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Fri Aug 17 03:11:56 BST 2007

I have the opinion that unless this patient had an unmanaged airway, the original EMS responders might have been a better service to take him directly to a Level I center. It changes little to second guess the field providers, not knowing what they were looking at on the scene though. 

  As for a transfer, as terrible as it may sound, many level II and level III centers around my home like to "turf" responsibility to the level I. They transfer any and everything, or worse divert directly to the regional level I. While I am proud to say I was part of the Level I team for many years and it is an outstanding center, there is still a finite level of resources. (ED, Trauma staff, Surgical staff, SICU beds, other ICU beds,etc.) Also consider every other trauma coming in to the center directly. I have experienced that whether it is a mass casualty, out of hospital, or developing "healthcare" location, over-utilization of facilities seems like not only a waste of resources for generally poor outcomes, but also negatively affects the patients already at the location.

  If the Patient is unstable, by the time he is packaged, transported, reassessed (hopefully radiographs are transferable and acceptable to the receiving facility) and the decision is made to take him to OR, it will likely become a "teaching case." 

  It might be more expedious to have Gen Surg start to look at his liver/splenic injuries and call in other specialists as needed from a logistical point of view. Consider also how much care can really be given by a Mobile Intensive Care Team, especially in the cramped quarters of an aircraft with usually 2 medical crewmen.  

  As for legality, In my home town, the level I can only refuse a transfer when ICU beds are unavailable or all Surgeons are already operating. (not common but I have seen it happen a few times) 

  Mike  

Pret Bjorn <p.bjorn at netzero.net> wrote:
  Better question is how did your system select this guy for a level III
center with a level I so close by. 

A level III hospital with an "OR team in house" by no means ensures prompt
or proper damage control. The simple fact that a patient with presumably
submissive hypotension has already had a chest and abdomen CT suggests that
this initial destination was a dreadful mistake.

Your level I's ability or enthusiasm to help this poor fellow was made
irrelevant by the lack of sophistication in the larger system.

Just me, just now.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of ABMoss at aol.com
Sent: Thursday, August 16, 2007 8:11 PM
To: trauma-list at trauma.org
Subject: Transfer

A question to the group. Does a Level 1 Trauma Center have a
responsibility 
to accept an "unstable" patient from a Level 3 Trauma Center? 30yr male 
MVC, GCS 15, systolic BP 40-60. Resuscitation with crystalloids and PRBC.
CT 
revealed liver & spleen laceration and suspected aortic injury. OR team in 
house but no cardiothoracic capabilities. Level 1 Trauma Center is about
15 
miles away.

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