101 Things the Fire Department wishes you knew



Friday, April 3

You Make the Call...Trauma Diversion


I'm dispatched to a gas station in a sketchy part of town for a man down.
We arrive to find a man lying supine on the ground, bloodied, with multiple traumatic injuries to his chest, face and neck. He is responding to loud verbal with slurs and swears.

This man has taken a serious beating and clearly lost.

We get him exposed and onto a board with collar. Airway is clear and all vital signs are checking out. There is a heavy odor of alcohol on his breath and clothing. Bleeding is controlled and IV access is established enroute to the trauma center.

All night on the radio we've been hearing multiple trauma transports and expect a full house when we arrive.

After giving my radio report, instead of hearing the usual, "Copy that, we'll see you in 5 minutes" I get a response from the Medical Director who is on staff.
He asks, "Do you think you can divert to another hospital? This patient sounds stable."

The patient is indeed stable, but meets trauma center criteria. This is the only trauma center in the region.

Before I can respond my driver informs me we're almost arriving.

What do I do? You make the call.

6 comments:

mike said...

No win situation here, just shades of "oh crap!";
-if your "nearly arriving" and actually on hospital property it's a no-brainer, you have to go in.
-if not, then soft wrist restraints (sedation/RSI anyone?..anyone?..Bueller?...) and divert (make sure you're Medical Director knows he owes you big!)
I'm a regular reader (US medic - NJ) and know you have the chops to keep him alive until you get there, although the ETOH smell may get you first!

Bernice said...

Interesting... Well honestly, I think I would have a moment of *panic* and WTF! and then I would realize that several factors would come into play. The actual distance/time of "nearly arriving" and the distance/time it would take to head to another hospital. Sure the patient in stable, but from your description it sounds like he is one that could surprise you quickly when his condition crashes. As for sedation/restraints that Mike suggested, I didn't pick up on anything in your post that warranted it besides slurring and swearing. Then again, his ability to get nasty with you would certainly factor into how stable I think he is.

Ack... that still doesn't answer the question though. So - since the resulting transport to another facility would add at least another hour on, I would bring the patient into the originally intended trauma center. Forgiveness rather than permission in this case.

AdCy said...

I would have to agree with Bernice. I have been placed in this situation a couple of times, and have done both. In the long run, I got into more trouble diverting, even under MD orders. I would inform the MD that you are pulling into the ambulance bay, and you will see him in 30 seconds. You are your patient's advocate, and if you believed your patient needed a trauma center, then he probably did. We don't have x-ray vision! How do we know if he has a head injury, or is just drunk? Stick to your guns! Better to ask forgiveness then seek permission.

medicblog999 said...

I would take the patient into the intended receiving trauma centre. You obviously had enough concerns with the patients presentation that you decided on that centre for definitive care. Nothing has changed just because they are busy!
If you transported to the other facility and the guy arrested and died en route, Im assuming it wouldnt be the doc from the trauma having to provide statements etc for the potential litigation.

I know things might work differently over there but in the same situation over here, that is what I would do. Ultimately, I dont answer to the docs in our Accident and Emergency departments so I would just have to do what I felt was right and support my decision with sound clinical rationale

Big Show said...

Was he recommending going to the nearest ER instead of the trauma center? If so, your pt is probably going to end up at that hospital anyway after you show up to the ER with him, so all you would be doing by driving the extra distance, for the triage nurse at that hospital to start flipping out, and get him transferred back to the place you were going to take him to in the first place...in the end the whole "Golden Hour" would be so far out the door, and it would cause more harm than good. Even if he is stable, he still is going to need a trauma surgeon to fix all the injures, something that your local ER isn't going to be equipped to handle.

brendan said...

"You obviously had enough concerns with the patients presentation that you decided on that centre for definitive care."

Doesn't sound that way to me.

The key sentence is this:

"The patient is indeed stable, but meets trauma center criteria."

This isn't a transport to a trauma center due to EMS clinical judgment. This looks to me like a protocol transport. A protocol that takes away the ability for the provider in the field to say "You know what? He doesn't need to be at the trauma center, a community hospital ER will do just fine," thereby avoiding this situation in the first place.

I'd say if the only reason for transporting to the trauma center in the first place is a line in a protocol and not your own clinical assessment and judgment, screw it. Next hospital.