Most Appropriate Hospital
	Date: Thu, 02 Oct 1997 22:13:49 +0100 From: John Warwick [john.warwick@virgin.net] What are the list members views on the current practice and protocol of the UK ambulance services to take patients to the nearest hospital regardless of the patients medical needs. Do list members feel that patients should be taken direct to the most appropriate treatment facility, even if this does mean slightly longer transport times. I am thinking of serious head injuries, thoracic trauma, opthalmic trauma etc etc. Secondary transfers can take a long time to arrange, and possible 'windows of opportunity' may be closed. Any references in the liturature would be gratefully recieved. John Warwick Diploma student University of Hertfordshire
	Date: Fri, 3 Oct 1997 18:41:55 +0100 From: Dr. Ed Walker [Ed_trauma@limeland.demon.co.uk] We have a specific gripe about this with our local ambulance service at the moment. Local haemophilia sufferers with trauma get brought to us. We can do most things, but conjuring factor VIII out of thin air ain't one of them. The powers that be stick stubbornly to the rule of 'nearest hospital', despite knowing perfectly well that the patient needs a regional centre. You can only do so much with FFP and DDAVP. By the time we can get factor VIII over in a taxi, a lot of time has been lost.
	Date: Sun, 5 Oct 1997 11:13:02 +0200 From: Arnaud Derossi [aderossi@pratique.fr] Why not take a look at the french system, with centralized dispatching centres, aware of their local (and regional) medical facilities, available surgical teams or intensive care teams, and therefore able to send the ambulances directly to the appropriate place ? Arnaud Derossi
	Date: Fri, 3 Oct 1997 07:19:36 -0400 (EDT) From: Davy Gunn [DavyGunn@aol.com] I would like to hear from the list views on John Warwicks request and in addition put severe hypothermia on the list. To the nearest hospital? or the one with full extra corporeal warming facilities which may be 80 to 100 miles away by road, or 55 mins by air weather permitting. Davy Gunn Glencoe Rescue
	Date: Mon, 06 Oct 1997 22:11:17 +0100 From: Hamish LAING [hamish.laing@virgin.net] It is certainly frustrating to await a patient with Burns who has gone to the nearest Hospital just for the sake of a (probably inexperienced) assessment, a phoned referral to the Burns Unit and an IVI. This adds considerably to the time taken to get to the most appropriate environment and allows the patient to get colder which contributes to a poor prognosis. Unless there is concern about the airway (inhalational burn) why not go direct to the Burns Unit? It also saves keeping an ambulance sitting outside the local emergency department waiting for the inevitable transfer of a big burn? If I was an ambulance paramedic/technician it would drive me to despair! -- Hamish Laing, Welsh Centre for Burns & Plastic Surgery, Morriston
	Date: Sun, 5 Oct 1997 18:05:03 +1000 From: A K Bacon [bacona@zen.ocean.com.au] In Victoria, Australia, we have a committee which assesses the level of the receiving hospital and ambulance officers are directed by standard operational procedures to take the patient to the nearest 'appropriate' hospital. The key word is 'appropriate'. In general, trauma goes to larger, publicly funded, hospitals, and minor problems go to the nearest publicly funded hospital. The patient can request transport to a private hospital emergency department if that is approved for the level of the care by the co-ordinating committee. Burns, paediatrics and spinal trauma are usually secondary transfers, but where the initial transport time is reasonable, or one of the helicopter ambulances is used, then direct admission to one of the more specialised units is allowed. If there is a problem finding critical care beds then we have a centralised bed bureau, which can authorise private hospital resources when the public sector has insufficient beds.
	Date: Tue, 07 Oct 1997 21:35:17 +0100 From: Howard J Rayner [Howard@hjrayner.demon.co.uk] Contact your local ambulance service training school and also contact their paramedic steering committee. Between them they should be able to issue guidelines for who or what goes where. Crews in Berkshire will take the pt to the nearest appropriate A&E. Not neccessarily the nearest.
	Date: Wed, 8 Oct 1997 11:51:42 -0400 From: Stephen M Stowe, M.D. [102747.3140@compuserve.com] I think that it is important to identify the nature of an injury and to transport the patient to the correct facility when possible. Major Trauma Centers, Burn Units, Hyperbaric Medicine Units are all very specialized and are really the place where patients with specific problems belong. If a patients with caisson disease is brought to a facility without a chamber the patient might just as well be left on the scene. Stephen M. Stowe, M.D.
	Date: Sun, 12 Oct 1997 17:34:39 +1000 From: Glen Hawkins [glenhawk@ozemail.com.au] I agree with this...it reminds me of a case we had in Sydney 54 year old male stabbed in left chest with kitchen knife. Awake and conscious at scene but because of severity of injury the ambulance followed protocol and brought the patient to the nearest hospital (ours) a district hospital with good surgical facilities but no cardiothoracic cover. The major trauma hospital was 10-15 minutes by road with a full Cardiothoracic Unit. We attempted to stabilize the patient for immediate transport and kept him alive for 90 minutes but eventually he died. There was a penetrating injury to the left atrium through to the other side so it was probably an unsurvivable injury but still it was inappropriate hospital selection for this type of injury Cheers Glen
	Date: Sun, 12 Oct 1997 02:24:55 -0400 (EDT) From: Charles Krin [Krin135@aol.com] While I tend to agree with the general tone that specialty hospitals are the best place for problems in their specialty, carried to an extreme, the idea can be a bit drastic- for example, even though there are a couple of single place 30 psig (3ATA) chambers in this area (Northeast Louisiana), only a few of us have qualified for DCS treatment- most of the docs who are doing chamber work are doing wound care at 2 ATA max. To get to the nearest mult place 5 ATA chamber (which is "required" for the "proper" treatment of DCS (US Navy Table 2)) would require a trip of over 100 miles- yet, we still have a certain amount of sport diving in the area- should I worry that a DCS pt is on the way in to my hospital and that I can't get him to a major chamber, or should I start O2, fluids, Trendelenberg, etc, while making arrangements to get the patient into one of the mono's? All humor aside, if the patient is crashing, most ED's are better equiped than most ambulances here Stateside.... and if the extra transport time to an "appropriate" facility is going to adversely impact on an unstable patient... where an "inappropriate" facility might be able to help stablize the patient while the helicopter or heavy transport team is en route... which would you rather have your mother in? Incidently, you might want to search DejaNews- we played this thread out on one of the ems news groups this past spring!