Re: Pt. Scenario

["Tom Brazelton, MD, MPH" <brazeltoniii@facstaff.wisc.edu>]

I must've missed something too. The consensus is clearly (a) fly (b) 
to regional trauma center. So what's the problem?

Jackie, a partial answer to your question is that yes, except in the 
case of rural trauma (Rogers et al, J Trauma 2/99), there is plenty 
of "evidence" that outcomes are improved and mortality reduced with 
prompt triage and transport to regional trauma centers. This is 
especially true in pediatrics (Kanter et el, Peds 12/92) where the 
system is usually activated and the transport completed sooner, up to 
twice as fast (Harrison et al, Am J Emerg Med 3/97). Glad to see you 
all have your priorities straight!

I enjoy quietly reading these but, in keeping with my New Year's 
resolution to speak up more often (and to not mumble during 
codes---though they are quieter that way), have to comment on this 
one:

>>  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.

Allan, if you can figure out how to "regionally protocolize" the 
factors by which you "already knew" that the patient needed the 
trauma center (and thereby avoid "wasting" the Platinum Half-Hour or 
Golden Hour) than you should share it with the rest of us. There is a 
great deal of lab and x-ray duplication (and time wasted) when triage 
systems are poorly designed, not adhered to, or nonexistent.

This is one of the main reasons for statewide trauma systems with 
regionalized centers certified according to American College of 
Surgeons standards. One of the explicitly stated objectives is that 
"a state trauma system will provide for a coordinated and better 
trained EMS system to make a higher level of trauma care available 
statewide." So you better watch out, you may get what you ask for and 
find those bottom-dwelling ground units force you to retract your 
lofty statement
>that most flight crews can arguably provide better care due
>their greater experience dealing with major trauma and their (usually) more
advanced protocols!!

Take care,

Tom Brazelton
UW Children's PICU (& MedFlight)
Madison, WI


>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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