Mountain Res-Q
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Okay, just wanted to get your thoughts on transport decisions for higher priority patients in a more rural setting, where helicopters are often needed (but sometimes not available) to get critical patients to Trauma Centers, Cath Labs, Burn Centers, etc…
You are working a roll-over MVA. Single vehicle, ETOH involved, three patients in the car. One patient is immediately classified as critical and in need of extrication. The other two are delayed; one with minor scrapes and bruises, the other with back and leg pain. However, we will focus this scenario on the critical patient.
Patient (~25y/o male) was the unrestrained driver, trapped, Fire working on extrication (15 minute eta). Patient is unconscious in the vehicle, unresponsive to all stimuli, obvious facial/cranial trauma, pupils are fixed and are not equal (one is sluggish). 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.
Your location is in my rural neck of the woods. You are 12-15 minutes code 3 east of the Local Hospital, a Basic ER with nothing in the way of neurologic facilities or specialists. The closest Trauma Center is 65-70 minutes code 3 west of the accident by ground. Immediately you request an Air Ambulance to rendezvous with you at the Local ER Helipad. 10 minutes latter (and Fire still working on extrication) you are informed that the Air Ambulance is grounded due to Low Cloud Cover/Fog that is sitting right over any possible receiving facilities... oh, and it is a night.
So, three questions:
1. What are you field clinical impressions (i.e. non-MD diagnosis) and treatment wishes?
2. Do you agree with the initial request for a Helicopter?
3. What do you feel you should do now as far as transport? Code 2/3 to the closest ER 15 minutes away? Immediate code 2/3 to the Trauma Center over an hour away? Code 2/3 to the closest ER and request an MICN join you for a code 2/3 transport to the Trauma Center (after an evaluation by the on duty MD of course)? Other? Since the local ER can do nothing meaningful neurologically for this patient if it is a legit closed head injury, do you spend the time transporting to that ER when what he really needs is a Trauma Center with Neuro Capabilities (if that is also your opinion)?
What I am really interested in is your thoughts on the logistics behind transporting this patient? I know that local protocols play a role in such decisions, but that aside: What do you think should be done and is in the best interest of the patient?
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*As far as that Palp thing goes: This is a real call and those are the vitals relayed by the Medic. Before you all complain about how Palp BPs are almost never acceptable, especially with this type of injury where documenting trends that could indicate a progression of serious neurologic issues is a must, I am not clear on why a palp BP was taken (maybe the noise on scene with the Jaws running and what not) but it was taken that way… I don't like it either... live with it…
You are working a roll-over MVA. Single vehicle, ETOH involved, three patients in the car. One patient is immediately classified as critical and in need of extrication. The other two are delayed; one with minor scrapes and bruises, the other with back and leg pain. However, we will focus this scenario on the critical patient.
Patient (~25y/o male) was the unrestrained driver, trapped, Fire working on extrication (15 minute eta). Patient is unconscious in the vehicle, unresponsive to all stimuli, obvious facial/cranial trauma, pupils are fixed and are not equal (one is sluggish). 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.
Your location is in my rural neck of the woods. You are 12-15 minutes code 3 east of the Local Hospital, a Basic ER with nothing in the way of neurologic facilities or specialists. The closest Trauma Center is 65-70 minutes code 3 west of the accident by ground. Immediately you request an Air Ambulance to rendezvous with you at the Local ER Helipad. 10 minutes latter (and Fire still working on extrication) you are informed that the Air Ambulance is grounded due to Low Cloud Cover/Fog that is sitting right over any possible receiving facilities... oh, and it is a night.
So, three questions:
1. What are you field clinical impressions (i.e. non-MD diagnosis) and treatment wishes?
2. Do you agree with the initial request for a Helicopter?
3. What do you feel you should do now as far as transport? Code 2/3 to the closest ER 15 minutes away? Immediate code 2/3 to the Trauma Center over an hour away? Code 2/3 to the closest ER and request an MICN join you for a code 2/3 transport to the Trauma Center (after an evaluation by the on duty MD of course)? Other? Since the local ER can do nothing meaningful neurologically for this patient if it is a legit closed head injury, do you spend the time transporting to that ER when what he really needs is a Trauma Center with Neuro Capabilities (if that is also your opinion)?
What I am really interested in is your thoughts on the logistics behind transporting this patient? I know that local protocols play a role in such decisions, but that aside: What do you think should be done and is in the best interest of the patient?
---
*As far as that Palp thing goes: This is a real call and those are the vitals relayed by the Medic. Before you all complain about how Palp BPs are almost never acceptable, especially with this type of injury where documenting trends that could indicate a progression of serious neurologic issues is a must, I am not clear on why a palp BP was taken (maybe the noise on scene with the Jaws running and what not) but it was taken that way… I don't like it either... live with it…
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