Situation, had to make a tough decision. Need advice.

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Mike Mathers

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Ok guys let me cut to the chase. I arrive to a MVA. This was in Idaho. There's a young male intoxicated (he said he was) and had a big laceration across the front side of the head. I immediately started to control the bleeding (able to gain control). I access his vitals. Nothing is abnormal all within range. The closet hospital in within a 7 minute drive so I tell my partner not to consider ALS because I would get to the hospital before meeting up with them. (ALS was not immediately dispatched when the call went out) While transporting I could his face was swelling up and he was getting worst. We took all nesscary precautions with a KED, backboard, c collar. I was later told by my boss that I should have requested ALS because he found out his injuries where severe and he ended up being transported to another hospital. I'm just at a cross road because I told my boss there no way I can diagonis his injuries and it was 100 percent my call not to request ALS. He told me there was a lot of blood loss and I told him the vital signs where inact with the bleeding controlled. Keep in mind my boss said he shoulda gone to a trauma center which is about an 34 minute drive.

What would u guys have done?
 
Was your boss, who insists there was "a lot of blood loss", on scene? Was there actually significant bleeding? Yes its a vascular area, but are we talking trauma-alert worth significant bleeding?

If not, what were your indications for spine boarding, other than intoxication? Any specific physical signs? As well, can you describe the MVA?

Last one. You are saying that his face was swelling, and he was getting worse. Where was the swelling, and in what way was he getting worse (shocky? bleeding more? AMS?)

I've never worked in a system that utilized ALS intercepts, so I can't really comment on that aspect. I'm happy to give my take on hospital/ALS choice if you answer the questions above though.
 
The way I see it, the hospital is closer and has doctors, ALS is further away and they aren't doctors. I think you made the right choice.
 
MedicDelta said:
The way I see it, the hospital is closer and has doctors, ALS is further away and they aren't doctors. I think you made the right choice.
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The closest hospital is not always the most appropriate. Taking the pt to the trauma Center would have had them at the trauma Center in about 30 min. Going to the local hospital is say 10 minutes. The docs mess around for 45 min to an hour. A transfer is called in so another 15-30 min then the 30-40 min drive to the trauma Center.

See what I'm getting at?
 
Medic Tim said:
The closest hospital is not always the most appropriate. Taking the pt to the trauma Center would have had them at the trauma Center in about 30 min. Going to the local hospital is say 10 minutes. The docs mess around for 45 min to an hour. A transfer is called in so another 15-30 min then the 30-40 min drive to the trauma Center.

See what I'm getting at?
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Yeah I understand. I have no real experience in EMS and this appears to be a question for those who have lots. Was just putting my 2 cents in.
 
MedicDelta said:
Yeah I understand. I have no real experience in EMS and this appears to be a question for those who have lots. Was just putting my 2 cents in.
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No worries, I wasn't coming down on you or anything. These are things you will pick up as you get more experience and progress.
 
Medic Tim said:
No worries, I wasn't coming down on you or anything. These are things you will pick up as you get more experience and progress.
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Yeah for sure. I'm here to learn, and I've just learnt something haha, so thanks.
 
I think the fact that the patient is altered makes this a bit less straightforward. He obviously has head trauma, and you have no way of knowing what's the alcohol talking and what's a concussion or something.

In this situation I call for ALS mostly as a formality to CYA. 90% of the time dispatch just tells us to go to the hospital. But at least then you can put in the run report, "requested ALS, dispatch replied that closest ALS is X hospital".

What constitutes "normal vitals" in this situation? Dude just got in a car accident - if he's not tachycardic and hypertensive I'm a bit concerned. Then again he's intoxicated to some unknown degree. Who they heck knows what is "normal" for this guy in this situation. It's kind of a gray and difficult area, and there isn't realistically much medics will do for this guy that you can't... But I think it wouldn't have been a bad idea to CYA and call for them.
 
I agree with @Medic Tim and @J B

I probably would have put in an ALS request as formality, if we can meet up great but if not the oh well, I tried.

As to whether it was a good move or not, only you and maybe your partner know the real answer. If you are second guessing yourself, maybe you can learn from the experience and feel more confident next time you are this situation. You might want to review your trauma activation protocols to see if this guy met trauma criteria and should have gone directly to a trauma center...especially with increasing facial swelling and "getting "worst"". Also, remember transport is dynamic, you can always request intercept en route and also change your destination while en route.
 
Did he meet state trauma criteria? If he did you made the wrong call. We have very specific trauma criteria here that require transportation to a TC unless we make base contact with the TC and the hospital the patient wants to go to and both agree it's alright to go to the non-trauma hospital. Without knowing more about the call other than it was an MVA, he had a lac that was bleeding and was intoxicated it's difficult to give you answers to your questions. Also, I'm not familiar with Idaho's trauma system.

Why the KED?

I've also never worked in a system with ALS intercepts, we run P/I ambulances so there's always an ALS provide on scene.

I'll give you an example of trauma criteria, this is Nevada's state trauma criteria that requires transport to a trauma center. In frontier EMS situations they can transport to their local hospital but generally if they find anything besides a simple orthopedic injury they will be transferred to the TC.

Mechanism:
Fall >20 feet, MVA >40 MPH, MVA with >19 inches of severe damage, Rollover >90*, MVA with death in the same vehicle, MV vs. Ped >6mph or run-over/thrown at any speed, >11 inches of intrusion to passenger side of compartment, Motorcycle accident >20 MPH or thrown, Extrication >20 minutes, Ejection.

Injury:
Flail chest, Acute Paralysis, 2 or more long bone fractures, Burns >15% tBSA or involving face or airway, Penetrating chest, abdomen, head, neck or groin injury, Amputation proximal to wrist or ankle.

Physiologic:
SBP <90 mmHg, RR <10 or >29, Revised Trauma Score <11, GCS <14.

Like I said, this is Nevada's but most if not all states have a trauma criteria that requires transport to a Trauma Center. Technically if a patient meets any of these criteria we have to transport them to a L I or L II but since we have the only TC, which is a L II, outside of Las Vegas it's our only option. Next closest is UC Davis which is a L I and our closest Burn Center. We don't transport by ground to there though, only HEMS or a scheduled fixed wing transfer.
 
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Grimes said:
I heard you like immobilizing, so I got you an immobilizer for your immobilizer, so you can immobilize the immobilized.
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Hahaha.

In all seriousness I've used the KED more than most. We have selective spinal motion restriction but more often than not my hands are tied. I use it quite often on kyphotic or lordotic patients when there's no way for me to get around placing them in SMR. I've only once used it in conjunction with a LSB and that was a guy who rode his bicycle into a ~6 foot deep construction trench drunk as a skunk and had acute paralysis from the clavicles down. Only reason I asked is it doesn't sound like it was indicated in this situation.

To the OP, I'm not trying to come down on you but if you felt the need for ALS why not request them while you're working on getting him out of the car? KED isn't as slow as they say in school but it does take time, especially if you're going to move them to a board and then secure them to it as well.
 
My local six bed ED is a trauma center. It's a level IV but if we so choose we can bring them any trauma patient we have. Whether or not that's an appropriate decision is a whole nother question as we have two Level IIs within 40 minutes of that.

The point being is that in some areas local hospitals are designated trauma receiving facilities. Their role is stabilize and then give them back to you and sometimes that is a better option than bypassing them and trying to make it the "right" facility immediately. If ALS had a significant response time I would have absolutely transported to the local hospital if I was on a BLS ambulance.
 
Request ALS and begin transport to the closest hospital, if ALS arrives before you get to the hospital allow them to make the call to change destination. Otherwise you get them to the hospital, there they stabilize and decide what the patient needs. You don't know if he has some injury that needs immediate medication that you don't have/can't give. In my opinion you should have requested ALS but made the right call to go to the nearest destination. Also based upon your description it appeared only as a head lac, easy fix with fluids and stitches...however very interesting that you took vitals and then back boarded (at least thats how it sounds). Just don't get complacent no call is as simple as it seems and head injuries are ALS (at least where i work)
 
Every system I have ever worked in has had trauma triage guidelines for transport destinations. Is this not commonplace?
This isn't one I have used as I am not from the states but it is similar.
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