Transport Question

[bmgriffin]

Ok, hypothetical situation.

Man vrs Car, hit and run, car won. Response time to scene less than 2 min, patient scooped up, boarded, hard stick with one IV started. BP 70/46, confirmed with no radial, tachy on monitor. Although patient is spastic and alert, possible injuries include head injury and deformed pelvis. Total scene time less than 10 minutes.

So do you transport to the nearest non trauma level (no surgery staff on call) hospital that's less than 2 minutes away or do you have helicopter meet you on scene? Arriving helicopter (who lets say was not activated as per protocol by 911 at start of call) has a response time of 10-15 min and then a transport to nearest appropriate trauma ER of 35 minutes.

Do you wait on scene with a patient that could expire before the bird lands or do you get to a more stable enviroment that could possibly prolong definitive care as opposed to flying the patient?

[needlejockey]

I would advice the local ER of what you have and ask if they want a helicopter to go direct to their location. If the doc says no, then that's why it's Medical Command.

[preston124]

With over an hour before the patient would get to the trauma center, I would consider going to the closest facility. At least the patient could get some prelim x-rays, CT maybe, and possibly blood hung while the bird can meet them there. Callin the doc never hurts either.

[wag11c]

No doubt- air transport! If you called for the helo upon arriving on scene they would be on the ground considering your 10 min scene time. The majority of Helicopters often provide an advanced level of care beyond what we do in the street. Most likely the definitive treatment for this pt is surgical intervention and it sounds like your local facility does not provide that. It's nice to have trauma transport protocols in place.

[Ridryder911]

I agree Trauma Transport protocols should be in place. If you transport to a local then they ae now stuck with doing a complete work up before referring them. CT, lab, x-ray etc..(COBRA) takes longer than an hour and then the patient still has to be transported.. so you actually caused a delay.

I suggest a rendezvous point,to meet the helicopter. This will decrease the time on both. Pre-plan sites for the future such as known parking lots, road side parks etc.. where there is a clearing and discuss with the helicopter crew, they probably know more areas.

I know our area we meet them all the time, mid-way if needed.

Good luck,
R/R 911

[CH47Doc]

Fer starters 70/40, massive trauma (deformed pelvis) and only 1 iv going? Anyways. Helicopters (at least ours) have plasma on hand if the guy really needed it, but you answered your own question really. You should transport to the nearest APPROPRIATE facility. Now that being said, ive transported to a level 3 hospital because they have a prefab LZ in place and they have blood and CT/X-ray and all that crap. But i have the bird otw as i am enroute with my patient. our nearest level 1 is 30min away running red all the way. if they only get 10 min to shoot films then thats all they get, but the bird is on the way to expedite the transport time.

[bmgriffin]

Stuck 4 times, got one to flow. 70/40 is almost grounds for vascular compromise in the extremities. I had my one line running wide open, and about to start hunting for an EJ. Not having a great way to offset loss of blood due to the pelvic injury, I was looking to transport to a more stable facility.

Helo was called and met at the hospital... but... once a patient rolls in the hospital protocols start up..CTs, X-rays, labs... Now if I had my 2cents in on the whole matter, you shoot what you can in the ER, get another line and wheel the patient right out to the helo pad. CT and Xrays can be read and faxed to the recieving facility.

Also, our helos don't have plasma...

Fer starters 70/40, massive trauma (deformed pelvis) and only 1 iv going? Anyways. Helicopters (at least ours) have plasma on hand if the guy really needed it, but you answered your own question really. You should transport to the nearest APPROPRIATE facility. Now that being said, ive transported to a level 3 hospital because they have a prefab LZ in place and they have blood and CT/X-ray and all that crap. But i have the bird otw as i am enroute with my patient. our nearest level 1 is 30min away running red all the way. if they only get 10 min to shoot films then thats all they get, but the bird is on the way to expedite the transport time.

[mitllesmertz1]

Good discussion, kind of a tricky one.
Protocols might say call the bird, wait at scene for it.
I might be inclined to get him to the ED, it's amazing what a few portable films can tell ya (ie need for chest tubes etc).
Someone else mentioned hanging blood, great idea. Dumping saline into him will just make pink blood, alot of research showing this isn't a good idea anymore :)
I would imagine this happens fairly often in the more rural areas- nice to hear the thinking going on here.

[croaker260]

Helo was called and met at the hospital... but... once a patient rolls in the hospital protocols start up..CTs, X-rays, labs... Now if I had my 2cents in on the whole matter, you shoot what you can in the ER, get another line and wheel the patient right out to the helo pad. CT and Xrays can be read and faxed to the recieving facility.



While the situation you describe (delays caused by hospityals playing CYA and trying to comply with every possible intepretation of EMTALA) is more common than not...A lot of it depends on how fired up the ER doc is on trauma sytems and the size of boot he can put in a nurses *** to get things moving.

At one local hospital I have seen a few of the ER DOCS have 15 minute in department times before the patient is out the door to the local trauma center (a Level II...before you ask, there is no Level I in Idaho or even close to it). The key there, just like in the field, is motivation, organization and prioritization.
I can see it happening, if the doctor has the testicular fortitude and the vision to make it happen.

I have also seen the opposite, where the doctor wants them out of the ER NOW, but they have been there for an hour and nothing has been done (including blood, CT, or airway management) while they stare at the patient and wait for the flight crew.

[MetalMedic]

A squad in my area has experienced a similar scenario which resulted in some additions to our protocals. If you retrieve your patient and then just sit in the ambulance and wait for a helicopter, you are not meeting your level of care which is to transport to the nearest location for definitive care. If the patient expires while you are waiting for the helicopter, you have comitted a potential abandonment for not delivering an expected standard of care.

The procedure we have is that we call for the helicopted and if the patient is extricated and loaded before the helicopter arrives, we transport to the hospital and contact the helicopter to divert to the landing pad at said hospital. We then contact the hospital to advise that a helicopter is inbound to their location. If the helicopter arrives before we do, we dleiver the patient to the helipad. If we arrive first, the ER doc will normally meet the squad at the ER door and access the patient and then decide if we enter the ER or proceed to the landing pad to wait. Usually by this time, the helicopter would be arriving and the flight doc gets to give some input on the decision so everyone is happy.

[OCFirePM]

Ok, hypothetical situation.

Man vrs Car, hit and run, car won. Response time to scene less than 2 min, patient scooped up, boarded, hard stick with one IV started. BP 70/46, confirmed with no radial, tachy on monitor. Although patient is spastic and alert, possible injuries include head injury and deformed pelvis. Total scene time less than 10 minutes.

So do you transport to the nearest non trauma level (no surgery staff on call) hospital that's less than 2 minutes away or do you have helicopter meet you on scene? Arriving helicopter (who lets say was not activated as per protocol by 911 at start of call) has a response time of 10-15 min and then a transport to nearest appropriate trauma ER of 35 minutes.

Do you wait on scene with a patient that could expire before the bird lands or do you get to a more stable enviroment that could possibly prolong definitive care as opposed to flying the patient?



BLS, or if available, taxi cab..................ha

[ProMedic138]

Ok, hypothetical situation.

Man vrs Car, hit and run, car won. Response time to scene less than 2 min, patient scooped up, boarded, hard stick with one IV started. BP 70/46, confirmed with no radial, tachy on monitor. Although patient is spastic and alert, possible injuries include head injury and deformed pelvis. Total scene time less than 10 minutes.

So do you transport to the nearest non trauma level (no surgery staff on call) hospital that's less than 2 minutes away or do you have helicopter meet you on scene? Arriving helicopter (who lets say was not activated as per protocol by 911 at start of call) has a response time of 10-15 min and then a transport to nearest appropriate trauma ER of 35 minutes.

Do you wait on scene with a patient that could expire before the bird lands or do you get to a more stable enviroment that could possibly prolong definitive care as opposed to flying the patient?




Nothing wrong with scoop and run. Get to the hospital, let the doctor do his thing and let the bird go to the hospital. Could be over and done with in 30mins.
The doc in the box could think the pt is stable enough for the surgeons the next day

[pfd4life]

Get him to the hospital...period. No need in waiting, call for the bird on arrival, load and go.

[montet202]

Helo: I don't know how many times I have seen level 2 and lower waste tiem with massive trauma. I am in a rural area and for every serious sounding MVC a helicopter is placed on standby-meaning they do their preflights and sit and wait. Upon arrival if it even looks serious from my driver's seat the copter is called for. Generally they are landing at the time we are ready to transport.

As for the lines--No IJ or Sub Clav?

[mitllesmertz1]

Helo: I am in a rural area and for every serious sounding MVC a helicopter is placed on standby-meaning they do their preflights and sit and wait.
I assume you are referring to ALNW, which in Washington is the only medical helo around other than MAST.
When they are placed on "standby", they don't go out to the bird and do a preflight, and then sit in it and wait :D
Far from it. It just means they try to wake up, get off the stairstepper, go to the bathroom, check the weather,etc.
If another call comes in, the bird is no longer yours.Standby doesn't reserve the bird for you.
Preflight is done in the morning, they don't preflight the bird every call.
Standby just makes you feel good, it does nothing for response times etc. Might cut 30 seconds off because they don't have to stop at the bathroom first...
My wife works ALNW, except when she's pregnant :)

As for the lines--No IJ or Sub Clav?
this is a skill set that most responders aren't using in the field.

[montet202]

Actually we have Life Flight out of Oregon too. Who, I have been told, does do their preflights. Everything but start to turn their rotors. This is the first place I have worked at in Wshington that does put ALNW on standby, but if it saves one minute I think it is worth it. Especiall since I am by myself (with volunteer EMT's).

Give my regards to your wife. They have had a rough year. We definitely appreciate them very much down here.

My point is...the sooner you get the ball rolling, the better. Don't wait untill you have the patient extricated to make initial transport decisions.

[bmgriffin]

As for the lines--No IJ or Sub Clav?

I was looking around the neck as we rolled up, but c-collar adds a bit of a challenge. ;)

And no sub clavs by EMS in TN.

[bmgriffin]

Actually we have Life Flight out of Oregon too. Who, I have been told, does do their preflights. Everything but start to turn their rotors. This is the first place I have worked at in Wshington that does put ALNW on standby, but if it saves one minute I think it is worth it. Especiall since I am by myself (with volunteer EMT's).

Give my regards to your wife. They have had a rough year. We definitely appreciate them very much down here.

My point is...the sooner you get the ball rolling, the better. Don't wait untill you have the patient extricated to make initial transport decisions.


But it gets sticky when you look at the numbers. In 12 minutes I left the building, scooped the patient up, stuck 4 times and hit one, and was back on the road and could see the hospital through the cab window. Now, average helo time to that location was 10 minutes under best conditions regardless of 'preactivation'.

So, if helo was called you have a slim chance of being there just as you load and go. Otherwise you kinda of sit there and determine you next route of preventing further hypotension.

Helo is a great option I know, but as far as PHTLS/ACLS/BLS there isn't much more they can do in the air as opposed to my truck.

My main concern is what if the patient expires or degrades in the 3-5 minutes waiting on scene for a helo when the hospistal is literally less than 2 minutes down the road.

[CH47Doc]

In an extrication type scenario i agree. you pretty much know if the Pt is gonna crunk on ya or if hes stable. if hes FTD then have a bird enroute during extrication. As stated our local hospital is a level 3 and our docs are pretty good about gettin people out NOW! if they gotta go. Im sure some inexperienced docs might wanna poke and prod a little while they decide of they can actually help them. we have x-ray fax capability so we can send Ct's, sometimes hand carried on a CD-ROM, films and whatever else to the trauma center ahead of the patient.

I also agree on the waiting at the scene issue. Our aircraft usually have about a 15-20min ETA to our county. So thats a 40min round trip not including scene time. If im close enough to drive, say 15-20 min out, ill go ahead and drive em in instead of calling the bird. But you gotta know if you have the tools on hand to keep your Pt alive to make the trip.

[CH47Doc]

I was looking around the neck as we rolled up, but c-collar adds a bit of a challenge. ;)

And no sub clavs by EMS in TN.

I know you said pretty bad pelvic fracture, did he have distal pulses? and do you do adult IO? could that have been an option?

[montet202]

Don't get me wrong...just curious questions. I obviously was not there and cary no judgment. Sounds like you have answered your own question and did what was appripriate for your area. I like an IJ for major trauma and will have an EMT hold stabilization, romove the collar and get the stick and tube if neccessary. Seems to work well. Don't know if you tried it or even had time. I have heard from a freind that the adult IOs are great, but haven't had the chsance to see/try them myself. Sounds like a good tool, thought I'd rather stick 'em in the neck.

[Weruj1]

Well you learn something for better or for worse on these forums. Here when we place a air ambulacne on stand by that means the helo is moved out of the hangar, weather and pre flight checks are done and someone is bringing blood to the copter. Then everyone boards and buckles in and waits with the rotors truning. I would wait for the copter myself as when you transport to these outlying facilities there is ALOT of pussyfooting around with the patient, or could they divert you ?> At any rate why have a pretty good Statewide Trauma SYStem here in Ohio that lets you bypass these facilities if practical. So I would have had them on stand by and called for them.

[preston124]

We are only about 15-45 minutes from a level 2 here (traffic) but do sometimes use the bird. Our local hosp has a pad (there are few other places to land it here) but somebody, either the hosp or the bird ppl say that if we make it on to hosp property, we have to bring that patient into the ER there (even if everybody knows the trauma center is needed) Any thoughts on that? Anyone can shed some light on laws?

[wag11c]

Werju: That sounds like a lot to do for a standby: Every time those rotor turns equals more maintenance hours. When I was flying we would rush to the bird on a standby and have everything ready. As time went on and more and more standbys turned to junk all it meant was take a **** and pay more attention to the radios. Itb is kinda nice though to hear of flight crews who are willing and waiting to be ready.

[Dubbsy]

Itb is kinda nice though to hear of flight crews who are willing and waiting to be ready.


We're very fortunate up here then apparently.. The bird we have access to (Meritcare Life Flight out of Fargo, ND) has told us again and again that they're more than willing to get off the ground (weather permitting) and get headed our way early with the possibility of getting sent home. Because of that we often call real early - usually before we even get a full crew and go enroute. (we call for most MVAs)

Flight time is somewhere between 20 and 30 minutes if I recall correctly - one way (by ground it's appx 55 miles). It's not always a whole lot faster than by ground, but it gets the pt in ALS care quicker and saves them a rough ride.



As for the question.. transport to the nearest facility and have the helo meet you there.

[bmgriffin]

I know you said pretty bad pelvic fracture, did he have distal pulses? and do you do adult IO? could that have been an option?


No adult IOs here :( Pedis only.

[rolandthunder]

No contest hit the closest ER. The bird can be diverted there. Advanced care in any form is better then the pt can get from EMS in the field. I would never advise bypassing a local hospital for a trauma center.

[SSTONER]

I am courious as to how long it take helo to lift once you request it? Here we have lifeline and lifenet - some take longet than others but on average it takes on company about 10 minutes to LIFT in addition to the ETA once in the air.

[Weruj1]

No contest hit the closest ER. The bird can be diverted there. Advanced care in any form is better then the pt can get from EMS in the field. I would never advise bypassing a local hospital for a trauma center.
......in some places unless you are in an arrest it is law that you bypass and go to a trauma center.

[jtkmedic69]

We have called the helo and had them meet us at the ER just incase there was some time available for the er staff to work on him and stabalize him a bit more. Then fly them to the nearest level one center. This is obviously a load and go patient. Maintain airway, C spine him and do everything else enroute.

[engine4cLT]

We have to transport to the closest appropriate facility. Our local level IV Er would NOT be even close to appropriate for that trauma. They would have to go to a level I which is about 15mins further up the road.