Bringing Pts To The Closest Appropriate Hospital

[ny10570 745]

We have to pay attention that we are bringing people to the closest appropriate facility. In NYC anyone with an amputation is suppose to go to the nearest reimplatation center if stable enough to survive the transport. In the bronx, that would be Montefiore. At Jacobi, the leg is probably going to wind up in the trash. At Montefiore, the pt at least has a chance at keeping the limb. This problem goes deeper to our every day transports. Was as insiders know which hospitals are better at treating what problems and we should be looking out for out pt's best interest and going to those hospitals, and not just one that is 5 minutes closer because we can dump the pt faster there.

[INIT915 1,119]

Is Montefiore just a reimplantation center or a designated Trauma Center? If they don't have Trauma Center designation, the Jacobi is the most appropriate facility based on WREMSCO Protocols. If they do have that designation, then Montefiore would be an appropriate venue for an injury such as this.

[IzzyEng4 427]

Up here in the New Haven CT area, we have specific protocols set up by our C-MEDS wich are basically all the same.

All patients may be brought to one of the area hospitals of thier choice under no life threatening circumstances however it must a resonable driver. Anotherwords a patient can't be transported from a Scene in Greenwich to Yale-New Haven hospital in New Haven. If you are say in Ansonia, which is off Route 8 north of Bridgeport, a patient instead of going to Griffin Hospital in neighboring Derby, may choose to go to one of the hospitals in Milford, Bridgeport, New Haven or Waterbury or if they are a veteran, the VA in West Haven.

Now the protocols change alittle bit. If the person is having a MI, in full arrest (the term code or code 100 for us) or suffereing from a stroke, they are to go to the closest hospital reguardless and pach in to medical control at that hospital.

Traumas are a little different. If there is any question that a patient might not need a trauma facility, then the crew may patch to the closest no trauma center hospital with medical direction. The doctor will determine a trauma hospital is needed and divert the unit or not. Any major trauma, aka mva extriacations, amputations, go to the closest trauma hospital. If the trauma is a tramatic arrest (for us a Code 200) then the patient is brought to the closest hospital, reguardless of being a trama canter or not to stablize the patient prior to going to a trauma center.

Where I live I am luck to have 8 hopitals plus the VA in West Haven with in a 20 mile radius. Out of those 8 hospitals, we have one level 1 trauma center(Yale- New Haven) and 7 Level 2 (St. Ray's in NEw Haven, Bridgeport and St. Vincent's in Bridgeport, and St. Mary's and Waterbury Hospital in Waterbury) The two others, non trauma are Milford Hospital and Griffin in Derby.

[Guest]

Montefiore is only a replant center, not a trauma center.

Bellevue is the only other replant center in the city.

from the FDNY ops guide...

"Unstable or Multi-Trauma patients with compromised vascular status, regardless of the level of injury, shall be treated and transported in acordance with applicable patient care protocols. Following stabilization at the appropriate hospital, transfer of these patients to a Replant Center should be considered."

Common sense tells me a replant center should be a trauma center first, but, what do I know.

[WAS967 97]

Was as insiders know which hospitals are better at treating what problems and we should be looking out for out pt's best interest and going to those hospitals, and not just one that is 5 minutes closer because we can dump the pt faster there.

Common sense would dictate that we should be taking our active MI cases to a Heart Center where Angioplasty/Bypass can be performed. Yet our protocols do not support us transporting to anywhere but the closest facility. Why do you think that is? We have designated stroke centers, but not designated heart centers. Something needs to change.

[STAT213 332]

Common sense would dictate that we should be taking our active MI cases to a Heart Center where Angioplasty/Bypass can be performed. Yet our protocols do not support us transporting to anywhere but the closest facility. Why do you think that is? We have designated stroke centers, but not designated heart centers. Something needs to change.

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Huh? Closest MOST Appropriate facility, right? Did I miss something. The WREMSCO protocol defines it as nearest appropriate. So, where is the problem. Take the patient where they need to go? Who will question this or attack your decision? I am curious why people don't expand the protocol to its limit. Where is the apprehension?

[INIT915 1,119]

Huh?  Closest MOST Appropriate facility, right?  Did I miss something.  The WREMSCO protocol defines it as nearest appropriate.  So, where is the problem.  Take the patient where they need to go?  Who will question this or attack your decision?  I am curious why people don't expand the protocol to its limit.  Where is the apprehension?

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WREMSCO states on on Page 79:

Automatic Regional Trauma Center Criteria:

On the list, skip to #3, which lists Limb Amputation requiring Reimplantaion.

Doesn’t seem to me to be much room for interpretation. Maybe the REMAC could look into amending this to include reimplantation centers.

[Guest]

First, page 79 of the WREMSCO paramedic protocols refers to the algorhythm for helicopter transport.

Also, if we follow the protocol verbatim, then Jacobi is also inappropriate because it is not the REGIONAL trauma center. (Don't worry, my trauma patients from Westchester County go to the nearest appropriate facility- including Jacobi, region be damned. And wouldn't you know, I've never heard a complaint about it.)

If the patient has life threatening injuries, take him/her to a Trauma Center. Still in doubt?, call medical control and make a sound clinical decision with the physician on the other end. He can allow you to deviate from the protocols (see page 6). But geesh, don't let the protocol stop you from making a rational decision.

[jps385 0]

First, page 79 of the WREMSCO paramedic protocols refers to the algorhythm for helicopter transport.

Also, if we follow the protocol verbatim, then Jacobi is also inappropriate because it is not the REGIONAL trauma center. (Don't worry, my trauma patients from Westchester County go to the nearest appropriate facility- including Jacobi, region be damned. And wouldn't you know, I've never heard a complaint about it.)

If the patient has life threatening injuries, take him/her to a Trauma Center. Still in doubt?, call medical control and make a sound clinical decision with the physician on the other end. He can allow you to deviate from the protocols (see page 6). But geesh, don't let the protocol stop you from making a rational decision.

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"regional" trauma center refers to the fact that it is level 1 as opposed to a area or level 2 center. Not the fact that it is located in your region. This is a DOH designation. This has nothing to do with the "EMS region". Many regions such as NYC and Nassau have multiple regional trauma centers.

Edited August 15, 2006 by jps385

[INIT915 1,119]

First, page 79 of the WREMSCO paramedic protocols refers to the algorhythm for helicopter transport.

Also, if we follow the protocol verbatim, then Jacobi is also inappropriate because it is not the REGIONAL trauma center. (Don't worry, my trauma patients from Westchester County go to the nearest appropriate facility- including Jacobi, region be damned. And wouldn't you know, I've never heard a complaint about it.)

If the patient has life threatening injuries, take him/her to a Trauma Center. Still in doubt?, call medical control and make a sound clinical decision with the physician on the other end. He can allow you to deviate from the protocols (see page 6). But geesh, don't let the protocol stop you from making a rational decision.

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Clutch,

You are correct the heading for Pg 79 is Helicopter protocols. However, if you skip ahead all the way to Pg 80, you will see the same for ground transport.

And, if you go past Pg 80, to Pg 84, you will see Jacobi is recognized as a Regional/Burn Trauma Center.

I do believe everyone is aware you may contact Medical Control for these purposes. But, getting back to the point made earlier, regarding Reimplantation vs. Trauma Center. And which is most appropriate.

[ems-buff 81]

Stop nick-picking. You're beginning to sound pathetic here. Take the patient to the nearest APPROPRIATE facility. Who the heck cares where regional this and that are. Grow some testies and do what's right for Pete's sake. Wah, wah, wah. I'm a medic, but I can't make a decision! Wah, wah, wah.

[IzzyEng4 427]

You mean that you have to take a patient to a specific hostipat if there is a difference for replants, heart, stroke, ect.?????????

That is kinda messed up, and I say this because I am looking from a different set of rules and regulations. Yes we have specific hospitals that specialized in acute care but transports to these facilities (with the exception of traumas) are done after a patient has been stablized unless transportation to Bridgeport's Burn Unit, for example, is with in a reasonable time either by Lifestar or ground. Otherwise the burn patient is transported to a trauma center and stableized before going to a specific acute care hospital.

I've always had a hard time understanding NY's protocols.

[INIT915 1,119]

Stop nick-picking. You're beginning  to sound pathetic here. Take the patient to the nearest APPROPRIATE facility. Who the heck cares where regional this and that are. Grow some testies and do what's right for Pete's sake. Wah, wah, wah. I'm a medic, but I can't make a decision! Wah, wah, wah.

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EMS Buff,

Actually we were discussing which facility was most appropriate? A trauma center or a reimplantation center that happens to not be designated a trauma center.

Any input on that subject aside from your extraneous comments?

[Skooter92 7]

Izzy-you think YOU have difficulty understanding NY State's logic? Join the crowd. At a recent call audit, I along with some other folks sat and listened in amazement as one of the people who work in the REMSCO office explained that, as far as NY State was concerned, if I take a patient to an out-of-state trauma center, even if it's the closest "appropriate" facility for the patient, I haven't actually taken them to a trauma center because NEW YORK STATE HASN'T DESIGNATED/RECOGNIZED IT AS ONE. Never mind that the other state has-NY hasn't, therefore it's a PROTOCOL VIOLATION.

So, do the right thing by the patient and you still may take it up the a$$ as far as NY is concerned.

Edited August 16, 2006 by Skooter92

[Skooter92 7]

P.S.-Don't blame the region-it's all about the state.

Edited August 16, 2006 by Skooter92

[ny10570 745]

After talking with the some people in the know at Monty, the empress crew was right to take the pt to Jacobi. With multi-system trauma, the nearest trauma center is appropriate. As far at the confusing nature of NY's protocols, I don't see it. NYC is about as confusing as it gets with some being peds trauma only, adult trauma only, psych only etc. Even with all of that, its not hard. We are tasked with remembering and handling more complicated situation on a regular basis.

[Guest alsfirefighter]

I guess then I've transported a few patients to unrecognized trauma centers when I've gone to Danbury. lol. Then again, so have countless other medics in the areas bordering CT where that was quicker then to wait for a medevac.

As far as what it says on what page. I refuse to be a cookbook medic. Turn to page this for that, but on page so and so its says in this instant do this but only if this isn't occuring. Now don't get me wrong, I think that protocol knowledge is extremeley critical and that the following of such in regards to patient treatment is important, but as long as you have common sense and a good clinical ability. The day any region or the state starts questioning good common sense, clinical judgment on where a Paramedic transports too, and backs it up with good assessment, treatment and documentation as to why, is the day the state should start sending all their personnel to handle what we do.

WAS, I understand partly what you are saying in regard to cardiac vs. the stroke treatment facilities. I don't think you're too far off in regard to having hospitals with a cardiac designation, however I think that it hasn't occurred in part due to there are many more cardiac conditions and treatments available then in retrospect to CVA. If there were a push to get "cardiac" designated hospitals, then I would think that there should be a big push to get ALS to the level that we need (and should) be at in regard to treating such as well. Telemetry that actually works, more aggressive medications such as TpA which is being used down south very successfully by Paramedics in the field and so on. Some of what your describing many of us, including you have basically done when we've worked in areas with multiple hospitals in the same area and one had a cath lab and one didn't. You took the patient to the one that did, unless they requested the other and then you explained to them why you wanted them to go to hospital X and if they still chose the other then you documented such.

[Guest]

There is no substitute for GOOD CLINICAL JUDGEMENT.........I think it says that in the protocols,something like these are not guidelines ..............

[mlfcemt093 0]

Why is this so hard to understand?..........Bottom line it!!........ if a certain hospital has a speciality deferal and ur pt is stable enough to transport them another 5 mins in nyc's case then DO SO!..... I personaly have driven right passed hosp 25 jacobi med ctr to take an amputee to hosp 29 monti so just do whats right by the pt don't take them to a hosp that has no stroke protocal for example take them to a hosp where thrombolitics can possibly be admin depending on the bleed that hosp already has estabalished guidlines and speciality teams on call ur all making this way to complicated.........make ur own decisions........... GUIDELINES........GET IT? Do ur job!!! Be a pt advocate!!!!