Weird question for acute care/EM docs

[DeadliestSnatch]

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So, there's a pretty nice hospital with an acute care center down the road. The other day I saw a car accident just a few blocks away from the place. I don't know what kind of condition the victim was in, but I saw the ambulance speed away from the scene, sirens/lights on, and head away from the hospital, so I'm going to assume that someone was in the ambulance.

Now, I understand that centers like this don't take traumas and that they're not legally allowed to, but I'm a little confused as to why/how. Wouldn't it be better for the crash victim to be rushed to the nearest medical facility, even if it's not as well-equipped, than to die in the ambulance on the 30-minute trip to the closest ED? There are three Level II trauma centers about 20-30 minutes from here, and that seems like a long trip to me. I guess this place probably doesn't have any surgeons in-house, so maybe that's why, but still...the idea of that 30 minute ambulance ride is bugging me.

Are there any scenarios at all---like natural disaster, a factory explosion, etc.---in which this hospital COULD conceivably take patients, or would they all still be transported to other places?

 

[SoCuteMD]

Sorry, what is an acute care center? Do you mean an urgent care?

 

[leviathan]

If you have a trauma hospital within 20-30 minutes, it's more appropriate to take them to that hospital. Most community hospitals do not have the training or staff to manage surgical emergencies. The only time I could see you going to the closest hospital is if they are already in cardiac arrest, but if it's a blunt trauma arrest they're dead anyhow.

 

[DeadliestSnatch]

Sorry, what is an acute care center? Do you mean an urgent care?

Sorry, yeah. I thought the sign outside the hospital said acute, but maybe it says urgent. D'oh!

 

[SoCuteMD]

Sorry, yeah. I thought the sign outside the hospital said acute, but maybe it says urgent. D'oh!

So, is it a hospital? Or an urgent care center? Does it have an emergency department?

 

[DeadliestSnatch]

So, is it a hospital? Or an urgent care center? Does it have an emergency department?

Definitely no ED. I think it's a hospital AND an urgent care center; is that possible? My mom went there once for a migraine, and she said there was a separate "urgent care" wing/area where she was admitted and the rest of it was like a typical hospital.

 

[SoCuteMD]

Hm, interesting. Anyways, I believe it's definitely better for trauma patients to go to a trauma center rather than the closest facility. If you end up at a facility without the proper resources (and I'm betting this place probably doesn't even have an EM doc all the time, maybe they have some on staff) you're up s--- creek without a paddle. What many of the most urgent trauma patients, which granted is a small portion of the "traumas" that roll in, need is not a CT scan or an EM physician but an OR and a surgeon.

As for whether this place would receive disaster patients, since it isn't a trauma center it might not be included in any disaster planning.

 

[Wrigleyville]

Most urgent care places are set up for minor injuries and illnesses (Like the "fast track" area in many ERs), and are staffed by moonlighting FM/IM docs or PAs. They are not equipped for an MVC trauma.

 

[southerndoc]

Arranging a transfer isn't as simple as just calling up a facility and sending the patient. Often times there are no critical care beds available, and many hospitals will not accept patients if there isn't a bed available. They won't let patients just sit in their ER waiting on a bed to open up, even if definitive care is available there. (The exception to this is where I trained during residency. They accepted critical patients regardless of bed situation.)

If something is wrong with the patient, then it will take time to arrange the transfer to an appropriate facility since the one the patient was transported to likely cannot handle the patient. They may not have general surgery, anesthesia 24/7, orthopedic coverage, etc. Since the ambulance left with lights and siren, I imagine there was at least a severe mechanism of injury, which makes a severe injury more likely.

I've had critical patients that I had to transfer out (since we have no neurosurgery coverage), and I've shopped for hospitals with beds, which takes time. Once it took me two hours to find an accepting facility for an intracerebral hemorrhage in a 32 year old. Once I found the facility, then the helicopter would finally come to the hospital (they wouldn't just stand by at the hospital), which took another 10 minutes. Then another 20 minute flight to the receiving hospital. Total time was 2 hours 30 minutes from the time the CT scan was done at my facility (another 30 minutes to get it done and read by the radiologist). That's 3 hours before the patient had definitive neurosurgical care. Had the paramedics delivered the patient to a hospital with neurosurgical coverage (an additional 20 minute drive), the patient would have been seen quicker by the neurosurgeon. Even though the closer facility had no ICU beds, if paramedics had delivered the patient to them, they would have treated him. They just couldn't accept a transfer.

The moral of the story is that the closest facility isn't always the best choice. It's the closest appropriate facility that should be chosen by the EMS crew.

 

[pseudoknot]

It would be better to smother a trauma patient with a pillow onscene than to take them to an urgent care facility.

It's also possible the ambulance didn't transport anyone from the accident the OP saw and simply got another call somewhere else.

 

[Apollyon]

Arranging a transfer isn't as simple as just calling up a facility and sending the patient. Often times there are no critical care beds available, and many hospitals will not accept patients if there isn't a bed available. They won't let patients just sit in their ER waiting on a bed to open up, even if definitive care is available there. (The exception to this is where I trained during residency. They accepted critical patients regardless of bed situation.)

If something is wrong with the patient, then it will take time to arrange the transfer to an appropriate facility since the one the patient was transported to likely cannot handle the patient. They may not have general surgery, anesthesia 24/7, orthopedic coverage, etc. Since the ambulance left with lights and siren, I imagine there was at least a severe mechanism of injury, which makes a severe injury more likely.

I've had critical patients that I had to transfer out (since we have no neurosurgery coverage), and I've shopped for hospitals with beds, which takes time. Once it took me two hours to find an accepting facility for an intracerebral hemorrhage in a 32 year old. Once I found the facility, then the helicopter would finally come to the hospital (they wouldn't just stand by at the hospital), which took another 10 minutes. Then another 20 minute flight to the receiving hospital. Total time was 2 hours 30 minutes from the time the CT scan was done at my facility (another 30 minutes to get it done and read by the radiologist). That's 3 hours before the patient had definitive neurosurgical care. Had the paramedics delivered the patient to a hospital with neurosurgical coverage (an additional 20 minute drive), the patient would have been seen quicker by the neurosurgeon. Even though the closer facility had no ICU beds, if paramedics had delivered the patient to them, they would have treated him. They just couldn't accept a transfer.

The moral of the story is that the closest facility isn't always the best choice. It's the closest appropriate facility that should be chosen by the EMS crew.

Part of EMTALA is that you have to have an actual bed available when the transprort commences - that means open, and cleaned. You can't start sending them even with an accepting doctor and a bed that will be clean when they get there. That's why the ED codicil occurs - EDs are presumed to always have one open bed for transfers, so, in my world, it's mostly general surgery and cardiology, and the patient gets the facility fee, but not the ED MD fee when they hit the ED.

Docs are like Batman - we can do a very little bit with our hands, but we need our toys to be maximally efficient.

 

[Dwindlin]

In my area this issue is always huge. The closest trauma facility in either direction is 45-50 minutes by ground.

 

[Octagonecology]

At my department we did not have the option to txp. to an urgent care center. I'm not sure if that was medical director policy, county ordinance or state law...

Any patient had to be transported to an actual emergency room.

 

[deleted65604]

I take offense at the statement above. Don't get me wrong, Superman could totally kick Batman's butt, however, Batman is one bad hombre. In my observation, he dispenses with his opponents mostly with his fists.

In my 7 person ER group, I think a comparison with the Mystery Men would be more appropriate. I would probably be compared to the super-hero Spleen.

 

[lisadawn]

Just to chime in, I work at a level 4 trauma center (who knew there was such a thing) and am often the only doc there.

We occasionally see bad trauma (self-presented or Mass causality incidents). We stabilize and transfer -- which is not always a speedy process. As someone else said, if someone is dying from trauma, it usually takes a surgeon and an OR to save them, and maybe blood. In my ED we have no in house surgeon or OR team, and only two units of O- blood (the rest comes from a facility 8 miles away, as needed, after cross match).

So, when you get shot in the chest (true story), and dropped on my doorstep, I am going to get a chest x-ray, place the chest tube, call the trauma center, read the x-ray, reposition the chest tube, look nervously at 1200cc blood that has drained, call the ambulance, locate O- blood, do about 10 pages of paperwork, and load you in the ambulance. This process takes at least an hour. You would have been better driving the extra 8 miles to a trauma center.

 

[docB]

Just to chime in, I work at a level 4 trauma center (who knew there was such a thing) and am often the only doc there.

I feel your pain.

Here's one for you:

What does it take to be a Level 4 trauma center? A mission statement and a check to the ACS. (That sounds like it's a joke but it isn't.)

 

[aphistis]

Just to chime in, I work at a level 4 trauma center (who knew there was such a thing) and am often the only doc there.

We occasionally see bad trauma (self-presented or Mass causality incidents). We stabilize and transfer -- which is not always a speedy process. As someone else said, if someone is dying from trauma, it usually takes a surgeon and an OR to save them, and maybe blood. In my ED we have no in house surgeon or OR team, and only two units of O- blood (the rest comes from a facility 8 miles away, as needed, after cross match).

So, when you get shot in the chest (true story), and dropped on my doorstep, I am going to get a chest x-ray, place the chest tube, call the trauma center, read the x-ray, reposition the chest tube, look nervously at 1200cc blood that has drained, call the ambulance, locate O- blood, do about 10 pages of paperwork, and load you in the ambulance. This process takes at least an hour. You would have been better driving the extra 8 miles to a trauma center.

I know it's just a misprint, but I have to admit the concept of a "mass causality incident" got me thinking. Forget the trauma surgeon, you'd be the first physician in history to consult Stephen Hawking.

 

[GeneralVeers]

I know it's just a misprint, but I have to admit the concept of a "mass causality incident" got me thinking. Forget the trauma surgeon, you'd be the first physician in history to consult Stephen Hawking.

That would only occur if a quantum singularity appeared over a mass gathering of people and was stable enough to last more than a few microseconds. You'd also never get the people to hospital, as the resultant time dilation would mean they'd be in transport forever (like an ambulance on the L.A. freeways).

 

[Apollyon]

That would only occur if a quantum singularity appeared over a mass gathering of people and was stable enough to last more than a few microseconds. You'd also never get the people to hospital, as the resultant time dilation would mean they'd be in transport forever (like an ambulance on the L.A. freeways).

Hmm...you're smarter than you look.

 

[Rendar5]

Hmm...you're smarter than you look.

Mein Gott, man! Look at his avatar =p

 

[GeneralVeers]

Hmm...you're smarter than you look.

I'm building a time machine in my spare time. I just need some plutonium.....

 

[deleted109597]

EMTALA doesn't apply to East Carolina. We get all kinds of horse**** transfers ED to ED because the outside hospitals insist that no doctors there can manage isolated rib fractures. That and they like to tube first and ask questions later. Weekly we extubate people and discharge them home.

 

[Dwindlin]

How are you guys exempt from EMTALA? I thought I understood it, apparently not as well as I thought I did...

 

[docB]

How are you guys exempt from EMTALA? I thought I understood it, apparently not as well as I thought I did...

He's kidding and complaining at the same time. I'm surprised you didn't pick up on it immediately as it's a skill set pioneered and perfected in the prehospital arena😀.

 

[Dwindlin]

wow, I feel foolish now. As I reread it I agree, not quite sure how I missed this as sarcasm...thanks for pointing it out though!

 

[DoctorMedic]

having worked in NY and PA EMS for 8 yrs i can tell you urgent care centers are not considered definitive care for any amublance pt. I understand there are plenty of toothaces that are 200 ft from the hospital and still call an ambulance at 2am (seriously called a medic unit for this) and we could easily drop them off anywhere, but the state doesnt allow this. Has to be considered definitive care, and an ED is the only thing that qualifies. As far as which facility is appropriate, I have taken many trauma patients from across the street of our local community hospital level 3 trauma center about 40 minutes down the road to the level 2 center. This is only done if we feel the pt is stable enough for the trip, if we think the patient is crashing, protocol is nearest ED. hope that clarifies things.