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Tue Jun 12 15:23:49 BST 2007

Dr. Capropreso,

Sounds like this thread is wrapping up.  Sorry I missed most of it, and
that I have little to add.

First -- and I'm sorry to lead with a downer, BUT -- we should all be
aware that this discussion contains sufficient context identifiers as to
flirt with a HIPAA violation.  I already Googled a photo of the crash
scene.

We're all good people engaging in a useful performance improvement
exercise here, but we're doing it in public.  If any subsequent
information comes from hospital contacts, consent the patient.

As for all the rest, there's nothing here to suggest that the case was
handled inappropriately.  The SYSTEM issues become hypothetical, but it
might be useful to consider the extremes:

One the one hand: does the Iowa trauma system behave differently if your
strictly anatomic criteria are combined with physiologic instability?
It'd be a shame for a patient to die on the way to Des Moines when a
respectable OR is waiting just down the street.  Maine has many thankful
citizens who owe there lives to damage control by dedicated surgeons at
remote "system hospitals" (roughly equivalent to ACS Level III's).

On the other: can the protocol be aborted if, once the tractor is off,
we see that the patient has stable vitals and garden-variety orthopedic
injuries?  Compelling the flight not only impacts the patient (who has
to deal with being charged thousands of dollars to be treated several
hours from her home and support); but also may distract the aircraft and
a CCT team from other more urgent tasks.

For my own part, I think the "modified scene" response suggested here --
wherein the local ambulance meets the helicopter at the local hospital
-- is quite defensible.  First, it's presumably a safer landing zone;
plus, you can have a surgeon or EM clinician walk along from the
ambulance to the airframe: nothing wrong with an extra set of trained
eyes.

Thanks for the discussion.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of pjcabdds at mchsi.com
Sent: Tuesday, June 12, 2007 8:41 AM
To: Trauma &amp; Critical Care mailing list
Subject: Re: EMS management/crush injury

Hi Rob,
Thanks again for taking the time to write and answer the questions that
I
presented. Rumor has it that the patient had a traumatic amputation thru
the
thigh, and a crush/loss of substance in the opposite leg. Terrible. Such
injuries will require tertiary care. Obviously, if a leg is severed,
there is no
need for suspicion. When I get more definite information, I will forward
it. A
few thoughts: transferring a patient on suspicion alone will result in
significant overtriage; faster transport and bypass of a facility may
not always
be the best tactic, ie, in this case, major vessels open up and
hemorrhage in
route; decision to transfer/destination may be facilitated by
discussion/communication with readily available physicians, who are
actively
involved with trauma care. 

--
Kind regards,
Phil
Phil Caropreso, MD, FACS
1813 Grand Avenue
Keokuk, Iowa, USA, 52632
pjcabdds at mchsi.com

----------------------  Original Message:  ---------------------
From:    "Rob Farnum" <latigo at firehousemail.com>
To:      <trauma-list at trauma.org>
Subject: Re: EMS management/crush injury
Date:    Tue, 12 Jun 2007 03:37:47 +0000

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