemming from the earlier incident.

Thus, for that department, more education would definitely be the answer.

There comes a time when Paramedics must be taught beyond just what the recipe states. When there is any doubt, they should be able to establish death by an alternative means. The "I was just following protocols" should not excuse the Paramedic from thinking.

But then again this is why I say we are Medics not coroners.

Do you realize that coroners in many areas have no medical training?

 

[Medic744]

Jeffrey and 18G thank you for your input and Im sorry that this thread took a turn towards the nasty for ya'll. I was always taught that what the books tell you to do and what you will actually do will be diffrent.

After a few days of mulling this over I can honestly say that I wouldnt have done anything different than what that crew did. The mother was in capable hands and the baby needed immediate attention.

As for science vs theological, both are falliable. There are truths held in science and it works for us but it is not indisputable. There are many theories that are put into question every day, if there werent then there would be a ton of researchers out of business. Just because something works one time doesnt mean that it will work again, it takes practice, failure, and research to accomplish a constant. As for the theological side of things, who am I to say that there isnt a higher being that makes the impossible become possible. There is plenty of evidence out there of things occuring for no scientific reason and people are willing to accept that. Let them. Everyone needs something to hold on to.

For some it is an option to leaving your emotions at the door and for you it must be wonderful never to have a thought about a patient once you turn them over. Im not being sarcastic, Im being honest. I belive that my emotions dont retract from my job so much as add to it. I do think about the child I left to be treated following a MVC, or the elderly man who woke up having a stroke, or any number of patients. Maybe its because I grew up near where I work and it is close nit and everyone knows everyone. (Although Im sure I would fell this way no matter the population) I stray from protocol but I do know that the extra effort that is put in to what I do is well worth it when I can walk away knowing that the pt and their family knows I care and am not just putting on an act and could actually care less. A lot of you may see that as weakness but I see it as a strength and it makes me the best person I can be. I am not defined by my job. I love my job and all that it entails. The good, the bad, the ugly.

Back to the original thread. From the other side as a mother, if I were to ever find myself in this situation and somebody walked in and deemed that my childs life was not worth even trying (I have said this before) it wouldnt be pleasant. That is coming from somebody in the medical community, try explaining that to a hormonal, hysterical layman.

What's the difference between God and a Paramedic?

God doesnt pretend to be a Paramedic.

 

[Veneficus]

Back to experience and responsibility…

The higher up the ladder you climb, the more factors are added to your decision tree. In a small system, with relatively low volume, a provider may not have to worry about things like available resources, turnaround time for resources, and saturation of such resources.

In larger areas taking a unit out of service to transport a dead person or one likely to die, stresses the system. It adds volume to the other crews, it makes other calling for help (who are more likely to benefit) wait longer, when you finally get to the hospital, it uses resources there that have an impact on others who require help. Many of us keep talking about doing the most good for the most people. It is part of our responsibility everyday. Our perspective is different, I am sure we all wish we had unlimited resources and could go the distance for everyone, but we do not live in such a world. If you continue in the emergency or medical fields I am certain you will see it from our point eventually.

The grieving process will start on a nonviable patient. Personally I think it is a dereliction of duty as a healthcare provider when you pass the responsibility of helping a family start that process to another provider. How do you feel about telling the family of somebody elses patient they died? Also please consider: The determination of death will likely be the last memory the family has of the person. It will be the most vivid, particularly that of a parent, forever. What medical providers can do to a person can be out right scary,” All we can do” is nothing short of Frankenstein’s monster. I would encourage you (and I am sure others here can attest) to go to a post operative care unit, or an ICU and see the reactions of fear and horror of laypersons when they first see the patient. At what point of abusing a corpse for “every chance” is a provider working a code for themselves instead of the patient or family? Only you can answer that. In my experience it is more often than not more humane and compassionate not to make families wonder if the patient was in pain when the cartilage separates from the sternum; if all those tubes and needles etc hurt or not? After the fact you can tell the family it didn’t hurt, but after the sights and sounds, your words will mean little. End of life care can have a positive effect. More so than a futile resuscitation.

The land of the fee. If you are from the US you live there. Not all of our colleagues from other countries here have to worry about the financial impact. I hope you will. A resuscitation attempt can cost tens of thousands of dollars. If you are not successful that bill doesn’t go away. Especially the hospital portion. People do have to pay for the blood tests that were reported hours after time of death. In many poor areas, multiple generations live in homes paid for by generations past. When that bill to “do all you can” goes to collections, you can displace multiple generations of a family to the street. In the US medical bills are the #1 reason for bankruptcy. Who do you help generating a bill that puts multiple people out on the street and breaks up families? How about the health and psychological effects of losing a family member and winding up homeless and bankrupt? Those funeral costs still need to be covered. Today how many middle class families are on the verge of bankruptcy or foreclosure? A sudden medical bill for minor care can be devastating. One for a resuscitation attempt will certainly push them over the brink. In the US everyday people have to choose between medical care, a place to live, and food. By initiating a futile resuscitation, you are making that choice for them. You might go back to the station or your daily life and not have to worry about the consequences and might even feel good about what you did. But it certainly doesn’t absolve the survivors. In fact their troubles may be just beginning.

If choosing to do the most good for the most people, assisting in the grieving process instead of delaying it, and taking into account the long term consequences of my decisions on others makes me cold and uncaring, I guess that’s what I am. Deciding nothing medical can be done for a patient doesn’t make me think I am God. If it did, I would think to miracle them up the solutions for all their other problems too. There is a point when modern medicine causes more harm than it helps.

 

[18G]

I think its clear that this topic has been debated to the fullest by everyone who has been participating. While I don't agree with everyone's view I think it was a worthwhile topic to discuss. So thank you Medic 744 for taking the time to post.

With that said I just wanna comment on a few things in the post by Venificus.

In larger areas taking a unit out of service to transport a dead person or one likely to die, stresses the system. It adds volume to the other crews, it makes other calling for help (who are more likely to benefit) wait longer, when you finally get to the hospital, it uses resources there that have an impact on others who require help.

I definitely understand where your coming from with resource management but its not always cut and dry. An eight year in arrest is not the same as an 88 year old. An 88 year old has lived their life and the body is just worn out. Family members are prepared for the day they pass on. On the other hand, an eight year old is a very vibrant and healthy child. Their parents, family, and friends at school are not prepared in the least to let them pass on.

The reason I am contrasting these two age groups is this. You can tell the family of the 88 year old there is nothing you can do and they will be a lot more accepting and it will be beneficial to avoid the elements of a resuscitation. We all know age brings about death. The 88 year old probably has a funeral home and grave plot already picked out.

But an eight year old? Just to casually tell mom and dad, "sorry, nothing we can do" while their son or daughter is laying there lifeless. Granted some situations its obvious and those cases are not what we been talking about. I believe we been talking about those border line cases. As a parent, it would help me a lot more to know my child was given the very best chance of survival and having everything done that was humanly possible. I wouldn't want any doubt and have to think "what if the Paramedic was wrong?". Just do it. Like Medic744, don't be the Paramedic in the same room with me when you try to tell me there is nothing you can do.

There is no absolute right or wrong here. As much as we need to maintain our objectivity as providers, belief systems naturally do play a part of our care regardless if it is conscious or subconscious.

By supporting each other and having intelligent and respectful debate on issues we are more likely to garner respect and may even sway someone to our side of the fence (not that, that's the intention necessarily). There is enough hostility in the world we deal with everyday. Lets not deal with it within the ranks as well.

 

[Veneficus]

I definitely understand where your coming from with resource management but its not always cut and dry. An eight year in arrest is not the same as an 88 year old. An 88 year old has lived their life and the body is just worn out. Family members are prepared for the day they pass on. On the other hand, an eight year old is a very vibrant and healthy child. Their parents, family, and friends at school are not prepared in the least to let them pass on.

As a rule, healthy people do not need to be resuscitated, especially from an arrest. Additionally, not everyone is prepared to have relative of any age die.

The reason I am contrasting these two age groups is this. You can tell the family of the 88 year old there is nothing you can do and they will be a lot more accepting and it will be beneficial to avoid the elements of a resuscitation. We all know age brings about death. The 88 year old probably has a funeral home and grave plot already picked out.

Bold assumption. Did they prepay for it on their fixed income? Are their children and grandchildren depending on that income too? If this is the primary breadwinner and they know their family depends on them, do they accept the idea they had a life alredy so nothing more is done? Maybe they have one more thing to do like make sure little Suzie has shoes to go to school in?

But an eight year old? Just to casually tell mom and dad, "sorry, nothing we can do" while their son or daughter is laying there lifeless. Granted some situations its obvious and those cases are not what we been talking about..

There is a difference between proper end of life care and casually telling somebody there is nothing you can do. On deciding what you can do, surely in your education you were taught that it is more likely to resuscitate an older person than a child? If not, you should go back to your school and demand your money back, they failed to teach you what you paid for.

I believe we been talking about those border line cases. As a parent, it would help me a lot more to know my child was given the very best chance of survival and having everything done that was humanly possible. I wouldn't want any doubt and have to think "what if the Paramedic was wrong?". Just do it. Like Medic744, don't be the Paramedic in the same room with me when you try to tell me there is nothing you can do.

This sounds to me like you are imposing your values on others. Is there a difference when a physician tells you nothing more can be done? There is no boarder lines with kids. You need to do something before they arrest. If you are not convinced by the statistics and science, ask around.

There is no absolute right or wrong here. As much as we need to maintain our objectivity as providers, belief systems naturally do play a part of our care regardless if it is conscious or subconscious.

undoubtably, but I always make a concious effort to see if what I am planning or doing will or is likely to cause harm. I make an effort to see the longterm outcome. Finally I always ask myself, "am I doing this for me or for them?"

By supporting each other and having intelligent and respectful debate on issues we are more likely to garner respect and may even sway someone to our side of the fence (not that, that's the intention necessarily). There is enough hostility in the world we deal with everyday. Lets not deal with it within the ranks as well.

I think this has been a very respectful debate. I have stated my position based on my experience, knowledge, and education. Some will find it valuable, others will not. "right or wrong" is a matter of perspective. Nobody here is obliged to do what I say yet. Most likely they will never be. Best of all I don't have to convince anyone. I have noticed that experience and education is largely the dividing line on opinion with this issue. I hope some will be proactive and take this up with thier medical director or superior because ultimately, a provider will have to follow those orders.

 

[Jeffrey_169]

Perhaps I misunderstood the story, and if so I apologize. I gained a different impression, but then again I was tired and it is very possible I misunderstood and thus misspoke.

 

[redcrossemt]

I was thinking about asking if anyone wanted to side with the religious pharmacists refusing to dispense "Plan B"...? Is that inappropriate?

 

[VentMedic]

I was thinking about asking if anyone wanted to side with the religious pharmacists refusing to dispense "Plan B"...? Is that inappropriate?

How about the EMTs or Paramedics who might be Jehovah's Witnesses and are against blood products? Some have even been known to discuss this with the patient on the way to the trauma center?