The patient has been entrapped for almost thirty minutes. An unrestrained driver going 50 mph who lost control and struck a tree, he is now unresponsive, bleeding profusely, and has the outline of a steering wheel tattooed across his chest. His face was crushed on impact. You’ve managed to insert an OPA, you are suctioning his airway and providing ventilations, but his condition is deteriorating with each passing minute. At last, his legs are free and the patient is packaged. The next critical juncture in patient care arrives: how and where will the patient be transported?
With every emergency call, a paramedic must make transport decisions that will impact the patient’s outcome. Excellent care in the field is diminished if it is followed by poor decisions concerning transport. Here are a few considerations.
How Should the Patient Be Transported?
With the rise of helicopter EMS transport (HEMS), you may be faced with the decision of ground versus air. The growth of HEMS has made transport via helicopter a common occurrence, but just because it is an option doesn’t mean it should be considered a standard mode. HEMS is inherently dangerous – not only for the patient, but for the HEMS crew. So its use should be restricted to only those patients who meet HEMS criteria, which generally include:
- Patients requiring a higher level of care not available through ground transport.
- Patients whose treatment is time critical, where HEMS can deliver the patient much faster than transport via ground.
- Scenes located in geographically isolated areas, making ground transport difficult, if not impossible.
- Situations when local EMS resources are overextended, such as disasters or mass casualty incidents.
When considering transport by air, be sure your patient meets the criteria. Just because a patient needs a trauma center does not mean he or she must go by air. Use good judgement when making the decision to drive or fly.
Where Should the Patient Be Transported?
Once you’ve decided on the best mode of transport, you then must decide where the patient should go. On routine calls, the patient typically decides, based on their preference or insurance needs. The closest facility is always a reasonable choice. But certain patients require specialized facilities; none more so than trauma.
Here is a quick review of the guidelines laid out by the Centers for Disease Control that dictate which patients require the highest level of trauma care available (preferably a Level I trauma center). The criteria are broken down into two categories: physiological and anatomical.
- Glasgow Coma Score ≤ 13, or
- Systolic blood pressure < 90 mmHg, or
- Respiratory rate of < 10 or > 29 breaths per minute or need for ventilatory support
- All penetrating injuries to the head, neck, torso and extremities proximal to elbow or knee
- Chest wall instability or deformity
- Two or more proximal long-bone fractures
- Crushed, degloved, mangled, or pulseless extremity
- Amputation proximal to wrist or ankle
- Pelvic fracture
- Open or depressed skull fracture
It’s up to you as the paramedic to decide the most appropriate destination for your patient, so know the criteria and follow your instinct and agency protocols.
Finally, there are some patients who may require special transport considerations, based not only on their etiology, but on their demeanor.
Special Transport Considerations
- Neonates and pediatrics – consider a special facility, if one is available.
- High-risk pregnancies – also consider a special facility, if available.
- Combative patients – have law enforcement accompany the patient to the hospital (crew safety is priority one!).
- Intoxicated patients – determine whether the emergency room or a detox facility is most appropriate.
When deciding the best transport alternatives for your patients, know your protocols, follow those protocols, and most importantly, use good judgement.