Going back as little as ten years ago, all paramedics brought all patients to the “nearest” hospital. Paramedics were given very little freedom to choose the hospital that they were to take their patient to, or determine which hospital was most appropriate for which patient. In the world of modern Ambulance Services, paramedics are aided in this decision by the adjunct of many computer systems, matrixes, hospital allocation cards and private/public patient’s requests.
However, there is now a greater emphasis on paramedics being able to be more than robots that follow flow charts and algorithyms, and actually think about what is best for their patients.
I recently attended an 18 year old male who had been hit by a car while walking across a busy road. The mechanism was car vs pedestrian 60 km/h. The patient was knocked over the windscreen and had a head injury.
On arrival, the patient was Airway: Minor Stridor/snorring (rectified with O/P airway); Breathing: Normal; Circulation: Tachycardic 132, radial pulses present, BP 102/44. Disability: Unconscious, with a GCS of 3. Exposure: Head: PEARL5mm, large haematoma to occiput with a “boggy mass”, Neck: NAD, Chest: Clear, Good air entry to bases, L=R, Abdo, rigid on palpation and appears swollen on the left side (query splenic rupture), Pelvis, NAD, Limbs: NAD (but unable to assess motory/sensory due to patient being unconscious).
Treatment on scene: O/P airway inserted, O2 therapy via a non-rebreather mask, spinal precautions including, cervical collar, sandbags, spineboard and anti-emetics.
Treatment enroute: urgent transport, IVC inserted, fluids set up, but not adminstered.
Transport decisions: There were three hospitals available to us. Two were close, but unable to provide major surgical interventions, and one was close to an hour away, but was a major trauma centre capable of providing surgical solutions (ie, for a ruptured spleen, enclosed head injury).
In the end we opted to the major trauma hospital, because it was the only place where that patient could get definitive treatment. The risks included:
1. The patient may deteriorate and require intubation and we would be unable to successfully intubate;
2. The patient may become profoundly hypovolaemic and go into cardiac arrest.
At the end of the day, it was determined that the best possible chance that this patient would have of survival required early surgical interventions, and although the closer hospitals could provide a higher level of emergency medical care, they could not treat the injuries and therefore that patient was taken to the major trauma hospital.