Rural Transport Decisions

[Mountain Res-Q]

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?

---

*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…

 

[HuiNeng]

One word

My only qualification for providing this response is a CERT class:
Triage.
When resources are limited, save the saveable. Or so I'm told.

 

[mycrofft]

Logo, commo, prep and ICS/delegation

1. Get the CERT guy or gal with the green bump hat to tx the minimal (cuts and bruises) then report back to you, the IC.
2. Hope you have a binder with local and not so local alternate helispots and pads including master map, road directions and GPS coords. Needs to be coordinated with heli service for your area. Inlcude freqs, phone #s for on-incident coordination. Check the info twice a year, summer and winter, go see the sites in person.
3. Info to have before the pt is ready to transport: is there an alternate helo rendevous they will fly to available close enough that the pt will benefit going there instead of the hospital? Can the hospital, perhaps with telephone and webcam link to, say, UC Davis, be able to maintain the pt if taken there awaiting helo? This has to be learned before the pt has been pkged for movement and tx begun.
4. If all else fails, remember "any port in a storm". Tell the hospital ASAP that you are coming in so they can prepare (turn out the lights, hang out the CLOSED sign and hide under the desk).

Commo is important and can be tricky in the mts. You may need to send someone to a cell spot or landline phone with phone numbers and written messages, and they might not get back before it is time to go; arrange for them to go to the hospital if they come back to an empty scene, or try to talk to you enroute.

Maybe preplanning should include scouting helipad sites useable by all for these situations, maybe at a lower or higher elevation, and making some more?

PS: any fixed-wing air assets of benefit and with instruments to fly in soup?

 

[HuiNeng]

7 Ps

3. Info to have before the pt is ready to transport: is there an alternate helo rendevous they will fly to available close enough that the pt will benefit going there instead of the hospital? Can the hospital, perhaps with telephone and webcam link to, say, UC Davis, be able to maintain the pt if taken there awaiting helo? This has to be learned before the pt has been pkged for movement and tx begun.

Systems analysis, otoh, I can handle: you've got a big set of fuzzy-valued parameters with, possibly, no fully satisfactory solutions. People do PhDs in computer science on such problems.

A rural theater will have widely dispersed potential accident sites. The terrain, especially if mountainous, will present divergent solutions vis a vis air ceilings, air time/distance, land time/distance... Oy vey. Optimal solutions would be tough to compute ahead of time. The IC would have to do just what OP described: check off possibilities in rough order.

In the specific scenario, why does the nearby hospital even have a helipad if they don't have the mojo to accept and stablilize incoming? With no air transport available and without the suggested binder of contact information, the best solution is casevac to the closest higher reachable echelon of care: the local ED. What the on-scene medic thinks about neurological trauma don't make no nevermind.

Meanwhile, Green Helmet has put a collar on the back and leg pain, assessed the leg, stabilized it PRN, and done secondary assessments on both yellow tags.

How are the FF coming along with the extrication?

 

[thatJeffguy]

HuiNeng - I'm curious as to why you use the word "CASEVAC". Did I miss something in the OP?

 

[medicdan]

HuiNeng - I'm curious as to why you use the word "CASEVAC". Did I miss something in the OP?

Casevac is a military term meaning casualty evacuation.

 

[mycrofft]

I cheated, I am familiar with his area. (heh heh)

The inherency of fuzzy parameters (and "art"/luck aspect of extrication and medicine) is part of why simulations are so darned hard to make relevent to a global exercise, they are best focused onto one or two aspects you want the learner to "get", or used to study how people respond to a given situation to figure how best to plan for it etc.

The generic local hosp in scenario, as in many throughout at least California's rural areas, might have an ED but not a big hospital behind it ("medium hat/few cattle"). Typically the parking lot might have an area with lights and markings which is kept cleared of snow and if parking is allowed, it is for staff only so they can move their cars, maybe a smal helipad. They can generically accept casualties but OP is trying to optimize outcome.

Commo and coord preplanning and execution (and gear!) are essential, elsewise you might find yourself sitting at the rendevous listening to the helo hover in circles above the murk above you. Or starting, stopping and doing CA's to try to meet up.

Once the pt is free and set to leave, the decision needs to be made.

(ps mycrofft is level 3 CERT. Good to hear from at least one other around here!).

 

[thatJeffguy]

Casevac is a military term meaning casualty evacuation.

Partially. A CASEVAC is an evacuation from a "military war zone", a hot zone. A MEDEVAC is a medical evacuation from a non-hot zone.

 

[Mountain Res-Q]

okay, so...

Helicopters will not take off, hence the word "grounded". The helo is out of the question no matter where you wish to set up the LZ, and trust me, there are plenty of designated (and undesignrated) LZs up here.

Second, communications, while problematic in the mountians, but agencies that live/work up here have overcome these issues 95% of the time... everyone had comms with their dispatchers, dispatchers that have all the resouces at their finge tips to order and arrange for helicopters. If for some reason radios are a no go... one particular cell phone provider works great, and I have actually been able to talk to Dispatch via my cell phone in the middle of a designated wilderness while my radio can't reach out to anyone.

Triage? So we are going to focus on the bumps, bruises, and back pain and then ignore the brain bleed because the lack of a helicopter makes him unsalvagable? 3 Engines on scene staffed with MFRs and EMTs as well as 2 ambulances (you requested a second). That makes 2 Medics and 10 EMTs that will swoop in on the deplayed patients, ignoring the critical patient? Fine... backboard one... bandaid the second... transport both in one of the ambulances to the local ER... Now how do we deal with the critical? Where does he go? Local? Trauma Center? Funeral Home?

The question remains... what treatment/transport desisions do you make or do you want to make that will be 100% in the best interest of keeping him alive and give him the best chance of a meaningful recovery...

 

[HuiNeng]

...
The question remains... what treatment/transport desisions do you make or do you want to make that will be 100% in the best interest of keeping him alive and give him the best chance of a meaningful recovery...

Ok, playing with additional scenario background here. Local EMS knows the capabilities of the nearby ED, which seem to be "urgent care plus", and of their "helipad", which is mostly for outbound transfer (in good weather). Comms are adequate if sometimes kludged. Location is California mountains.

With that background, the medics should load and go, pedal to the metal, for the trauma center. Backache and bandaid both go to the local hospital.

The principles of triage still apply and they are not congruent with the scenario requirement to keep that one patient alive and well. It doesn't matter how many EMTs and Medics are standing around.

Air to trauma? No, transport is grounded.
Land to local? No, ED is not equipped and the wrong direction.
Land to Trauma? Yes, it's the only remaining choice. That is if and only if there is sufficient transportation capability to also care for the back and leg guy should his secondary assessment show, say, femur fx or deteriorated GCS.

Some more thoughts: What is the season? Are those low clouds apt to drop snow or rain on the road in the next hour? The Trauma center is specified as an hour away: does the road penetrate the cloud layer, i.e, fog, on the way? How's traffic? Is this a holiday weekend?

BTW, thanks for your patience. I appreciate the opportunity to participate in a scenario.

 

[Mountain Res-Q]

What is the season? Are those low clouds apt to drop snow or rain on the road in the next hour? The Trauma center is specified as an hour away: does the road penetrate the cloud layer, i.e, fog, on the way? How's traffic? Is this a holiday weekend?

It is November... Low Clouds (as in FOG) will not drop snow or rain... the trauma center is more than an hour away... the main route to the trauma center may have some fog on it, but you don't really know before hand, although historically, very little fog will be found except in some patches... traffic will be light in the mountains and light 75% of the way to the trauma center, but will get heavier as you approach the trauma center (there are actually 2 trauma centers within 3 miles of one another) since both trauma centers are located in the center of a far larger population center... not a holiday, it is in fact midweek at around 2230 hours...

 

[VentMedic]

GCS 3 (but does have a gag reflex), SpO2 90% on 15lpm via NR.

At least get the patient to someplace that can establish some type of airway even if it is by BVM. You've got tissue dying here. Or is this the patient you have triaged to leave as dead?

 

[Mountain Res-Q]

At least get the patient to someplace that can establish some type of airway even if it is by BVM. You've got tissue dying here. Or is this the patient you have triaged to leave as dead?

The NR was placed by Fire while the patient was still trapped. It wasn't until Medics were on scene and checked saturation that the low SpO2 was found even on high flow O2. While SpO2 is low with a NR, that does not mean that the NR was the end of any Airway/Breathing interventions. So in you opinion, you would transport to the ER for intubation versus having the Medic (yourself in this case) intubate or at least start ventilation via BVM?

Oh, and I triage this patient as Immedite; someone who can be saved if the proper desisions are made. Someone else here inferred that the patient may be unsalvagable, which I disagree with... You are not dead until I say you are...

 

[HuiNeng]

Oh, and I triage this patient as Immedite; someone who can be saved if the proper desisions are made. Someone else here inferred that the patient may be unsalvagable, which I disagree with... You are not dead until I say you are...

The patient is right on the line between red and black. The decision is very sensitive to the details of the scenario. That's why it's so interesting. In my mental picture of the scene, based on the first post, he was a goner. We apparently have different mental images of "rural."

(So, two trauma centers 3 miles apart, major metro area, California, earlier reference to UC Davis: I'm guessing somewhere on I80 between Vacaville and Fairfield?)

Right. He's on the bus heading east, two 'medics in back, one of the EMTs driving, another EMT riding shotgun. Having not attended class yet, I thought 90% SpO2 didn't sound so bad. Hm. Lesson learned.

What do we see in secondary assessment? Anything icky coming out nose or ears? Battle's sign? Racoon eyes? Depressed cranial fx? C-spine feel ok under the collar? JVD? Trachea midline? How does the chest sound? Bilateral? Airway still patent? How's that SpO2 looking? Still got good rhythm? What's the real BP, now that we're in a nice quiet code 3 ambo going 80?

Anything else of note? Scenario said he was trapped. Any longbone fx? Might they be bleeders?

Consider NPA if gag reflex is still there and if facial injuries don't contraindicate. Think about RSI if O2 is falling and gag reflex still present--but that's for the exalted ones in the back to determine.

Not starting fluids. Not with possible intracranial pressure problems. Are we there yet?

 

[Mountain Res-Q]

Very different ideas of Rural; I live in real rural, as in response times for ambulances can be 45+ minutes in some areas and transport times by ground to the little ER can be 60+ minutes. No, you are far off on location. I am in the real mountains, as in the Sierra Nevada’s, and this incident took place where the Mountains and Foothills meet...

I am curious what criteria you think this patient meets to be abandoned as a goner... maintaining own airway initially... breathing on own (although inadequate as determined latter)... still has a pulse... You would black tag this guy and allow him to slowly die in this wreck as you take care of the others with bruises and bumps? (oh and a SpO2 of 90 on a previously health young male even though he is being provided high flow O2 is a very bad thing. I am just a few years older than this guy and I am sating ~99% right now on room air.)

2 Medics and an EMT in the back with another EMT driving? LOL... ya, really different idea on rural. We have three ambulances covering the entire north side of the county and 1 ambulance covering the south side... and the ambulances are Medic/EMT. You already have 2 ambulances on scene for the 3 patients. One can take the critical and one can take the other two. The other ambulance is on a call for a man down and will not be available for 30 minutes. And before you ask about the south side ambulance... 45 minutes to get on scene (it is a large county, very rural...) As it is all Medics and Ambulances are unavailable for other calls as are 50% of the Staffed Fire Resources in the general area... 2 Medics and 2 EMTs? LOL... If need be you could take a Firefighter or two with you, but why do you need them?

As far as the other questions, not information needed to make a transport decision IMHO; the head injury, SpO2, and GCS is enough to classify this patient and make a decision on transport, but...

Anything icky coming out nose or ears? Battle's sign? Racoon eyes? Depressed cranial fx? C-spine feel ok under the collar? JVD? Trachea midline? How does the chest sound? Still got good rhythm? All good... your only evidence of the head injury was the abrasions and lacerations to the head and face; as well as the sluggish pupils and the general LOC/GCS. C-Spine palpates fine, but c-spine precautions are taken due to LOC and MOI. No JVD, tracheal shift, and the rhythm in the rig was, again, 122 sinus.

Airway still patent? How's that SpO2 looking? What's the real BP, now that we're in a nice quiet code 3 ambo going 80? Like I said, airway being supported by the patient, however breath sounds are clear but deep at a rate of 28. SpO2 does not change on a NR. BP remains 120/P... I know... that is BS and I have no excuse for the Medic reporting anything else.

Anything else of note? Scenario said he was trapped. Any longbone fx? Might they be bleeders? No other obvious fractures, although possible with the MOI, but nothing significant noted initially, especially to femurs or pelvis. Abdominal bleed? Possible, but no evidence in the field...

NPA thrown in my Fire initially. IV established in the rig for access, but fluids are withheld for the moment. RSI is a possibility, however does you transport decision have an effect on the RSI decision? In short... where do you want to go? Take the ambo out of the county for hours with a Medic in the back alone? Intubate him and ventilate with a BVM for over an hour? Hope that you can get to the Trauma Center before he codes? Head to the local ER and be done with it; it is someone else’s problem?

Like I said, I have my opinions and (as this call really happened) there was a decision made with real results... but this type of logistical situation is real life for a lot of people. The further you move away from urbanania, the more peaceful and tranquil your life can be... and the further you remove yourself from any benefits that urbanania offers, such as Trauma Centers and Doctors that have stopped bloodletting practices...

 

[Mountain Res-Q]

As far as the other questions, not information needed to make a transport decision IMHO; the head injury, SpO2, and GCS is enough to classify this patient and make a decision on transport, but...

I take that back... other complicating injuried such as tracheal shift or JVD might indicate the need to transport first to the local ER in the hopes that these issues can be dealt with first before dealing with any head injuries... However, no, these did not appear to be issues...

 

[WTEngel]

With a GCS of 3 without a gag reflex I think intubation would be in order. Protect the airway in case of vomiting, there is no reason not to. Intubation can be accomplished during extrication. Adjust ventilation rate per protocol on head injury.

NPA is absolutely contraindicated in this patient with a head injury and cranio facial injuries.

Establish IV access bilaterally with large bore catheters during extrication. Run fluids for systolic BP of 100.

My thoughts on this patient are that most of your first line interventions can be accomplished during extrication.

Now, I don't know how aggressive your local protocols are, however rural protocols tend to go either way, either very aggressive, or very basic. If your protocols are not advanced enough to manage a head injury for transport to the trauma center, then go to the local ED. If your protocols are advanced enough to manage the head injury for transport, then hammer down and hit the road ASAP.

The ideal solution to this problem would be to contact your medical director during extrication with your assessment of the patient. The medical director may be able to give you some online direction for the management of the head injury in order to facilitate the longer transport time.

If unable to contact medical control and you don't have the tools or protocols available to manage the head injury, then nobody can fault you for transporting to the nearest point of higher care (local ER).

In the end, treat the treatable, take away the pain, and do no harm.

 

[lightsandsirens5]

Well, for us, the descision is already made. Protocols state that, if it is a "critical" pt (other than in town really, and our hospital is a leval IV trauma center) then we call the bird.

As for the meeting the bird at the hospital helipad, apparently the law here states that if the pt comes onto hospital property, they must be evaluated there. (Trust me, got in trouble for this. We now meet at the airport.)

Also, we are not alloud to bypass Mt. Carmel (or St. Joseph's, whichever is closer, both lvl 4) under any conditions. (It doesn't help that the closest lvl 2 is 90 minutes away and the closest lvl 1 is over eight or nine hours away!)

So 98% of our pt's fall under the transp. to Mt. Carmel automatically, the rest go via MedStar air.

(Never mind we reall should call for air TONS more than we do......)

 

[HuiNeng]

This is fun. I haven't felt like a dull student for decades .

abandoned as a goner... maintaining own airway initially... breathing on own (although inadequate as determined latter)... still has a pulse...

My initial response, black tagging, was that I thought there was no way to get him to a facility in time to do him any good. That, I understand now, was a mistake.

As to the overfull stuffing of the ambulance: This guy's going to need med control communication for the whole trip. Because there were so many people standing around, I picked one of them to handle comms from the front seat. (Is that done?) Another junior does the driving, and the two 'medics mentioned do their thing in back with the patient. The only resource available in excess in this scenario is manpower.

I'm happy that a second ambulance is available. The two from the back seat go to the local ED and live happily ever after.

Taking the rig out of county? Sure. Having crossed off all the other possibilities and made the decision to transport to the trauma center, go with it. The second rig will be back in service soon because they've only got to go to the nearby ED. The other two rigs can keep doing whatever they were doing before. The fire folk need to clear the road and get home.

The other questions were assessment in the back of the speeding rig. Now that we're stuck in this guy's company for another hour or so, might as well be productive . This guy only has face lacs and whiny scrapes? This is looking more medical as time passes.

What's his glucose? Anything besides EtOH on his breath? <--Sniffing for ketones. MedAlert jewelry? He's ventilating but not oxygenating; heart rate's trying to accomodate for lower oxygenation. Is there an ETCO2 sensor available? Something's not right with the biochemistry.

 

[Mountain Res-Q]

lightsandsirens: That sucks simply because what is often protocol may not be in the best interest of the patient... but it is what it is.

WTEngel: 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. Otherwise, I like you... you're smart... want a drink? I agree that Medical Control needs to be consulted to see if they (the hospital) wants to recieve this patient initially or the MD wants the crew to haul azz to the Trauma Center. As far as protocol... I will leave that up to you... if you want to exist in a progressive system where you have more free reign to do what needs to be done, then good... but in this case... it is in restrictive California, and despite being a more liberal County, it is still CA.

HuiNeng: Still confused on Ambulance Staffing. You have ONE (1) Medics and ONE (1) EMT on an ambulance. You have 2 Ambulances on scene; 1 for the critical and 1 for the delayed patients. All others on scene are Fire EMTs. No one is standing around. The FFs are working as IC, Extrication, Traffic Control, etc. while the Ambulance Crews are also working. There is no excess manpower because if there was then the resources would be cancelled and sent back to station to cover a resource poor county. Your crew for a transport to the hospital (whichever one) is the EMT (driver), the Medic, and any FFs you rob from the scene... The patient is 100% trauma. He is critical if he indeed does have a closed head injury, as evidenced by the MOI (high speed roll over), head trauma, GCS, and pupils. No known medical history per family/friend in car with him and unless diabetes is contagious it is gonna be ETOH... the others in the car were also hammered... in fact the car was rolled on a road leading away from the biggest attraction in our county... a casino... and at 2230? ETOH! As far as progressive assessments... you don't unless you decide to transport for over an hour to the Trauma Center... and since the question being asked is transport related... what you have for assessment on scene is what you get... ^_^