To Golden Hour or Golden 3 hrs

[Guest guest]

Need some of the docs on here and others to weight in on this one to see if this

situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while

pt is palced on back board and moved from truck to ambulance for better

inspection and assessment. Once in unit, pt is stripped and flipped to check

for additional injuries and such. Only the three are noted, pressure is still

being held, but occlusive dressings have been placed over each and covered with

4x4s and secured. Pt has one other small lac to top of right shoulder, that is

deep as you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what

is covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness

to the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even

if the service does not agree with them, they should still be used. Why send a

pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like

that, but if they need immediate cath it's better to send them to a facility

that can do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

I'm in the same situation where I work, but our helo ETAs are closer to 35min,

and the hospital here doesn't mind us flying stuff out because that means less

work for them, but most of our crews transport there anyway.

Back to your topic, I think you were in the right to fly, the pt. was sent to

the closest APPROPRIATE facility. Penetrating trauma to the chest, abdomen or

back was an automatic level I trauma activation at the ER I worked in.

I'd start looking for a new job if your big wigs don't want patients treated

properly.

Garrett

To Golden Hour or Golden 3 hrs

Need some of the docs on here and others to weight in on this one to see if

this situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while

pt is palced on back board and moved from truck to ambulance for better

inspection and assessment. Once in unit, pt is stripped and flipped to check for

additional injuries and such. Only the three are noted, pressure is still being

held, but occlusive dressings have been placed over each and covered with 4x4s

and secured. Pt has one other small lac to top of right shoulder, that is deep

as you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits

because this pt was flown and not brought to the local ER. Even though they

would have shipped him out after 2 hrs or so. What is worse the EMS Director is

defending the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency

Medicine. We have this time to do what is best for the pt and this is what the

crew did. Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even

if the service does not agree with them, they should still be used. Why send a

pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER

and bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4

or General ER cannot handle things that a level 2 or 3 can. Someone to die in

the ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

I am assuming from reading this a few things...

1.  Small Community

2.  Only one hospital (presumably a Level 4, but may be non-participating)

3.  Only other choices are Level 2 and 3's...no level 1

4.  Local RAC has trauma bypass protocols but no trauma transfer plan

5.  Local hospital has some affiliation with the local EMS agency

6.  Local hospital has no surgical services

I would like to know how far away the Level 2 and 3 trauma centers are.  I

would also like to know more about this patient including multiple sets of vital

signs...was the bleeding able to be controlled?  If the wounds are on the upper

chest, curious why we think there may be a spleen injury.  Lastly, I would like

to know what the protocols for this EMS agency state to do with these patients

and what their transport destination protocol states.  I would also like to

know the other side of this story.

Thoughts...the " golden hour " is an advertising slogan, although I do not feel we

should dabble on scene with seriously injured trauma patients, if they are not

dying this second, we probably have some time to get them to definitive care. 

There have been a number of changes in trauma care over the last 5 to 10 years

and unfortunately, EMS education has not kept up.  Still teaching " golden hour "

and 2-large bore IV's and pumping up the BP...as well as MOI as a critical

factor in destination choice are all still taught daily although they have all

been moved away from by the trauma community (except for media and

advertising). 

On your STEMI concerns, if there is a system in place, and depending upon time

and distance, it may make more sense to go to the ER 1/2 mile away for

thrombolytics before being transferred to a PCI center...

Above all, if there is a system, it is up to all of us to operate within that

system or work to change it if we see a better way.  When and if we freelance,

then we get into trouble...and like another post said, if you can't operate in

the current system and cannot get it changed...then one would have to think

about relocating into a different system. 

Have a good week everybody.

Dudley

To Golden Hour or Golden 3 hrs

Need some of the docs on here and others to weight in on this one to see if this

situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while pt

is palced on back board and moved from truck to ambulance for better inspection

and assessment. Once in unit, pt is stripped and flipped to check for additional

injuries and such. Only the three are noted, pressure is still being held, but

occlusive dressings have been placed over each and covered with 4x4s and

secured. Pt has one other small lac to top of right shoulder, that is deep as

you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even if

the service does not agree with them, they should still be used. Why send a pt

to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

wayne, is this up here?? d/fw area?? what the heck is a level 5 ED??

we have 3 level 1, 3 level 2, 3 level 3 and 13 level 4 trauma centers in

tsa-e.

jim davis

Wayne D wrote:

Need some of the docs on here and others to weight in on this one to

see if this situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while pt

is palced on back board and moved from truck to ambulance for better inspection

and assessment. Once in unit, pt is stripped and flipped to check for additional

injuries and such. Only the three are noted, pressure is still being held, but

occlusive dressings have been placed over each and covered with 4x4s and

secured. Pt has one other small lac to top of right shoulder, that is deep as

you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even if

the service does not agree with them, they should still be used. Why send a pt

to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

Dudley,

I'll answer your questions within your e-mail.

THEDUDMAN@... wrote:

I am assuming from reading this a few things...

1. Small Community Yes

2. Only one hospital (presumably a Level 4, but may be non-participating) yes,

level 4 I found out. Yes, they are apart of the local RAC

3. Only other choices are Level 2 and 3's...no level 1 Yes, level 3 is 50 miles

away by ground and 14 minutes by air.

4. Local RAC has trauma bypass protocols but no trauma transfer plan They have

some kind of bypass, but is not very detailed. 5 lines of information

5. Local hospital has some affiliation with the local EMS agency Yes, they are

apart of the hospital but a county service

6. Local hospital has no surgical services True. Just minor surgery, not able

to surgically stablize a trauma pt.

I would like to know how far away the Level 2 and 3 trauma centers are. I would

also like to know more about this patient including multiple sets of vital

signs...was the bleeding able to be controlled? If the wounds are on the upper

chest, curious why we think there may be a spleen injury. Lastly, I would like

to know what the protocols for this EMS agency state to do with these patients

and what their transport destination protocol states. I would also like to know

the other side of this story. Level 3 would be Abilene and Level 2 or higher

would be Lubbock, Temple or Waco. Another level 3 in San Angelo. V/S remained

about the same all the time the crew had the pt. 140s/70s, with one in the

120s/70s. Yes, bleeding was controlled, if not stopped while EMS had pt. THe

spleen theory was stated, because it was not known just which direction the

knife may have went.

I did look and the helicopter activation section covers dispatching,

packaging, LZ Info and safety. Also states if there is a delay in getting an

aircraft to the scene to transport to the ER. However, the crew was in contact

with the air medical service and by they were launched once the crew got on

scene. By the time the crew got the pt loaded and everything done and to the

airport, the bird was 2 minutes out, so there was no wasted time sitting on

scene. They are 14 minutes away most of the time.

The main argument that is being made is, that the crew did the right thing to

get this pt to a higher level of care, because going to a level 4 and waiting to

be transported out, is not definative care that a trauma pt needs.

This is why I carry and everyone that knows me, knows that I'm sick or should

be a trauma pt, I'm to be flown to Hillcrest in Waco or or JPS. If the

local system want call and I can call myself, I'll AMA and call for air

transport myself.

Other EMS providers fly out pts that the local level 4 is not able to treat

and would have to be flown out anyway, and nothing is ever said. But, when your

rubber stamp MD is not involved until you do something you feel is right, and

they or the service managers don't there is a problem. EMS should do what is

best for the pt and not have to answer why, unless there was something that they

did wrong to cause other problems or the death of the pt. This pt was stable by

all means.

The pt did get a chest tube and surgery at the level 3 and there were 3 true

stab wounds, in which the lung was injuried. Pt is doing fine now.

this is the only system that I've seen where you are repremanded for flying

out a trauma pt and no one will stand behind the crews for doing what is in the

best intrest of the pt.

Thoughts...the " golden hour " is an advertising slogan, although I do not feel we

should dabble on scene with seriously injured trauma patients, if they are not

dying this second, we probably have some time to get them to definitive care.

There have been a number of changes in trauma care over the last 5 to 10 years

and unfortunately, EMS education has not kept up. Still teaching " golden hour "

and 2-large bore IV's and pumping up the BP...as well as MOI as a critical

factor in destination choice are all still taught daily although they have all

been moved away from by the trauma community (except for media and advertising).

On your STEMI concerns, if there is a system in place, and depending upon time

and distance, it may make more sense to go to the ER 1/2 mile away for

thrombolytics before being transferred to a PCI center...

Above all, if there is a system, it is up to all of us to operate within that

system or work to change it if we see a better way. When and if we freelance,

then we get into trouble...and like another post said, if you can't operate in

the current system and cannot get it changed...then one would have to think

about relocating into a different system.

Have a good week everybody.

Dudley

To Golden Hour or Golden 3 hrs

Need some of the docs on here and others to weight in on this one to see if this

situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while pt

is palced on back board and moved from truck to ambulance for better inspection

and assessment. Once in unit, pt is stripped and flipped to check for additional

injuries and such. Only the three are noted, pressure is still being held, but

occlusive dressings have been placed over each and covered with 4x4s and

secured. Pt has one other small lac to top of right shoulder, that is deep as

you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even if

the service does not agree with them, they should still be used. Why send a pt

to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

Jim,

No this was not in the DFW area. I think a level 5 is a minor emergency

clinic? Actually, I put that in by mistake...too many level numbers.

Wayne

james davis wrote:

wayne, is this up here?? d/fw area?? what the heck is a level 5 ED??

we have 3 level 1, 3 level 2, 3 level 3 and 13 level 4 trauma centers in tsa-e.

jim davis

Wayne D wrote:

Need some of the docs on here and others to weight in on this one to see if this

situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while pt

is palced on back board and moved from truck to ambulance for better inspection

and assessment. Once in unit, pt is stripped and flipped to check for additional

injuries and such. Only the three are noted, pressure is still being held, but

occlusive dressings have been placed over each and covered with 4x4s and

secured. Pt has one other small lac to top of right shoulder, that is deep as

you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even if

the service does not agree with them, they should still be used. Why send a pt

to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

That is what we are saying, a level 4 ER is NOT an APPROPRIATE facilty for this

type of pt, because there is NO definitive care available that this or these

type of pts need. They need a trauma center, where there are trauma surgeons

and a trauma team ready to do what is needed to treat these pt.

This is why I will AMA if I have to go to a level 4 as a medical or trauma pt.

I'll either call for air medical myself, or drive myself to Hillcrest in Waco,

not Abilene. If or JPS is closer then fly or drive me there. I've not

had good relations with small hospitals as I've had family in them and they

wanted to sit around and wait before transporting them out. It took me calling

for air medical to get them transported out of the facility and to Hillcrest in

Waco.

While these facilities are needed, they are just not able to handle every

situation that comes through the doors based on pt need.

Maybe I need to work for your service.

Wayne

ReD wrote:

I'm in the same situation where I work, but our helo ETAs are closer

to 35min, and the hospital here doesn't mind us flying stuff out because that

means less work for them, but most of our crews transport there anyway.

Back to your topic, I think you were in the right to fly, the pt. was sent to

the closest APPROPRIATE facility. Penetrating trauma to the chest, abdomen or

back was an automatic level I trauma activation at the ER I worked in.

I'd start looking for a new job if your big wigs don't want patients treated

properly.

Garrett

To Golden Hour or Golden 3 hrs

Need some of the docs on here and others to weight in on this one to see if this

situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while pt

is palced on back board and moved from truck to ambulance for better inspection

and assessment. Once in unit, pt is stripped and flipped to check for additional

injuries and such. Only the three are noted, pressure is still being held, but

occlusive dressings have been placed over each and covered with 4x4s and

secured. Pt has one other small lac to top of right shoulder, that is deep as

you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even if

the service does not agree with them, they should still be used. Why send a pt

to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________

[Guest guest]

How far was the incident from the Level I? If the ground crew had loaded

the patient immediately and gone enroute, what's the comparison of time of

arrival at the LEVEL I with when he arrived by air?

Gene G.

>

> I'm in the same situation where I work, but our helo ETAs are closer to

> 35min, and the hospital here doesn't mind us flying stuff out because that

means

> less work for them, but most of our crews transport there anyway.

>

> Back to your topic, I think you were in the right to fly, the pt. was sent

> to the closest APPROPRIATE facility. Penetrating trauma to the chest, abdomen

> or back was an automatic level I trauma activation at the ER I worked in.

>

> I'd start looking for a new job if your big wigs don't want patients treated

> properly.

>

> Garrett

>

> To Golden Hour or Golden 3 hrs

>

> Need some of the docs on here and others to weight in on this one to see if

> this situation was correct and in the best interest of the pt.

>

> you called for a stabbing victim at 230am. You go the few blocks and get

> there in less than 4 minutes. You find a 27 y/o male in the back of a pickup

> with friends around him. One person is holding pressure to the left side of

the

> pts back. upon removing the shirt that is being held in place, you notice

> about 3, 1-2 " puncture wounds to pts left side just to the side of the left

arm

> pit.

>

> Pt is alert & conscious, states he is SOB and hurting. Pressure is held

> while pt is palced on back board and moved from truck to ambulance for better

> inspection and assessment. Once in unit, pt is stripped and flipped to check

for

> additional injuries and such. Only the three are noted, pressure is still

> being held, but occlusive dressings have been placed over each and covered

with

> 4x4s and secured. Pt has one other small lac to top of right shoulder, that

> is deep as you can see underlying tissues, but is about 1 " long.

>

> Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have

> been started. Pt and clothing covered in blood, maybe about 500cc total, plus

> what is covering the pt. Pt does have BBS to left side, but c/o SOB and

> tenderness to the LUQ area. No deformities noted.

>

> once it was noted what the condition was, air medical support was called and

> have about a 15 ETA to LZ.

>

> OK here is the question. You are half a mile from a general ER, no trauma

> designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

> pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

> don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

> and transfer out to higher level of care.

>

> Now the MD which was the ER doc last night is throwing all kinds of fits

> because this pt was flown and not brought to the local ER. Even though they

> would have shipped him out after 2 hrs or so. What is worse the EMS Director

is

> defending the doc and not the crew for making a better call for the pt.

>

> We are taught about the golden hour when we get into EMS or Emergency

> Medicine. We have this time to do what is best for the pt and this is what the

crew

> did. Now they are having to exlpain themselves.

>

> I know that most RAC's have bypass protocols in place for such an event.

> Even if the service does not agree with them, they should still be used. Why

> send a pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where

you

> have trauma surgeons and more advanced treatment.

>

> this is guy had a spleen injury and he would have been taken to a level 4 ER

> and bleed out there, that is not definitive care when you have to transfer

> out.

>

> What is the best course of action to make these people realize that a level

> 4 or General ER cannot handle things that a level 2 or 3 can. Someone to die

> in the ER waiting for hospital and doc acceptance? Probabaly.

>

> It's not just trauma, but STEMI as well. Bring them here, we have no cath

> lab, but we can transfer out after 2 hrs. Yea they can give TPA and things

like

> that, but if they need immediate cath it's better to send them to a facility

> that can do that & has a team ready to go.

>

> Suggestions.

>

> Wayne

>

> ____________ ________ ________ ________ ________ _

>

[Guest guest]

I'm going to play Devil's Advocate and ask this rude question: How did

helicopter transport help the patient in this scenario? You sat on scene for

14

minutes or more, waiting for the bird, then he had to be loaded and the bird

get back up, so let's add 10 minutes, then 14 minutes back to the hospital,

another 5 or more into the ER. That's 43 minutes. If you had loaded your

patient and driven to the hospital, you would have been there within 10 minutes

of the helicopter, your patient would not have had a $20,000 helicopter bill,

and his outcome would have been exactly the same? No?

Gene G.

>

> Dudley,

>

> I'll answer your questions within your e-mail.

>

> THEDUDMAN@... wrote:

>

> I am assuming from reading this a few things...

>

> 1. Small Community Yes

>

> 2. Only one hospital (presumably a Level 4, but may be non-participating)

> yes, level 4 I found out. Yes, they are apart of the local RAC

>

> 3. Only other choices are Level 2 and 3's...no level 1 Yes, level 3 is 50

> miles away by ground and 14 minutes by air.

>

> 4. Local RAC has trauma bypass protocols but no trauma transfer plan They

> have some kind of bypass, but is not very detailed. 5 lines of information

>

> 5. Local hospital has some affiliation with the local EMS agency Yes, they

> are apart of the hospital but a county service

>

> 6. Local hospital has no surgical services True. Just minor surgery, not

> able to surgically stablize a trauma pt.

>

> I would like to know how far away the Level 2 and 3 trauma centers are. I

> would also like to know more about this patient including multiple sets of

> vital signs...was the bleeding able to be controlled? If the wounds are on the

> upper chest, curious why we think there may be a spleen injury. Lastly, I

would

> like to know what the protocols for this EMS agency state to do with these

> patients and what their transport destination protocol states. I would also

> like to know the other side of this story. Level 3 would be Abilene and Level

2

> or higher would be Lubbock, Temple or Waco. Another level 3 in San Angelo.

> V/S remained about the same all the time the crew had the pt. 140s/70s, with

> one in the 120s/70s. Yes, bleeding was controlled, if not stopped while EMS

> had pt. THe spleen theory was stated, because it was not known just which

> direction the knife may have went.

> I did look and the helicopter activation section covers dispatching,

> packaging, LZ Info and safety. Also states if there is a delay in getting an

> aircraft to the scene to transport to the ER. However, the crew was in contact

with

> the air medical service and by they were launched once the crew got on scene.

> By the time the crew got the pt loaded and everything done and to the

> airport, the bird was 2 minutes out, so there was no wasted time sitting on

scene.

> They are 14 minutes away most of the time.

> The main argument that is being made is, that the crew did the right thing

> to get this pt to a higher level of care, because going to a level 4 and

> waiting to be transported out, is not definative care that a trauma pt needs.

> This is why I carry and everyone that knows me, knows that I'm sick or

> should be a trauma pt, I'm to be flown to Hillcrest in Waco or or JPS.

If

> the local system want call and I can call myself, I'll AMA and call for air

> transport myself.

> Other EMS providers fly out pts that the local level 4 is not able to treat

> and would have to be flown out anyway, and nothing is ever said. But, when

> your rubber stamp MD is not involved until you do something you feel is right,

> and they or the service managers don't there is a problem. EMS should do what

> is best for the pt and not have to answer why, unless there was something

> that they did wrong to cause other problems or the death of the pt. This pt

was

> stable by all means.

> The pt did get a chest tube and surgery at the level 3 and there were 3 true

> stab wounds, in which the lung was injuried. Pt is doing fine now.

> this is the only system that I've seen where you are repremanded for flying

> out a trauma pt and no one will stand behind the crews for doing what is in

> the best intrest of the pt.

>

> Thoughts...the " golden hour " is an advertising slogan, although I do not

> feel we should dabble on scene with seriously injured trauma patients, if they

> are not dying this second, we probably have some time to get them to

> definitive care. There have been a number of changes in trauma care over the

last 5 to

> 10 years and unfortunately, EMS education has not kept up. Still teaching

> " golden hour " and 2-large bore IV's and pumping up the BP...as well as MOI as

a

> critical factor in destination choice are all still taught daily although

> they have all been moved away from by the trauma community (except for media

> and advertising) Th

>

> On your STEMI concerns, if there is a system in place, and depending upon

> time and distance, it may make more sense to go to the ER 1/2 mile away for

> thrombolytics before being transferred to a PCI center...

>

> Above all, if there is a system, it is up to all of us to operate within

> that system or work to change it if we see a better way. When and if we

> freelance, then we get into trouble...and like another post said, if you can't

> operate in the current system and cannot get it changed...then one would have

to

> think about relocating into a different system.

>

> Have a good week everybody.

>

> Dudley

>

> To Golden Hour or Golden 3 hrs

>

> Need some of the docs on here and others to weight in on this one to see if

> this situation was correct and in the best interest of the pt.

>

> you called for a stabbing victim at 230am. You go the few blocks and get

> there in less than 4 minutes. You find a 27 y/o male in the back of a pickup

> with friends around him. One person is holding pressure to the left side of

the

> pts back. upon removing the shirt that is being held in place, you notice

> about 3, 1-2 " puncture wounds to pts left side just to the side of the left

arm

> pit.

>

> Pt is alert & conscious, states he is SOB and hurting. Pressure is held

> while pt is palced on back board and moved from truck to ambulance for better

> inspection and assessment. Once in unit, pt is stripped and flipped to check

for

> additional injuries and such. Only the three are noted, pressure is still

> being held, but occlusive dressings have been placed over each and covered

with

> 4x4s and secured. Pt has one other small lac to top of right shoulder, that

> is deep as you can see underlying tissues, but is about 1 " long.

>

> Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have

> been started. Pt and clothing covered in blood, maybe about 500cc total, plus

> what is covering the pt. Pt does have BBS to left side, but c/o SOB and

> tenderness to the LUQ area. No deformities noted.

>

> once it was noted what the condition was, air medical support was called and

> have about a 15 ETA to LZ.

>

> OK here is the question. You are half a mile from a general ER, no trauma

> designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

> pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

> don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

> and transfer out to higher level of care.

>

> Now the MD which was the ER doc last night is throwing all kinds of fits

> because this pt was flown and not brought to the local ER. Even though they

> would have shipped him out after 2 hrs or so. What is worse the EMS Director

is

> defending the doc and not the crew for making a better call for the pt.

>

> We are taught about the golden hour when we get into EMS or Emergency

> Medicine. We have this time to do what is best for the pt and this is what the

crew

> did. Now they are having to exlpain themselves.

>

> I know that most RAC's have bypass protocols in place for such an event.

> Even if the service does not agree with them, they should still be used. Why

> send a pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where

you

> have trauma surgeons and more advanced treatment.

>

> this is guy had a spleen injury and he would have been taken to a level 4 ER

> and bleed out there, that is not definitive care when you have to transfer

> out.

>

> What is the best course of action to make these people realize that a level

> 4 or General ER cannot handle things that a level 2 or 3 can. Someone to die

> in the ER waiting for hospital and doc acceptance? Probabaly.

>

> It's not just trauma, but STEMI as well. Bring them here, we have no cath

> lab, but we can transfer out after 2 hrs. Yea they can give TPA and things

like

> that, but if they need immediate cath it's better to send them to a facility

> that can do that & has a team ready to go.

>

> Suggestions.

>

> Wayne

>

> ____________ ________ ________ ________ ________ _

>

[Guest guest]

Can someone tell me some things that a helicopter crew can do that will have an

immediate impact on patient care that a well-trained paramedic with good

protocols can't do in an ambulance while going to the hospital?

-Wes Ogilvie

To Golden Hour or Golden 3 hrs

>

> Need some of the docs on here and others to weight in on this one to see if

> this situation was correct and in the best interest of the pt.

>

> you called for a stabbing victim at 230am. You go the few blocks and get

> there in less than 4 minutes. You find a 27 y/o male in the back of a pickup

> with friends around him. One person is holding pressure to the left side of

the

> pts back. upon removing the shirt that is being held in place, you notice

> about 3, 1-2 " puncture wounds to pts left side just to the side of the left

arm

> pit.

>

> Pt is alert & conscious, states he is SOB and hurting. Pressure is held

> while pt is palced on back board and moved from truck to ambulance for better

> inspection and assessment. Once in unit, pt is stripped and flipped to check

for

> additional injuries and such. Only the three are noted, pressure is still

> being held, but occlusive dressings have been placed over each and covered

with

> 4x4s and secured. Pt has one other small lac to top of right shoulder, that

> is deep as you can see underlying tissues, but is about 1 " long.

>

> Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have

> been started. Pt and clothing covered in blood, maybe about 500cc total, plus

> what is covering the pt. Pt does have BBS to left side, but c/o SOB and

> tenderness to the LUQ area. No deformities noted.

>

> once it was noted what the condition was, air medical support was called and

> have about a 15 ETA to LZ.

>

> OK here is the question. You are half a mile from a general ER, no trauma

> designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

> pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

> don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

> and transfer out to higher level of care.

>

> Now the MD which was the ER doc last night is throwing all kinds of fits

> because this pt was flown and not brought to the local ER. Even though they

> would have shipped him out after 2 hrs or so. What is worse the EMS Director

is

> defending the doc and not the crew for making a better call for the pt.

>

> We are taught about the golden hour when we get into EMS or Emergency

> Medicine. We have this time to do what is best for the pt and this is what the

crew

> did. Now they are having to exlpain themselves.

>

> I know that most RAC's have bypass protocols in place for such an event.

> Even if the service does not agree with them, they should still be used. Why

> send a pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where

you

> have trauma surgeons and more advanced treatment.

>

> this is guy had a spleen injury and he would have been taken to a level 4 ER

> and bleed out there, that is not definitive care when you have to transfer

> out.

>

> What is the best course of action to make these people realize that a level

> 4 or General ER cannot handle things that a level 2 or 3 can. Someone to die

> in the ER waiting for hospital and doc acceptance? Probabaly.

>

> It's not just trauma, but STEMI as well. Bring them here, we have no cath

> lab, but we can transfer out after 2 hrs. Yea they can give TPA and things

like

> that, but if they need immediate cath it's better to send them to a facility

> that can do that & has a team ready to go.

>

> Suggestions.

>

> Wayne

>

> ____________ ________ ________ ________ ________ _

>

[Guest guest]

Great calculations Gene!

Eddie

EMS Coordinator -- Crockett County EMS

PO Box 577

Ozona, Texas 76943

w.

c.

f.

To Golden Hour or Golden 3 hrs

>

> Need some of the docs on here and others to weight in on this one to see if

> this situation was correct and in the best interest of the pt.

>

> you called for a stabbing victim at 230am. You go the few blocks and get

> there in less than 4 minutes. You find a 27 y/o male in the back of a pickup

> with friends around him. One person is holding pressure to the left side of

the

> pts back. upon removing the shirt that is being held in place, you notice

> about 3, 1-2 " puncture wounds to pts left side just to the side of the left

arm

> pit.

>

> Pt is alert & conscious, states he is SOB and hurting. Pressure is held

> while pt is palced on back board and moved from truck to ambulance for better

> inspection and assessment. Once in unit, pt is stripped and flipped to check

for

> additional injuries and such. Only the three are noted, pressure is still

> being held, but occlusive dressings have been placed over each and covered

with

> 4x4s and secured. Pt has one other small lac to top of right shoulder, that

> is deep as you can see underlying tissues, but is about 1 " long.

>

> Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have

> been started. Pt and clothing covered in blood, maybe about 500cc total, plus

> what is covering the pt. Pt does have BBS to left side, but c/o SOB and

> tenderness to the LUQ area. No deformities noted.

>

> once it was noted what the condition was, air medical support was called and

> have about a 15 ETA to LZ.

>

> OK here is the question. You are half a mile from a general ER, no trauma

> designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

> pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

> don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

> and transfer out to higher level of care.

>

> Now the MD which was the ER doc last night is throwing all kinds of fits

> because this pt was flown and not brought to the local ER. Even though they

> would have shipped him out after 2 hrs or so. What is worse the EMS Director

is

> defending the doc and not the crew for making a better call for the pt.

>

> We are taught about the golden hour when we get into EMS or Emergency

> Medicine. We have this time to do what is best for the pt and this is what the

crew

> did. Now they are having to exlpain themselves.

>

> I know that most RAC's have bypass protocols in place for such an event.

> Even if the service does not agree with them, they should still be used. Why

> send a pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where

you

> have trauma surgeons and more advanced treatment.

>

> this is guy had a spleen injury and he would have been taken to a level 4 ER

> and bleed out there, that is not definitive care when you have to transfer

> out.

>

> What is the best course of action to make these people realize that a level

> 4 or General ER cannot handle things that a level 2 or 3 can. Someone to die

> in the ER waiting for hospital and doc acceptance? Probabaly.

>

> It's not just trauma, but STEMI as well. Bring them here, we have no cath

> lab, but we can transfer out after 2 hrs. Yea they can give TPA and things

like

> that, but if they need immediate cath it's better to send them to a facility

> that can do that & has a team ready to go.

>

> Suggestions.

>

> Wayne

>

> ____________ ________ ________ ________ ________ _

>

[Guest guest]

Get the patient to a hospital quicker (depending on distance from said hospital)

But you had to go and mention good protocols. It would have been a happier

ending without that.

ExLngHrn@... wrote:

Can someone tell me some things that a helicopter crew can do that will have an

immediate impact on patient care that a well-trained paramedic with good

protocols can't do in an ambulance while going to the hospital?

-Wes Ogilvie

To Golden Hour or Golden 3 hrs

>

> Need some of the docs on here and others to weight in on this one to see if

> this situation was correct and in the best interest of the pt.

>

> you called for a stabbing victim at 230am. You go the few blocks and get

> there in less than 4 minutes. You find a 27 y/o male in the back of a pickup

> with friends around him. One person is holding pressure to the left side of

the

> pts back. upon removing the shirt that is being held in place, you notice

> about 3, 1-2 " puncture wounds to pts left side just to the side of the left

arm

> pit.

>

> Pt is alert & conscious, states he is SOB and hurting. Pressure is held

> while pt is palced on back board and moved from truck to ambulance for better

> inspection and assessment. Once in unit, pt is stripped and flipped to check

for

> additional injuries and such. Only the three are noted, pressure is still

> being held, but occlusive dressings have been placed over each and covered

with

> 4x4s and secured. Pt has one other small lac to top of right shoulder, that

> is deep as you can see underlying tissues, but is about 1 " long.

>

> Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have

> been started. Pt and clothing covered in blood, maybe about 500cc total, plus

> what is covering the pt. Pt does have BBS to left side, but c/o SOB and

> tenderness to the LUQ area. No deformities noted.

>

> once it was noted what the condition was, air medical support was called and

> have about a 15 ETA to LZ.

>

> OK here is the question. You are half a mile from a general ER, no trauma

> designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

> pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

> don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

> and transfer out to higher level of care.

>

> Now the MD which was the ER doc last night is throwing all kinds of fits

> because this pt was flown and not brought to the local ER. Even though they

> would have shipped him out after 2 hrs or so. What is worse the EMS Director

is

> defending the doc and not the crew for making a better call for the pt.

>

> We are taught about the golden hour when we get into EMS or Emergency

> Medicine. We have this time to do what is best for the pt and this is what the

crew

> did. Now they are having to exlpain themselves.

>

> I know that most RAC's have bypass protocols in place for such an event.

> Even if the service does not agree with them, they should still be used. Why

> send a pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where

you

> have trauma surgeons and more advanced treatment.

>

> this is guy had a spleen injury and he would have been taken to a level 4 ER

> and bleed out there, that is not definitive care when you have to transfer

> out.

>

> What is the best course of action to make these people realize that a level

> 4 or General ER cannot handle things that a level 2 or 3 can. Someone to die

> in the ER waiting for hospital and doc acceptance? Probabaly.

>

> It's not just trauma, but STEMI as well. Bring them here, we have no cath

> lab, but we can transfer out after 2 hrs. Yea they can give TPA and things

like

> that, but if they need immediate cath it's better to send them to a facility

> that can do that & has a team ready to go.

>

> Suggestions.

>

> Wayne

>

> ____________ ________ ________ ________ ________ _

>

[Guest guest]

Always the voice of reason. Show off!!!!!!

wegandy1938@... wrote: I'm going to play Devil's Advocate and ask

this rude question: How did

helicopter transport help the patient in this scenario? You sat on scene for 14

minutes or more, waiting for the bird, then he had to be loaded and the bird

get back up, so let's add 10 minutes, then 14 minutes back to the hospital,

another 5 or more into the ER. That's 43 minutes. If you had loaded your

patient and driven to the hospital, you would have been there within 10 minutes

of the helicopter, your patient would not have had a $20,000 helicopter bill,

and his outcome would have been exactly the same? No?

Gene G.

>

> Dudley,

>

> I'll answer your questions within your e-mail.

>

> THEDUDMAN@... wrote:

>

> I am assuming from reading this a few things...

>

> 1. Small Community Yes

>

> 2. Only one hospital (presumably a Level 4, but may be non-participating)

> yes, level 4 I found out. Yes, they are apart of the local RAC

>

> 3. Only other choices are Level 2 and 3's...no level 1 Yes, level 3 is 50

> miles away by ground and 14 minutes by air.

>

> 4. Local RAC has trauma bypass protocols but no trauma transfer plan They

> have some kind of bypass, but is not very detailed. 5 lines of information

>

> 5. Local hospital has some affiliation with the local EMS agency Yes, they

> are apart of the hospital but a county service

>

> 6. Local hospital has no surgical services True. Just minor surgery, not

> able to surgically stablize a trauma pt.

>

> I would like to know how far away the Level 2 and 3 trauma centers are. I

> would also like to know more about this patient including multiple sets of

> vital signs...was the bleeding able to be controlled? If the wounds are on the

> upper chest, curious why we think there may be a spleen injury. Lastly, I

would

> like to know what the protocols for this EMS agency state to do with these

> patients and what their transport destination protocol states. I would also

> like to know the other side of this story. Level 3 would be Abilene and Level

2

> or higher would be Lubbock, Temple or Waco. Another level 3 in San Angelo.

> V/S remained about the same all the time the crew had the pt. 140s/70s, with

> one in the 120s/70s. Yes, bleeding was controlled, if not stopped while EMS

> had pt. THe spleen theory was stated, because it was not known just which

> direction the knife may have went.

> I did look and the helicopter activation section covers dispatching,

> packaging, LZ Info and safety. Also states if there is a delay in getting an

> aircraft to the scene to transport to the ER. However, the crew was in contact

with

> the air medical service and by they were launched once the crew got on scene.

> By the time the crew got the pt loaded and everything done and to the

> airport, the bird was 2 minutes out, so there was no wasted time sitting on

scene.

> They are 14 minutes away most of the time.

> The main argument that is being made is, that the crew did the right thing

> to get this pt to a higher level of care, because going to a level 4 and

> waiting to be transported out, is not definative care that a trauma pt needs.

> This is why I carry and everyone that knows me, knows that I'm sick or

> should be a trauma pt, I'm to be flown to Hillcrest in Waco or or JPS.

If

> the local system want call and I can call myself, I'll AMA and call for air

> transport myself.

> Other EMS providers fly out pts that the local level 4 is not able to treat

> and would have to be flown out anyway, and nothing is ever said. But, when

> your rubber stamp MD is not involved until you do something you feel is right,

> and they or the service managers don't there is a problem. EMS should do what

> is best for the pt and not have to answer why, unless there was something

> that they did wrong to cause other problems or the death of the pt. This pt

was

> stable by all means.

> The pt did get a chest tube and surgery at the level 3 and there were 3 true

> stab wounds, in which the lung was injuried. Pt is doing fine now.

> this is the only system that I've seen where you are repremanded for flying

> out a trauma pt and no one will stand behind the crews for doing what is in

> the best intrest of the pt.

>

> Thoughts...the " golden hour " is an advertising slogan, although I do not

> feel we should dabble on scene with seriously injured trauma patients, if they

> are not dying this second, we probably have some time to get them to

> definitive care. There have been a number of changes in trauma care over the

last 5 to

> 10 years and unfortunately, EMS education has not kept up. Still teaching

> " golden hour " and 2-large bore IV's and pumping up the BP...as well as MOI as

a

> critical factor in destination choice are all still taught daily although

> they have all been moved away from by the trauma community (except for media

> and advertising) Th

>

> On your STEMI concerns, if there is a system in place, and depending upon

> time and distance, it may make more sense to go to the ER 1/2 mile away for

> thrombolytics before being transferred to a PCI center...

>

> Above all, if there is a system, it is up to all of us to operate within

> that system or work to change it if we see a better way. When and if we

> freelance, then we get into trouble...and like another post said, if you can't

> operate in the current system and cannot get it changed...then one would have

to

> think about relocating into a different system.

>

> Have a good week everybody.

>

> Dudley

>

> To Golden Hour or Golden 3 hrs

>

> Need some of the docs on here and others to weight in on this one to see if

> this situation was correct and in the best interest of the pt.

>

> you called for a stabbing victim at 230am. You go the few blocks and get

> there in less than 4 minutes. You find a 27 y/o male in the back of a pickup

> with friends around him. One person is holding pressure to the left side of

the

> pts back. upon removing the shirt that is being held in place, you notice

> about 3, 1-2 " puncture wounds to pts left side just to the side of the left

arm

> pit.

>

> Pt is alert & conscious, states he is SOB and hurting. Pressure is held

> while pt is palced on back board and moved from truck to ambulance for better

> inspection and assessment. Once in unit, pt is stripped and flipped to check

for

> additional injuries and such. Only the three are noted, pressure is still

> being held, but occlusive dressings have been placed over each and covered

with

> 4x4s and secured. Pt has one other small lac to top of right shoulder, that

> is deep as you can see underlying tissues, but is about 1 " long.

>

> Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have

> been started. Pt and clothing covered in blood, maybe about 500cc total, plus

> what is covering the pt. Pt does have BBS to left side, but c/o SOB and

> tenderness to the LUQ area. No deformities noted.

>

> once it was noted what the condition was, air medical support was called and

> have about a 15 ETA to LZ.

>

> OK here is the question. You are half a mile from a general ER, no trauma

> designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

> pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

> don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

> and transfer out to higher level of care.

>

> Now the MD which was the ER doc last night is throwing all kinds of fits

> because this pt was flown and not brought to the local ER. Even though they

> would have shipped him out after 2 hrs or so. What is worse the EMS Director

is

> defending the doc and not the crew for making a better call for the pt.

>

> We are taught about the golden hour when we get into EMS or Emergency

> Medicine. We have this time to do what is best for the pt and this is what the

crew

> did. Now they are having to exlpain themselves.

>

> I know that most RAC's have bypass protocols in place for such an event.

> Even if the service does not agree with them, they should still be used. Why

> send a pt to a level 4 or 5 ER when you can fly them to a level 3 or 2 where

you

> have trauma surgeons and more advanced treatment.

>

> this is guy had a spleen injury and he would have been taken to a level 4 ER

> and bleed out there, that is not definitive care when you have to transfer

> out.

>

> What is the best course of action to make these people realize that a level

> 4 or General ER cannot handle things that a level 2 or 3 can. Someone to die

> in the ER waiting for hospital and doc acceptance? Probabaly.

>

> It's not just trauma, but STEMI as well. Bring them here, we have no cath

> lab, but we can transfer out after 2 hrs. Yea they can give TPA and things

like

> that, but if they need immediate cath it's better to send them to a facility

> that can do that & has a team ready to go.

>

> Suggestions.

>

> Wayne

>

> ____________ ________ ________ ________ ________ _

>

[Guest guest]

I have taken your advise and have left. So, if anyone is looking for medic

position where you are questioned for doing what you feel is best for your pt,

Co. EMS has an opening, plus $1000 sign on bonus. Just remember, if you

fly anyone out, you will have to play the 20 questions game with the big wigs.

Don't expect your boss to back you up or stand up for you either.

Wayne

ReD wrote:

I'm in the same situation where I work, but our helo ETAs are closer

to 35min, and the hospital here doesn't mind us flying stuff out because that

means less work for them, but most of our crews transport there anyway.

Back to your topic, I think you were in the right to fly, the pt. was sent to

the closest APPROPRIATE facility. Penetrating trauma to the chest, abdomen or

back was an automatic level I trauma activation at the ER I worked in.

I'd start looking for a new job if your big wigs don't want patients treated

properly.

Garrett

To Golden Hour or Golden 3 hrs

Need some of the docs on here and others to weight in on this one to see if this

situation was correct and in the best interest of the pt.

you called for a stabbing victim at 230am. You go the few blocks and get there

in less than 4 minutes. You find a 27 y/o male in the back of a pickup with

friends around him. One person is holding pressure to the left side of the pts

back. upon removing the shirt that is being held in place, you notice about 3,

1-2 " puncture wounds to pts left side just to the side of the left arm pit.

Pt is alert & conscious, states he is SOB and hurting. Pressure is held while pt

is palced on back board and moved from truck to ambulance for better inspection

and assessment. Once in unit, pt is stripped and flipped to check for additional

injuries and such. Only the three are noted, pressure is still being held, but

occlusive dressings have been placed over each and covered with 4x4s and

secured. Pt has one other small lac to top of right shoulder, that is deep as

you can see underlying tissues, but is about 1 " long.

Pt is placed on 02 via NRB at 15 lpm, monitor, and 2 large bore IVs have been

started. Pt and clothing covered in blood, maybe about 500cc total, plus what is

covering the pt. Pt does have BBS to left side, but c/o SOB and tenderness to

the LUQ area. No deformities noted.

once it was noted what the condition was, air medical support was called and

have about a 15 ETA to LZ.

OK here is the question. You are half a mile from a general ER, no trauma

designation level, just general. Pt is stable, v/s are good 140's/70's, 90ish

pulse, resp 28, sat 99% with 02, 97% without. The hospital is the type that

don't want anything to go anywhere but there, no matter how severe. Wait 2 hrs

and transfer out to higher level of care.

Now the MD which was the ER doc last night is throwing all kinds of fits because

this pt was flown and not brought to the local ER. Even though they would have

shipped him out after 2 hrs or so. What is worse the EMS Director is defending

the doc and not the crew for making a better call for the pt.

We are taught about the golden hour when we get into EMS or Emergency Medicine.

We have this time to do what is best for the pt and this is what the crew did.

Now they are having to exlpain themselves.

I know that most RAC's have bypass protocols in place for such an event. Even if

the service does not agree with them, they should still be used. Why send a pt

to a level 4 or 5 ER when you can fly them to a level 3 or 2 where you have

trauma surgeons and more advanced treatment.

this is guy had a spleen injury and he would have been taken to a level 4 ER and

bleed out there, that is not definitive care when you have to transfer out.

What is the best course of action to make these people realize that a level 4 or

General ER cannot handle things that a level 2 or 3 can. Someone to die in the

ER waiting for hospital and doc acceptance? Probabaly.

It's not just trauma, but STEMI as well. Bring them here, we have no cath lab,

but we can transfer out after 2 hrs. Yea they can give TPA and things like that,

but if they need immediate cath it's better to send them to a facility that can

do that & has a team ready to go.

Suggestions.

Wayne

__________________________________________________