Most chest pain is bogus, only occasionally is it legit. Good triage nurses can tell the difference, which is how this guy ended up being sent straight back to a resuscitation room for evaluation. His EKG confirmed the heart attack, and we started the standard cocktail of meds.
Since we’re at a small hospital we don’t have an interventional cath lab available to bust up the clot sitting somewhere in his coronary arteries. Instead we use the one in the big hospital south of us, relying on a helicopter to get him there fast enough to make it worth his while.
The last few times I’ve initiated a helicopter transfer I’ve felt like the flight medics were moving too slow. With this patient I timed them: it took 20 minutes from their arrival to departure for the helipad.
A calm, collected, professional demeanor is appropriate and reassuring, but I think they’ve moved too far down this spectrum to cavalier, and are missing a sense of urgency. I transfer out a fair amount of patients but rarely by helicopter, only when time is of the absolute essence. It’s a cliche, but time is myocardium, particularly in this guy who by history and EKG we happened to catch really early leaving that much more heart muscle available to save.
No meds to give, no vent to manage, just sliding an alert patient from stretcher to stretcher. This shouldn’t take longer than 10 minutes, right? Time to light a fire.
December 30, 2008 at 6:13 am
Seriously. How long would it take for them to just drive?
December 30, 2008 at 12:47 pm
i do a fair number of cardiac cases like this on my local helicopter service (i’m a flight physician)….it should take no more than 15 minutes from shutdown to back to the helo……
December 30, 2008 at 2:57 pm
I do some transport, and actually much delay is in the paperwork. Is it all filled out and ready for us? Do we have to chase down copies of labs/ekgs etc? I agree 20 minutes seems long, but it is more than just throw a pt on a stretcher too. I aim for 15 minutes bedside for average pt, to 30 or as long as it takes to stabilize for others.
December 30, 2008 at 10:16 pm
I as well do I good amount of critical care transports and 90% of the time it’s waiting for paperwork. Even when all the doctors paperwork is there, is the nurses and ours and our consent forms? And you say there where no meds to give, but where meds already running (I.e. heprin or NTG) which would require them setting up thier pumps? If there really was nothing and all the paperwork was in order, I could see a 10 minute transfer very easily (couple mins to find the rn get thier report, then the MD and thier report, then a couple more to introduce yourself to the patient, explain what to do in the heli and then get consent signed, then finally a couple minutes to load the patient to our gurney and have the family say good bye). It all adds up quickly.
December 30, 2008 at 11:23 pm
On another note, don’t your receiving cardiologists want you to give thrombolytics in the interim? Our’s always ask the outlying hospitals to do so. If your receiving hospital is close enough to meet the door to balloon time window is it really faster to send them by air? When I did critical car transport we could do ground transfers much faster within a 20 mile radius.
January 1, 2009 at 1:32 am
I’ve always wondered about that. We are about 35 miles from the big level 1 hospital and when we send stuff out, it always seems like it is 25 or more minutes for the helicopter to arrive, they are met by an ambulance crew at the helipad half a mile away and then brought here where they write lots of notes on tape on their leg and spend what seems like an inordinate amount of time packing the patient up. then they get into the ambulance and go back to the helipad and fly out for the 15 minute flight. So 25 minutes plus 20 minutes plus 15 minutes = 1 hour. An emergency transport ambulance can be available in about 10 minutes, and it always seems like they are in and out a lot faster – maybe 10 minutes (assuming I’m done with paperwork), and it is a 25 minute transport, so 45 minutes. Even with snags, it is still just as fast, and much less dangerous. it just doesn’t seem worth it to me, especially since we don’t have the helipad on campus.
January 1, 2009 at 1:38 pm
As a 9now former) flight paramedic, I have been on the receiving end of an interventional cardiologists wrath because I *didn’t* do certain things to suspected AMI patients.
Y’all seem to forget that we catch hell no matter what we do: Spend a few minutes at the sending facility, and catch hell. Don’t spend that time and just transport, and catch hell on the tail end.
And we wonder why people quit.
January 1, 2009 at 1:40 pm
As a (now former) flight paramedic, I have been on the receiving end of an interventional cardiologists wrath because I *didn’t* do certain things to suspected AMI patients.
Y’all seem to forget that we catch hell no matter what we do: Spend a few minutes at the sending facility, and catch hell. Don’t spend that time and just transport, and catch hell on the tail end.
And we wonder why people quit.
January 1, 2009 at 2:25 pm
Didn’t do what?
January 1, 2009 at 4:10 pm
Depends, Doctor, on the individual case.
I’ve had sending physicians tell me “The intensivist at Big City Hospital doesn’t want the kid intubated” or “The Cardiologist at Man’s Best Hospital doesn’t want Drug XYZ” or other such commentary. Our protocols required it, the sending physician says the accepting physician said no, and the accepting physician wonders why we didn’t.
Further, air transport requires a bit of a different mindset. For example, intubating mid flight is difficult at best, and sometimes prophylactic intubation is better than crash intubation. Yes, that’s an extreme example, but it does serve to illustrate the point.
Yes, this becomes a communication issue, but the fundamental point remains: There are times when an intervention needs to be done before transport.
I’ll not suggest that I know all the details of the case you mention above: To do so would be the penultimate example of a Monday Morning Quarterback. And I’ll also support what I think is your basic premise: in certain cases, transport should be expedited as much as safety allows.
However, as Mary and Chris (rightly) note above, there are times when it’s not the transport crew being sluggish or slow, but the result of paperwork issues or the sending staff not being up to speed.
Good discussion. Oh, and happy New Year, all.
January 4, 2009 at 10:08 pm
So far, I have not encountered this with the level one patients that I have had to transport, they definitely can seem fairly relaxed, but they get the patients moving fairly quickly as well.
January 19, 2009 at 1:49 pm
I suggest: make a cover sheet with a checklist of all the paperwork needed for the flight crew. Have the flight crews work with you on this. When all items are checked off, all paperwork is ready to go.
If a piece of paper needs a critical item (like “This paper MUST HAVE doctor’s signature with TODAY’s date”), list it under the checkbox.