ASA and NTG or no?

[mikeymedic1984]

All ER's are set up to handle a stroke or brain trauma ??? Maybe in your neck of the woods. Not all hospitals in my area even have CT or MRI available, much less neurology, so yes they can throw a tube in his throat and transfer him 2 hours later, but thats about it. All hospitals can treat MI's, but are you argueing that it would be OK to transport an active STEMI to a hospital with no cath lab ???? If that is your only option, because you are in a remote location, then I guess it makes sense, but if there is a hospital within an hour away that has open heart capabilities, I think it would be better to go there, even if you have to use a helicopter to do it.

[ERDoc]

Most ERs do not have access to MRIs, but almost every one has a CT scanner. If you have tPA and a CT scanner, then yes you are set up to handle a stroke, at least in the initial stages. I do it in my neck of the woods all of the time. The few that get tPA get transferred to the tertiary care center, the ones that don't get admitted locally. I also have STEMIs in my neck of the woods without a cath lab because EMS goes to the closest facility with all STEMIs. The cath lab is about 45 min away by ground. I agree with you that we are no the best place for them to go but that is protocol. They don't even take the pt off their stretcher. When you know what is wrong and there is a hospital that can take care of it, you should go there. The problem with head injuries and strokes is that you don't know what is wrong until you obtain imaging (let me guess we should treat the pt and not the machine). A very small portion of head injury pts (especially the kind in this scenario) need a trauma team/neurosurgeon, most go home with a negative scan assuming one is done at all. Why use unnecessary resources?

[mikeymedic1984]

Because time is everything when it comes to saving lives (heart muscle and brain tissue). Just because your PROTOCOL says to go to the closest facility, does not make it right. It should be the most APPROPRIATE FACILITY (whether by ground or air). I would not take a pregnant woman who is having contractions at 20 weeks of pregnancy, to a hospital that does not have OB services. I would not take a critical or special needs pediatric patient to a band-aid station hospital that is going to have to transfer the patient later.

Yes dumping them off our stretcher faster makes our lives easier, but it is not always easy to make a secondary transfer to the the most appropriate facitlity later in a timely fashion. You waste at least an hour of time for the patient by taking them somewhere that can not fix what it is wrong (maybe 6-12 hours). And NO, I am treating the patient, NOT the machine, by taking them to the place that can fix whatever is wrong.

You don't take you car to the local "oil-change-only" shop, when you know you need a new transmission (by your logic, they have mechanics, tools, and a lift -- so they should be able to fix anything on a car). Why would you treat your car better than your patients ???

[ERDoc]

In every case you listed you know the diagnosis. You are completely missing the point and I don't think you will ever see it especially when you start using cliches. What do you think the Level 1 whatever center is going to do for someone who fell and hit their head? They are going to do a CT scan and if negative (assuming no other confounding issues) send them home. What is your local hospital going to do? Same thing. Again, you are using unnecessary resources for something that doesn't exist. Do you fly all of your fall/head injuries to the level 1 trauma center? You should be since they might have something that your local hospital can't handle. Do you fly all of your possible kidney stones to the tertiary care center because your local hospital doesn't have urology? Your thinking is seriously flawed. Do you take that 20 weeker to your local hospital that does have OB? If so, why? 20 weeks needs to go where you have MFM and NICU.

[mikeymedic1984]

No my local hospitals can handle everything except neuro, pediatrics, open heart, and trauma (mechanism or actual real traumatic injury requiring surgery).

Oh, i forgot ---- and renal, they don't do dialysis.

Edited December 16, 2014 by mikeymedic1984

[medicmole]

What's SMR? This is what I found when I googled SMR medical abbreviation :

SMR

Abbreviation for:

senior medical resident

severe mental retardation

sexual maturity rating

standard metabolic rate

standardised morbidity ratio

standardised mortality ratio, see there

streptomycin resistant

submucosal resection

None of those fit in this scenario though.

In this case SMR would be spinal motion restriction. It is from ITLS (International Trauma Life Support)

Edited December 16, 2014 by medicmole

[ERDoc]

OK, so again I ask. Do you fly every trip and fall who hits their head? According to your logic, your local hospital cannot handle them and they need to go to a trauma center because they might have something bad going on.

[mikeymedic1984]

No, but I think with obvious signs and symptoms of something more serious i would ere on the side of the most serious, do you disagree ????

[ERDoc]

It's hard to agree or disagree with such a vague statement. It sounds to me like you are following your trauma protocols.

[systemet]

What's SMR?

Sorry. I hate it when people introduce new abbreviations without defining them.

Spinal Motion Restriction.

Just another way of saying "take c-spine". Implicit to the term is the idea that you can't immobilise the c-spine short of surgical fixation, just that you're trying to reduce movement, i.e. not everyone needs to be on a long board, not everyone needs to be supine, and a collar isn't a halo.

.... lots of stuff about transport destination .....

Interesting discussion.

I don't see the need to take this person to a center with cathlab, CT-angio, neuro-ICU or trauma services.

It would be a good idea to aim towards a site with inpatient beds and a CT.

There's not much information available here to guide this decision. Common things being more likely, I wonder if, in the end, our fellow might not have a touch of the pneumonia, and be a little dehydrated, weak and/or orthostatic.

Edited December 16, 2014 by systemet