SC medics sued

[ncmedic309]

So he appeared stable so no need for immediate trauma surgery. Even the hospital he was at did not feel a need for a rush. MOI is not always indicative of severity. Treat the patient not the MOI. The medics will be OK if they did proper documentation so it is clear why they decided on this and not another hospital.

I agree that you shouldn't base your treatment on the MOI alone, but you should still allow the MOI to elevate your suspicions on the possibility of something more severe going on that hasn't yet manifested. In my region, it wouldn't be an issue - any facility that does not meet the trauma center classification will not accept patients with any significant MOI. I can't say that I blame them, it's to prevent cases like these from happening. There's no excuse for taking a patient with a signficant mechanism to a facility not equipped to deal with trauma services if you have other options nearby. Just because a patient appears "stable" doesn't mean we should let our guard down. All of my trauma patients that present with significant injury or mechanism will visit a level I or II trauma center, for their benefit as well as my own.

[CBEMT]

There's no excuse for taking a patient with a signficant mechanism to a facility not equipped to deal with trauma services if you have other options nearby.

A quick Googlemapping shows the scene as being 49 driving minutes from the scene of the crash to the trauma center the patient ultimately died at.

I'm not 100% sure I'm willing to make that long of a drive with a Level 1 patient who could decide to crump on me at any time, especially given my protocols (no RSI, OLMC for benzos, etc). I have a hard time arguing against the crew for defaulting to the closest facility given that they couldn't get a scene flight.

If I were the family, I'd be MUCH more interested in why Hilton Head @#$%ed around with my son for TWO HOURS before deciding that he was beyond their capabilities. The article doesn't mention what shape he was in at the time of transfer.

Edited May 20, 2009 by CBEMT

[VentMedic]

So he appeared stable so no need for immediate trauma surgery. Even the hospital he was at did not feel a need for a rush. MOI is not always indicative of severity. Treat the patient not the MOI. The medics will be OK if they did proper documentation so it is clear why they decided on this and not another hospital.

Let me tell you a little about interfacility transfer Hell.

Once a patient is taken to a hospital that does not offer alot of services that hospital will now have a greater burden of proof that a higher level of care is need than what would be expected of a Paramedic on scene to have. There will be various procedures and acceptance protocols that must be completed before the call is even made to a trauma center. That could take up to 2 - 4 hours. A flight team or qualified CCT might be put on alert that they have a call pending but usually can not leave the ground until acceptance is made. Also if a confirmed call comes in before that hospital is confirmed, we fly on the confirmed and they will have to find an alternative service...or wait until we are clear from the other transport. Our IFT flight transports can be lengthy due to the preparations to make the patient flight ready. We don't like to do a code in a helicopter. Once confirmed they may then have a 30 minute to an hour and 30 minute travel time to just reach the patient. By that time it may be decided that the patient is now deteriorating to where intubation and other meds will be needed before transport. That can take more time. Finally, they go enroute for the 30 minute to 1 hour and 30 minute transport.

If the transfer from an ED can not be made in a timely manner, say 24 hours, the patient may have to be admitted to the ICU at the local hospital. That is where the transfer now gets very difficult. There have been trauma patients trapped in small hospital ICUs for days that didn't quite meet the requirements for an ED to ED transfer to a trauma center and had difficulty getting a physician at another hospital to accept them for whatever reasons from insurance to just not wanting to take what will probably be a train wreck patient who will die from the time lost for serious intervention. If the patient is too unstable at the local hospital, the transfer will be aborted and the transport team leaves. That patient will remain at the local hospital usually to die.

If the local hospital has something that resembles a Pedi ICU, this can also happen to children. However, children's hospitals are often more accepting then others and will have their own transport teams under the direction of a pedi intensivist. That can make a big difference in their abilities.

Another issue faced in some regions is the licensing of the helicopters. Some that can do scene response for HEMS at the local level may not be able to do interfacility transport. Once the patient touches the hospital, another service must then be called. That then starts the whole process I described at the beginning of my post. The abilities of the CCTs can vary. Some CCTs are just the local ALS. So, a lot of it will be dependent on how their local services are certified and the agreements made with the trauma center or other hospitals. Every region is different which is why I am extremely careful in some parts of my state and others not to have my first MI or be a trauma in some counties or cities.

BTW, on some islands it can take less time to get transfer acceptance and be in the U.S. at a trauma center than it does within this country.

[HERBIE1]

A quick Googlemapping shows the scene as being 49 driving minutes from the scene of the crash to the trauma center the patient ultimately died at.

I'm not 100% sure I'm willing to make that long of a drive with a Level 1 patient who could decide to crump on me at any time, especially given my protocols (no RSI, OLMC for benzos, etc). I have a hard time arguing against the crew for defaulting to the closest facility given that they couldn't get a scene flight.

If I were the family, I'd be MUCH more interested in why Hilton Head @#$%ed around with my son for TWO HOURS before deciding that he was beyond their capabilities. The article doesn't mention what shape he was in at the time of transfer.

Agreed about the local ER- to a point. Unclear what the actual injury was, but a simple CT would have probably showed that they were not able to handle this guy's treatment. 2 hours before they could transfer? It may seem excessive, but... Even under ideal conditions, a transfer isn't going to happen in 5 minutes. The doc here can attest to that- you need to contact the appropriate receiving hospital, sort out insurance info, notify family if needed, get a physician to accept the patient, give the reports, copy any records and Xrays, call for a transport- this all takes time.

I still think that based on the MOI, if the crew make the choice to head to a Level One, everything could have been in place when the patient hit the door and a neurosurgeon could have been working on this patient long before he was transferred there. Maybe the outcome would have been the same, but at least he would have received definitive care LONG before he did.

[ncmedic309]

I'm not 100% sure I'm willing to make that long of a drive with a Level 1 patient who could decide to crump on me at any time, especially given my protocols (no RSI, OLMC for benzos, etc). I have a hard time arguing against the crew for defaulting to the closest facility given that they couldn't get a scene flight.

I can definitely understand those concerns, I wouldn't want to be halfway between here and there when things decided they were going to take a turn for the worse either. It's one of those calls you just have to make and go with it. If the patient was alert and oriented on scene and able to communicate as the article mentioned he could when he arrived at the receiving facility, it's time to take that chance and go ahead get the patient to definitive care. It's kind of the same principle with a patient that needs cardiac interventions - why waste the time taking them to a facility that doesn't have the services when you can get them somewhere that does, even if it's a longer drive? It may not always be an easy decision to make, but sometimes the closest facility just doesn't cut it. I could completely understand if the patient was showing imminent signs of decompensation or becoming unstable, but the article leads me to believe otherwise.

At the same time the information we're gathering from this is from the media, if it is in fact accurate then we're on the right track. I know that area is pretty cut up with waterways, etc. and I can't imagine that many ground transports are an easy trip. I just hope for the sake of the medics involved, they made a good decision based on their protocols and procedures even though ultimately it didn't favor a good patient outcome.

[FredG]

The article calls them paramedics, but when it gave their names and titles, it stated "Emergency Medical Techncian". It is possible that this was a BLS crew and the article is using the term paramedic interchangably (as most reporters do).

If they were a BLS crew, then I can understand why they went to the nearest facility. I wouldn't want to take a patient that has any chance of going downhill fast any further than necessary if going BLS. Now, if they really are ALS, then the 35 minute drive should have been fine.

[JakeEMTP]

" Beaufort County EMS owns 15 ambulances and 2 quick response units , all of which are capable of being staffed on a moment's notice. We staff 8 advanced life support ambulances and 2 quick response units 24 hours a day 365 days a year." Quote from the Beaufort County EMS website.

It would appear as if it was indeed a ALS crew. I feel for the medic. Based on the info provided, I might be inclined to agree with their destination choice. Short of having a CT in the ambulance, how can we determine the extent of his injuries? If the pt. was maintaining his airway, answering questions appropriately, A & O, can we justify a 50 min transport to a Level 1 Trauma centre? Again, I wasn't there and didn't assess this pt. MOI alone does not justify a Level 1 Trauma centre.

[VentMedic]

MOI alone does not justify a Level 1 Trauma centre.

It didn't state his other injuries or give vital signs. MOI (ejection or bent steering wheel) and usually one other criteria can get a trauma center in FL. MOI and the paramedic's judgement by assessment of the patient and scene can get the patient to a trauma center directly from scene also.

Florida's Trauma Alert criteria:

http://www.doh.state.fl.us/demo/Trauma/PDF...riaMeth1202.pdf

Criteria for an IFT of a trauma patient. Again, the burden of proof is on the sending facility and all criteria must be met to the trauma center's satisfaction.

http://www.doh.state.fl.us/demo/Trauma/PDF...cGuidelines.pdf

The guidelines for EMTALA must also be met which includes the appropriate transport personnel must be provided.

Edited May 21, 2009 by VentMedic

[ncmedic309]

If the pt. was maintaining his airway, answering questions appropriately, A & O, can we justify a 50 min transport to a Level 1 Trauma centre? Again, I wasn't there and didn't assess this pt. MOI alone does not justify a Level 1 Trauma centre.

I think you can easily justify the transport to the trauma center - look at the outcome of this call. A 50 minute ride via ground to definitive care is much better than a 3 or more hour delay to that needed care. I agree that MOI alone doesn't justify a Level 1 trauma center, but it does justify the need for the patient to be transported to a facility capable of providing trauma services.

[ERDoc]

As someone who works at both an inner city level 1 and a rural nontrauma center, I can tell you that 2 hours to get someone out the door is not bad. Once the pt is in your facility it takes a little while to get the CT done. Based on the 30 foot ejection there were probably multiple studies done which can take up to 30 minutes. Once the scans are done, a radiologist has to read them. Again, with multiple studies being done this can also take quite a while. When I work the overnights at the rural hospital the images get sent to a radiologist on a beach in Australia which usually takes longer. Once you have the results you need to contact the appropriate person at the receiving facility. Depending on how quickly they answer their pager, this can also take a while. As you can see, you are probably at least 60-90 minutes into it now. Once they are accepted you need to wait for the transfer to come which again can take a while.

As for the comment made in the article about the sending facility listing neurosurgery as the needed service, that is a lawyer who knows nothing about medicine focusing on one line of one form of an entire medical record. In order to be able to transfer a person legally, we have to fill out an EMTALA form justifying the transfer. One of the reasons given is to transfer the person to a facility that offers a service not offered at your facility. It sounds to me like the lawyer is giving much more meaning to something than it deserves. There is no way for the EMS crews to know what kind of injuries the pt has. This is the reason we do transfers. As with most law suits it sounds to me like this family is out to make some money. Why don't we put the blame where it belongs. This kid would more than likely still be alive if he was wearing his seatbelt (though without more details it is difficult to prove this). Let's blame those who tried to help the kid.

I think you can easily justify the transport to the trauma center - look at the outcome of this call.

I don't know too many ambulances that carry retrospectroscopes.