Monday, July 11, 2011

Officially official, and other things

I got my disco patch in the mail the other week.  I am now officially a paramedic.  Now all I have to do is get my state certification.

In other news, I recently read this post by Rogue Medic.  The part at the bottom about MD scaling back helicopter transports is what got me.  Now, I have to say...when I first moved to MD, I was astounded at what patients they would view as needing to fly.  Patients with a fractured femur who were less than 10 minutes from a Level II trauma center.  Patient's who were alert and oriented appropriately, although drunk as skunks, who had not lost consciousness during the collision, who wanted to REFUSE TO FLY (the patient was talked into flying to a Level II center that was approximately 30 minutes by ground).

Since the crash of Trooper 2, the state of MD has 'cracked down' on the use of medivac flights, which I fully support. Way too many patients are flown without need.  The problem we are seeing, however, is in areas that do not have close access to specialty centers.  For example, the closest eye center to my area is over an hour away (I admit that this is not a hugely long distance for some, and indeed, when I lived in PA, I wouldn't have considered this an abnormally long distance).  Some time ago I had a patient who had been struck in the face with some kind of broken glass, and the wound involved the eye.  The patient was complaining of severe pain, and was unable to see out of the affected eye (there was also EtOH involved).  I called for an ALS unit (technically we are not permitted to call specifically for pain management, but I do it anyway), and consulted with the eye center.  The eye center accepted the patient, but would not authorize a helicopter to transport the patient because the vitals were stable.  The medic was upset, given that the trip is about 1.5 hours one way, but to my mind, that was the correct call.  (The fact that the medic only asked for and got orders to give the patient 4mg of morphine total is another post all together).

A more recent call saw a patient mangle their thumb on a table saw.  There was significant involvement to the bone of the thumb, though the only portion of thumb recovered at the scene was the fleshy part.  The medic who was dispatched (I was on the BLS unit) consulted with the local 'chop shop' hospital (they can't deal with more than the most basic of emergencies) and the hand center, which is about 1.5 hours away.  Once again, the patient's vitals were stable, bleeding was controlled, though the patient was in a fair bit of pain.  To be honest, I am unsure of what exactly was said on the consult (I was in the back of the ambo with the patient), but the hand center refused to allow the patient to fly (again, a decision I was perfectly comfortable with).  Here is where things get sticky.  Per our protocols, a patient with a full or partial amputation of any finger or thumb should be transported to the nearest specialty hand center (there is only one in MD actually).  I classified our patient as priority 3, as he was stable, but he did potentially require 'time sensitive intervention' at the hand center (I'm no hand doc, and while I suspected nothing could have been done for the thumb, I have no earthly clue what they could have actually done).  The medic on scene made the decision that the patient would go to the local hospital, rather than be driven the 1.5 hours to the hand center.  And, as far as I was made aware, this was because the state protocols also state that if the trauma center or specialty center is more than 30 minutes away, the patient should be taken to the local ER.  So the patient lost half the thumb, because this was not something the local ER was equipped for.

Again, I have no clue what they would have done at the specialty center.  The remainder of the thumb was pretty mangled, but I have no idea what would have happened.

Which brings me to the point of this post.  I am not in any way, shape, or form advocating more medivac flights.  Not even a little bit.  However, much of the state protocols are written for the areas that are closest to the main hospitals.  Those of us who are father out from the specialty centers and trauma centers are left handicapped.  We can't fly if the patient is stable and the doc at the trauma or specialty center says no, but protocols don't generally allow for transporting more than 30 minutes away.  From some areas I run calls in, the closest Level II trauma center is more than that.

Another example, as relayed by a medic at my station (a medic who I would trust with my life and the lives of my family...she's GOOD), was a patient who was in a fairly severe motorcycle wreck involving wildlife.  The patient was alert and oriented, but a bit combative, and complaining of severe chest pain, and had been thrown a good distance.  The medic, who feels the way I do about helicopters, consulted with the closest Level I center (in DC), and the closest Level II center (about 40 minutes without traffic), and requested a helicopter (not sure of the patient's vitals, but I suspect she was concerned about chest wall and/or heart and lung injury), and was denied.  She transported by ground to the Level II, but was contacted later by one of the state medical directors and was given an "atta girl."  The hospital that refused the request was 'spoken to.'

Anyway, those of us in the 'wilds' of MD, away from the major hospitals and such, are being hamstrung if we choose to follow protocol exactly.  I have no problems transporting my patient by ground to a specialty center if their situation warrants it, regardless of how far it is (most of them are about 1.5 hours away, without traffic), but not all EMT's and medics are so willing to do so.  Especially in the busier areas where taking a medic unit out of the area for 4 hours or more is a hardship to the rest of the area.

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