Rural Transport Decisions

Personally?? I'd transport to the local ED and let them do what they could and get a CCT from the trauma center to come get this guy, and maybe even have them called while we're still extricating this guy.......Or if they were avaliable to come I'd ask med director if he would approve midway rendevous with CCT provided the guy didn't deteriorate after extrication.
 
FF-EMT Diver said:
Personally?? I'd transport to the local ED and let them do what they could and get a CCT from the trauma center to come get this guy, and maybe even have them called while we're still extricating this guy.......Or if they were avaliable to come I'd ask med director if he would approve midway rendevous with CCT provided the guy didn't deteriorate after extrication.
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CCT is all private ambulance and not staffed at night. It would probably take the closest CCT unit 2 hours to get to the local ER, assuming you could staff one. Not arguing, but why do you want the CCT unit over the ALS rig? Would, in your opinion, it be good enough to have an MICN from the local ER join the Medic in the back of the rig for a code 3 to the Trauma Center?

BTW, no wrong answers since everyones perspective and background is unique... and in your system, your choices might be best... although not the best (or even available) choices in other areas...
 
Go to trauma-receiving for whatever services they can provide. They can then call whether or not to send advanced care onward to the large trauma facility or rendezvous with another service.

This is assuming that the responding crew in this area is without a Paramedic.
 
Hal9000 said:
Go to trauma-receiving for whatever services they can provide. They can then call whether or not to send advanced care onward to the large trauma facility or rendezvous with another service.

This is assuming that the responding crew in this area is without a Paramedic.
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As stated before, all Ambulance Crews are staffed 1 Medic and 1 EMT. Transport to the local ER and hand it off to them? Okay, works for me, but just remember that if that hospital decides to transfer the patient to the Trauma Center (and it is likely them might if it is something that they can not handle) then there is a 33% chance that it will be your crew handling the transfer (66% chance it will be one of the other 2 ambulance covering the north side of the county). No transfers to another Ambulance since all you will be doing is spending/wasting time handing the patient off to another ALS rig. No right or wrong answers, but in your opinion, is it then worth taking the patient initially to the local ER?
 
If there is a gag, RSI him. Pain management and sedation will lower his ICP, and depending on where you work, a certain level of permissive hypotension with this patient may be allowable.

In my mind (having worked in both critical care and plain street level ALS) either rendezvousing with a critical care truck or picking up a physician or nurse is the best option to facilitate transport to the nearest APPROPRIATE facility.

In fact where I work, if the helicopters are grounded, guess who staffs the critical care truck? We (the flight team) do.

CCT transport is better in my mind for a few reasons. They are better equipped and trained to deal with the head injury, and they also will be able to treat the patient more in line with what the receiving facility is going to want (osmotic diuretics for ICP, hypertonic saline, blood possibly, etc.)

If the REAL question is what facility to go to, then you have to think, can I do more than the local ER that is 15 minutes away? If so, then truly they are not an appropriate facility and do not necessarily offer a higher level of care. If your hands are ties by protocol (or lack thereof) then you won't do the guy any good bouncing him down the road for an extra 45 minutes if you are unable to control his ICP and mitigate his other injuries.

From what I have read, the majority of the people on this forum should take the guy to the closest facility. In fact I have read a few responses here that make me think he would be better off at the local veterinary office than in the back of a few of you guys' rigs...
 
WTEngel said:
In fact where I work, if the helicopters are grounded, guess who staffs the critical care truck? We (the flight team) do.
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Now that is interesting. The closest CCT Unit to where I am is located near those Trauma Centers. I use to work some shifts on that unit as part of a MICN/EMT/EMT crew. We were only staffed for 12 hours a day from 0800 to 2000. However, the closest helicopter is based literally a stones throw away from my SAR Cache and it kinda makes sense to have a CCT rig sitting there (especially in winter) so that if ground the MICN and MICP working on the bird could jump on the CCT car and (literally) cover two counties (maybe with an EMT to play driver)...

The rest of the post rocks... I like your logical thinking... "Can the local ER do anyting that I can't on the rig?" Really depends on the system and if the Medic/EMT crew for 1 hour to a Trauma Center trumps MDs and MICNs in a small hospital for and then (maybe and after some time) a transfer with Medic/MICN to the same Trauma Center.

And from a former Vet Tech... thanks for the vote of confidence... ^_^
 
And just to add to that, where I work we are IFR, so we can shoot an approach in fog. So we would meet you at the local ED, plain and simple...
 
I would not want to be 30 minutes from skillsets and equipment above paramedic, so I would go to the local.

EDIT: Haven't had the time to read the thread. :(
 
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WTEngel, our fog isn't like their fog. You know Texans... they see a single cloud in the sky and they freak out! :P



Gag reflex? RSI him. He needs a definitive airway asap, and an OPA / BVM wont suffice if his ICP raises to the point of projective vomiting. Once airway is done, off you go to the trauma center an hour away. Everything else can wait until he's in the rig and you're on the road.
 
day late, dollar short

Oh, frell. Where's the fourth passenger? The woman who was ejected from the front passenger seat during the rollover?
 
I sense a thread coming on...(no not again)

"The Questions Medics Must Ask Themselves*"
1. "Would the local hospital remove this pt to my rig from their room so he could receive better care?". If the answer is NO, go to the hospital. If the answer is YES, the pt is tanking and they do not want him on their mortality statistics.

Dancing with treatment regimens for imaginary patients is fruitless, undoubtably on the real scene we would not actually do what we talk ourselves into doing in a forum like this; not becuase it is wrong, but because we build our own tautologies while sitting in warm rooms and eating popcorn.

In Mt's world on the ground it looks quite frontiery, but aerial photos show a surprisingly high lateral density (per sq mile) of buildings, little curly roads, etc. The vertical density (the curly little roads are going around up and down mountainsides) is the rub, there we are like ants finding our way out of a severely crumbled up newspaper. This combination makes for higher likelihood of incident (lateral density) but tricker transport (vertical relief, lotsa brown lines close together on the topo).

(You think Oprah would do a show about that?)
 
PS: If you ever want to complicate such a scenario...

Make it at night, introduce an open car door or gaping windshield or side window, and either an empty baby seat in the car, or out side by the car's missing glass... did that once, very exciting for a few minutes. (Kid was at home, Mom was obtunded).
 
I'd say your driver has a TBI, I would

1. Drop an LMA and see how SPO2 looks
2. Call for a helicopter and Advanced Paramedic capable of RSI
3. Pass GO directly to the trauma centre
4. See if Derek Sherpard is avaliable :rolleyes:
 
Mountain Res-Q said:
There is a gag relex. NPA was inserted by Fire, although I obviously agree that NPA's and trauma to the Head do not really mix.
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Right. Facial trauma is a major contraindication for an NPA, and a gag reflex is a contraindication for an OPA. But didn't you say you had a medic there? If so, with a GCS of 3, they should probably be tubing. As an EMT-B in a state that doesn't allow any other airway adjuncts, I'd be a bit screwed here, but that being said...

Mountain Res-Q said:
Initial vitals: HR 122, RR 28 and regular, BP 120/P (*see below), Sinus on the monitor, GCS 3 (but does have a gag reflex), SpO2 90% on 15lpm via NR.
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Respirations are 28. Patient's O2 saturation is low. Obviously, despite the "regular" breathing, he is not breathing adequately and needs to be ventilated. Someone should be bagging him. Given the facial trauma, I'm thinking suction would likewise be in order.

In terms of the transport decision, this patient has a significant MOI for transport to a trauma center. If you're in a rural area, that may mean a bird, but if they're not flying, then it has to be by ambulance. Once the fire department manages to get him disentangled, it's rapid take down onto a backboard and into the ambulance.

The only caveat I'd add is that given the length of the extracation (you said 15 minutes? For the FD to get there, or to get him out?) if he starts to crap out, I'd divert to the closest hospital to get him stable, depending on local protocols. Shock is going to be a major issue here, so ALS being along would be a good thing, otherwise it's high-flow O2, trandelenberg, transport.
 
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