Re: Pt. Scenario

[Wildmedic75@cs.com]

I hope you all are well.....Happy New Year!

I think the answer to the question "Should this patient be flown to the 
trauma center?" is rather obvious....of course she should. 

In fact, I doubt that any EMS protocols exist anywhere that would not require 
(or at least strongly suggest) that this patient be transported to the trauma 
center. Due to the mechanism of injury, abdominal pain, tachycardia, etoh, 
and apparent CHI, the patient would meet even the most stringent 
interpretation of "potential major trauma patient" and should therefore be 
transported to the closest trauma center by the quickest means possible.

Even if air transport time to the trauma center was significantly longer than 
ground transport to the local facility, the time elapsed between the 
infliction of the (potential) injuries and arrival at definitive surgical 
care is still probably MUCH less via air transport to the trauma center than 
if the patient went to the local hospital. This is not even taking into 
account the fact that most flight crews can arguably provide better care due 
their greater experience dealing with major trauma and their (usually) more 
advanced protocols. 

Remember, we must always assume the worst.....that this patient has serious 
internal injuries that will require specialized care in order to ensure her 
recovery.

In a situation such as this, the only contraindication to air transport that 
I can think of would be if transport time to the local hospital was 
significantly shorter, AND the crew was having a difficult time with airway 
control.....in that scenario it may be best to take the pt to the local ED, 
where hopefully the ED doc or an anesthesiologist would have better luck 
gaining control of the patients airway. The patient could then be flown to 
the trauma center.

Where I work, we have problems like this all the time.....the ground crews 
often don't request us because they can get the patient to the closest 
facility in 10-15 minutes, vs 20-25 minutes for us to get the patient to the 
trauma center. Sometimes it's because they don't want to wait for us to 
arrive, sometimes they just get scared having a critical patient on their 
hands so they run to the closest facility. Often we end up getting called to 
transfer the patient to the trauma center anyway.....but only after the local 
facility has "wasted" precious time getting labs and films in order to 
determine what we already knew was probably the case.....that the patient 
needs to be at the trauma center.

The answer is to have regional protolols REQUIRE (not just suggest) that air 
transport be used anytime certain physiological or MOI criteria are met (as 
long as the airway is adequately controlled)......and then the medical 
directors must be convinced to enforce their agencies adherence to the 
protocol.

Allan Bulkley, NREMT-P
Flight Paramedic   

<< Hi all.
 
 I would appreciate any feedback that you all might have to offer on this 
scenario:
 
 Pt. is a mid-thirties female, involved in MVC, unknown if restrained. Pt. is 
apparently the driver. Pt. vehicle hits utility pole at greater than 55mph 
producing significant damage to vehicle. (You later find out that the vehicle 
has also rolled over.) Approximately 20 minutes of extrication are required 
to disentangle the patient. Ambient air temperature is approx. 20 to 25 
degrees F.
 
 Pt. does not remember the crash. ETOH on board. Pt. oriented to person only. 
Pt. has a one inch laceration to the left temporal region and active bleeding 
from both nares. Pt. also c/o pain on palpation to the chest. Chest wall is 
intact with bilateral breath sounds clear and equal. Pt. co genralized ABD 
pain with increase on palpation of all quadrants. Pt. also c/o lower back 
pain. Pt. is slightly tachycardic with evelvated B/P. Resps and Sats WNL.
 
 Transport times as follows:
 
 By ground to trauma center: 30-40 minutes
 By air to trauma center: 10 minutes
 By ground to local community hospital: 10 minutes
 
 Does anybody feel that this particular patient recieves any benefit from 
going to the community hospital by ground?
 
 Thanks a lot and have a happy and safe new year!
 
 Adam Oplinger NREMT-P
  >>

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