Transfer or Don't Transfer ?

[medic53226]

I was disp to our local hospital for a emergent transfer to a larger hospital 27-30 miles away. Upon arrival you find a 80 y/o m pt in RM 3 that is intubated and has fluid running at 250 cc/hr, by orders of Dr, however, just before we transfer the pt to our cot the the nurse says that the last bp was 101/50, but just as we get ready to move the pt to the cot, the monitor shows a new bp of 75/30, and the nurse says as she increased the drip to W/O, that the pt has been running in the 80's and that she has been increasing the drip back and forth. To the that response the RT says I have had to suction fluid out of his tube 3-4 times. The orders for the trip are 250cc/hr, and 50% O2, per Dr in the ER. Enroute I suctioned the pt 2-3 times and bagged the pt with the pt breating against the BVM, and no one to help with the BP's but was still able to achieve, BP's hovered around 78-80's and the ER has said he was septic. I know what I did and I want on the info I told how you would have handled this run and remember the ER Doc hates EMS, and has expressed that we as useful as tits on a boar.

[vs-eh?]

I was disp to our local hospital for a emergent transfer to a larger hospital 27-30 miles away. Upon arrival you find a 80 y/o m pt in RM 3 that is intubated and has fluid running at 250 cc/hr, by orders of Dr, however, just before we transfer the pt to our cot the the nurse says that the last bp was 101/50, but just as we get ready to move the pt to the cot, the monitor shows a new bp of 75/30, and the nurse says as she increased the drip to W/O, that the pt has been running in the 80's and that she has been increasing the drip back and forth. To the that response the RT says I have had to suction fluid out of his tube 3-4 times. The orders for the trip are 250cc/hr, and 50% O2, per Dr in the ER. En-route I suctioned the pt 2-3 times and bagged the pt with the pt breathing against the BVM, and no one to help with the BP's but was still able to achieve, BP's hovered around 78-80's and the ER has said he was septic. I know what I did and I want on the info I told how you would have handled this run and remember the ER Doc hates EMS, and has expressed that we as useful as tits on a boar.

:shock: :shock: :shock: :shock:

Ummm...remind me never to go to Indiana!

Points on the transfer...

- This patient only had a saline drip and nothing else and was given sepsis as a dx and is hemodynamically unstable. No pressors, inotropes, antibiotics? Nothing, but bolusing an 80 year old heart?

- This 80 YEAR OLD PATIENT is being treated for his hemodynamic instability only by running IV's WIDE OPEN? Continuously bolusing an 80 year old heart is not such a good idea, especially when they are being suctioned pretty dynamically and likely are showing some signs of CHF (though I'm not saying only)...

- You had to BAG this patient for what? 20-30 mins? LOL!!!!! No vents or anything? Jesus...How are you maintaining an FiO2 of 0.5???? Pray-tell?

- You should not have done this transfer by yourself and have had at least another paramedic with you, if not an RN or RT or MD. Or any combo of that.

- You SHOULD NOT have taken this transfer with what you have stated happened in hospital. YOU SHOULD HAVE asked for more help, asked why other interventions weren't happening, and (I hate to say this) why the patient wasn't flown.

This would have been a Critical Care transfer here, either by land or air. Period. That or had an RN/RT/MD with a crew.

I would like to hear more. You put yourself at professional risk with this one my friend.

[rat115]

Here that transfer would have been a no go. That pt would have been flown by what ever company could have gotten a flight here the quickest.

Were I certified at that level, I don't think I would have been comfortable manning the back of the ambulance with a pt in that condition without someone to help ensure that everything could be taken care of properly and the quality of care was there.

[Dustdevil]

Meh... I don't see any automatic indication for aeromed in this situation. ALS? Definitely. But not flight. Not enough distance to be a time saver.

[medic001918]

Meh... I don't see any automatic indication for aeromed in this situation. ALS? Definitely. But not flight. Not enough distance to be a time saver.

+1. It is a critical care transfer, and one that should be able to be handled on the ground. It doesn't sound like your service is set up to properly handle a transfer with so much involvement. This kind of call would be best served by having a ventilator so you are not 100% committed to the patients airway and have the ability to further assess the patient.

I do agree that the patient should have had more than just a continuous bolus of NS, but was the doc in communication with the other hospital where they may have had some kind of different treatment plan? Did your service tell them when they called that they couldn't transport certain medications that the doc may have wanted the patient on? There are a number of variables here. It sounds like you weren't comfortable with the transport and chose to do it anyway without evaluation of your resources. Don't hesitate to ask for extra help if you feel it's needed. With the equipment it sounds like you had, an extra set of hands would have been more than justified...ALS hands at that.

Shane

NREMT-P

[PRPGfirerescuetech]

Meh... I don't see any automatic indication for aeromed in this situation. ALS? Definitely. But not flight. Not enough distance to be a time saver.

eh, thats not an absolute....

30 miles ground rural, suburban, or urban? Weather? Dispatch to arrival time for the flight? How far are they based from the pickup pointe?

Too many variables to make that statement an absolute.

Example.

I flew a patient to a trauma center 10 miles away just 2 weeks ago.

Flight time call to hospital, 20 minutes. At 6pm in that area, a ground run would have been 45 minutes.

Today, i took a 20 mile trip to a trauma center, by ground. Less than 30 minutes.

More info to decide your pointe.,...

[Dustdevil]

I agree. I suppose I misstated what I meant. I was basing my opinion on time, not distance. With the transport lasting "20-30 minutes," aeromed wouldn't have saved any time once you factor in response, evaluation time, loading and unloading, etc... Helicopter crews have an uncanny knack of dragging things way out. In my experience, most ground crews would have made the half hour trip long before the flight crew would have even taken off.

[PRPGfirerescuetech]

I agree. I suppose I misstated what I meant. I was basing my opinion on time, not distance. With the transport lasting "20-30 minutes," aeromed wouldn't have saved any time once you factor in response, evaluation time, loading and unloading, etc... Helicopter crews have an uncanny knack of dragging things way out. In my experience, most ground crews would have made the half hour trip long before the flight crew would have even taken off.

That ill give you.

A 20 to 30 minute trip is a ground run.

a 20 to thirty mile trip is a toss up.

Good points dust.

[chbare]

medic53226, I am sorry to hear about your bad transfer. Did you have the option of using vasopressors? I agree that this sounds like a critical care transfer and requires a service that can provide critical care interventions. (This is not to say that a helicopter/airplane is needed.)

Take care,

chbare.

[medic53226]

This run started with a bls unit not asking for a intercept, but got better at the hospital, when the doc was told that the pt was in distress and breathing at 4-6 bpm, by the charge nurse the doc looked at the nurse and I quote " SO " and mind you they are bagging this pt in the ER, and he gets up and walks into another room and takes a pt report, and they had to wait so, before I even got into the mix, we were behind the eight ball, and what made it even better my supervisor, said I would have got help for you, the ironic thing is she was the the one that took the call in the first place, and just found it was a paramedic run and that was it, I never know on all the transfers that I have recently took knew what the pt needed because dispatch is not required to get that info.