How helpful are your on-call general surgeons in trauma, in EDs that are NOT trauma centers?

[plick]

New-ish attending here just picked up a side gig at a medium sized community hospital without any trauma designation.

The general surgeons there typically want all trauma patients transferred to the nearest trauma center, which I agree with for the high risk cases. But I don't quite understand why general surgeons can't admit to manage the low risk cases themselves (for example stable low-grade splenic/liver lacs, or someone you'd rather be on the safe side keeping for observation for serial abd exams).

I suspect most non-trauma community EDs are similar to this, but just wondering if anyone out there has a different experience.

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[RustedFox]

New-ish attending here just picked up a side gig at a medium sized community hospital without any trauma designation.

The general surgeons there typically want all trauma patients transferred to the nearest trauma center, which I agree with for the high risk cases. But I don't quite understand why general surgeons can't admit to manage the low risk cases themselves (for example stable low-grade splenic/liver lacs, or someone you'd rather be on the safe side keeping for observation for serial abd exams).

I suspect most non-trauma community EDs are similar to this, but just wondering if anyone out there has a different experience.

Same way at my gig. If there's even a remotely "traumatic" mechanism, it's transfer-time.
My understanding is that it's not the surgeon, but rather its the staff/facility/etc that isn't used to dealing with these patients, and the patient is better off at a trauma facility.

 

[GeneralVeers]

It's a legal issue. If you admit a low level "trauma patient" to a non-trauma facility and there is a bad outcome, it is the potential for litigation. Transferring to the trauma center is generally the safest thing for medical and legal reasons.

 

[Tenk]

Actual traumas go to trauma centers. If anything bad happens the first question will be: why didn’t you transfer the patient?

 

[TraumaLlamaMD]

Rusted’s statement is accurate in my experience. You don’t necessarily need a trauma surgeon to manage an elderly patient with non-op rib fractures, but you do need an ICU capable of giving them the attention and pulmonary toileting they will require. If it’s a splenic blush undergoing conservative management, you need a place where IR is readily available (not just on call, but willing to come in quickly and without a huge fight) in case things go south. It’s always nice to have an OR capable of opening quickly for you in an emergency, because that patient who just needs serial abdominal exams for now may need to go for an ex lap tonight - that’s why you kept them in the first place. If you’re at a place where the only overnight anesthesiologist is in a case, his backup is 45 minutes away, and you have no circulator/scrub on backup call? Too bad, your now crashing patient is waiting for his laparotomy.

Unfortunately, a lot of hospitals just don’t have these capabilities, and mobilizing staff and resources quickly in a place that isn’t used to hustling for trauma is really, really hard.

 

[bravotwozero]

lol, they won't touch a spontaneous pneumothorax with chest tube, let alone trauma at my shop. Anything surgical that even smells like trauma gets transferred out.

 

[miacomet]

Outcomes for trauma patients are much, much better at trauma centers. Ours will admit occasional rib fxs, pneumos in younger, healthier people, but splenic and liver lacs? No way. What if they go south? Then they have to transport them to a trauma center. You are observing them for complications that can't be handled at your center. What happens if the splenic lac bleeds out? Emergent splenectomy? No spleen salvaging surgery? A surgeon who hasn't dealt with the spleen in years?

Additionally, your surgeons are probably not compensated for trauma call.

It would be insane to admit a splenic or liver lac to a no trauma center. It's also insane you are referring to this as soon as helpfulness issue, not a quality of care or patient safety issue.

 

[Groove]

Mine aren’t very helpful but will come in if I need them. I once had a ksw a few years ago that arrested from tamponade and he came in to help me with the open thoracotomy. In general, they want all of ours shipped pronto to the trauma center. Their excuse most of the time is that they not only aren’t trauma surgeons, but most haven’t done trauma in years. I think it’s a valid point.

 

[Groove]

In fact, I’ve got one surgeon pushing for a policy to let us clear the trauma pts that don’t need transfer and are candidates for admission to medicine. He said we have more experience evaluating and clearing trauma than he does at this point in his career.

 

[Apollyon]

@Groove ksw? I don't know that one.

 

[NSLDX]

@Groove ksw? I don't know that one.

Knife-Shot wound, you know those ballistic knives all the kids were playing with in call of duty 5+ years ago? Well, they are on the streets now.

 

[enalli]

In fact, I’ve got one surgeon pushing for a policy to let us clear the trauma pts that don’t need transfer and are candidates for admission to medicine. He said we have more experience evaluating and clearing trauma than he does at this point in his career.

What are your thoughts on this plan? My mind just went through a roller coaster of emotions after reading your post and I still don't know how I feel about it.

 

[Apollyon]

Knife-Shot wound, you know those ballistic knives all the kids were playing with in call of duty 5+ years ago? Well, they are on the streets now.

I've never played COD. However, I did try to research this, and got bupkus. Are you serious, or just playing at a GSW typo? I'm just a dumb ER doc, here!

 

[Groove]

@Groove ksw? I don't know that one.

ksw- knife stab wound.

This one went straight into his right ventricle underneath his xyphoid.. 27yo kid stepping in front of an assailant to protect his younger female cousin. Bad luck, sad case... I’m sure you guys can imagine how it ended. When I cut open the pericardial sac, blood blew out like a water balloon. I blew up a foley and tried to plug it and it just wasn’t big enough. Fastest running suture still couldn’t close it fast enough before he massively exsanguinated. The hospital also didn’t have a very well oiled massive transfusion protocol in place though it likely wouldn’t have made a difference.

 

[BoardingDoc]

I've never played COD. However, I did try to research this, and got bupkus. Are you serious, or just playing at a GSW typo? I'm just a dumb ER doc, here!

There weren't knife guns in COD, but people used to go around just stabbing people instead of using their guns because knives were an incredibly fast kill, assuming you got close enough to the person.

Also I agree. I've never heard KSW before and I've certainly had patients who have been stabbed.

 

[Groove]

What are your thoughts on this plan? My mind just went through a roller coaster of emotions after reading your post and I still don't know how I feel about it.

I’m surprisingly very comfortable with it.

 

[southerndoc]

It's a legal issue. If you admit a low level "trauma patient" to a non-trauma facility and there is a bad outcome, it is the potential for litigation. Transferring to the trauma center is generally the safest thing for medical and legal reasons.

Also a double-edged sword. Transfer an unstable splenic lac when you have a general surgeon on call, it's an EMTALA violation because your hospital had the capability to treat it.

I'm surprised at the number of transfers we get who are discharged from the ER because a physician isn't comfortable discharging them at the referring center. Some of these are discharged with a trauma surgeon seeing them. Some of the most notable are facial fractures (follow-up with OMFS/facial trauma next week without seeing in ER), peritonsillar abscesses (we drain them and discharge them, still baffled by the number of ER docs that don't drain these), etc.

 

[miacomet]

Also a double-edged sword. Transfer an unstable splenic lac when you have a general surgeon on call, it's an EMTALA violation because your hospital had the capability to treat it.

I'm surprised at the number of transfers we get who are discharged from the ER because a physician isn't comfortable discharging them at the referring center. Some of these are discharged with a trauma surgeon seeing them. Some of the most notable are facial fractures (follow-up with OMFS/facial trauma next week without seeing in ER), peritonsillar abscesses (we drain them and discharge them, still baffled by the number of ER docs that don't drain these), etc.

Obviously, if they are bleeding out, they can't be transferred, because they'll die. But that's not EMTALA or a legal concern; it's the best and only possible care to keep them.

It is not an EMTALA violation to transfer stable patient who needs trauma care to a trauma center. You are transferring them to a higher level of care.

 

[southerndoc]

Obviously, if they are bleeding out, they can't be transferred, because they'll die. But that's not EMTALA or a legal concern; it's the best and only possible care to keep them.

It is not an EMTALA violation to transfer stable patient who needs trauma care to a trauma center. You are transferring them to a higher level of care.

EMTALA can actually apply to both. If your hospital has the capability to treat it (i.e., monitor the patient), it can be an EMTALA violation to transfer the patient. It's all dependent on which investigator gets assigned your case.

 

[miacomet]

EMTALA can actually apply to both. If your hospital has the capability to treat it (i.e., monitor the patient), it can be an EMTALA violation to transfer the patient. It's all dependent on which investigator gets assigned your case.

In that case, we need to get rid of trauma centers entirely because any hospital with a general surgeon can theoretically take care of trauma patients.

 

[Dr Mantis Toboggan]

Some of the most notable are facial fractures (follow-up with OMFS/facial trauma next week without seeing in ER), peritonsillar abscesses (we drain them and discharge them, still baffled by the number of ER docs that don't drain these), etc.

I’d say the majority of new grads I’ve seen in the past 10 years have never drained a PTA. Did see an article where they gave ceftriaxone/clindamycin/dex IV and 1 liter IVF. If the patient looked OK and could take PO they went home on clinda with next day ENT f/u and the majority did not need aspiration or drainage. We don’t have ENT on call at my hospital so I generally drain these myself. On adults at least.

 

[Brigade4Radiant]

Splenic lacks mostly need vascular or IR on standbye and the need to go back to the OR often so I would say even if they are bleeding from their spleen hang blood and transfer to trauma center with patients blessing.

Also even at academic referral centers ENT comes down to drain the PTA. Most PTA do not need to be emergently drained but numbing the throat getting suction and airway equipment can be a real hassle plus complications. So I can see why a lot of docs ship or discharge out.

For face fractures that don’t need wiring nearly all of them have to follow up in clinic for staging and seeing how the face looks weeks after trauma.

 

[Birdstrike]

Money and lawyers drive everything in Medicine nowadays. Hanging on to a trauma that goes bad, leads to liability, which leads to lawsuits against the doctors and hospital, which leads to increased malpractice losses or insurance premiums, which leads to future patients being transferred whether they need it or not. Then, if people start getting sued or fined for EMTALA violations (more liability) then the trend reverses for a while. But it's pretty much all driven by money and lawyers.

Plus, trauma after the initial hour is a total bore, so no one wants to do it except medical students and interns.

 

[gro2001]

Splenic lacks mostly need vascular or IR on standbye and the need to go back to the OR often so I would say even if they are bleeding from their spleen hang blood and transfer to trauma center with patients blessing.

Also even at academic referral centers ENT comes down to drain the PTA. Most PTA do not need to be emergently drained but numbing the throat getting suction and airway equipment can be a real hassle plus complications. So I can see why a lot of docs ship or discharge out.

For face fractures that don’t need wiring nearly all of them have to follow up in clinic for staging and seeing how the face looks weeks after trauma.

Agree with you, except I still know some EM folks who do PTA drainage themselves. I, for one, love em. Possibly my favorite procedure.

 

[GonnaBeADoc2222]

I’d say the majority of new grads I’ve seen in the past 10 years have never drained a PTA. Did see an article where they gave ceftriaxone/clindamycin/dex IV and 1 liter IVF. If the patient looked OK and could take PO they went home on clinda with next day ENT f/u and the majority did not need aspiration or drainage. We don’t have ENT on call at my hospital so I generally drain these myself. On adults at least.

Really. That's pretty lame. I graduated ~2 yrs ago and did a handful of these in residency. I can't imagine ever transferring one of these out. Pretty bread and butter EM. Now if I were in the throes of a busy shift and it was daytime hours, I may ask ENT to come in and do it for me. But transfer out? Never.

 

[gro2001]

It actually makes a lot of sense to me to transfer low grade splenic lacs and other similar trauma situations. Yeah, most of the time you admit them and nothing happens. But we admit them in case they decompensate. If they decompensate, they would be much better off at a trauma center. Obviously it's better to transfer them while they are still stable, not after they've decompensated.

 

[TooMuchResearch]

Obviously, if they are bleeding out, they can't be transferred, because they'll die. But that's not EMTALA or a legal concern; it's the best and only possible care to keep them.

It is not an EMTALA violation to transfer stable patient who needs trauma care to a trauma center. You are transferring them to a higher level of care.

I find the unstable trauma patient tricky re: transfer.
I can start initial resuscitation, give them all the blood I have available, and get them to a higher level of care faster than I could muster my surgeon who hasn't done trauma in 15 years and a CRNA/surgery RNs/techs/etc.

 

[TooMuchResearch]

I’d say the majority of new grads I’ve seen in the past 10 years have never drained a PTA. Did see an article where they gave ceftriaxone/clindamycin/dex IV and 1 liter IVF. If the patient looked OK and could take PO they went home on clinda with next day ENT f/u and the majority did not need aspiration or drainage. We don’t have ENT on call at my hospital so I generally drain these myself. On adults at least.

We drained them in my program, graduated 2017. Still do it now, though if they do fine on abx, maybe we shouldn't.

 

[TooMuchResearch]

Really. That's pretty lame. I graduated ~2 yrs ago and did a handful of these in residency. I can't imagine ever transferring one of these out. Pretty bread and butter EM. Now if I were in the throes of a busy shift and it was daytime hours, I may ask ENT to come in and do it for me. But transfer out? Never.

This is a pretty quick procedure.
Hurricane spray.
Glob of the best lidocaine jelly/cream you have, dropped on the back of the tongue.
Injection lido w/ epi.
Start stabbing with your guarded needle/syringe.
Just stay medial to the maxillary molars and you probably won't hit anything important.

 

[SpacemanSpifff]

I’d say the majority of new grads I’ve seen in the past 10 years have never drained a PTA. Did see an article where they gave ceftriaxone/clindamycin/dex IV and 1 liter IVF. If the patient looked OK and could take PO they went home on clinda with next day ENT f/u and the majority did not need aspiration or drainage. We don’t have ENT on call at my hospital so I generally drain these myself. On adults at least.

That's a shame. At our academic referral center we drain all of these in the ED (or at least attempt) prior to involving ENT, if needed.

 

[miacomet]

I find the unstable trauma patient tricky re: transfer.
I can start initial resuscitation, give them all the blood I have available, and get them to a higher level of care faster than I could muster my surgeon who hasn't done trauma in 15 years and a CRNA/surgery RNs/techs/etc.

Agreed. Weather permitting, we can have them flown to the local trauma center faster than our OR team can come in.

 

[NSLDX]

I've never played COD. However, I did try to research this, and got bupkus. Are you serious, or just playing at a GSW typo? I'm just a dumb ER doc, here!

Hahahaha you aren't dumb at all, if I wasn't 18 when the game came out I would have no idea what it was. Ballistic knife - Wikipedia They are more of a toy than a real life weapon used on the streets, but I am sure some suburban ED has had to deal with some kid shooting himself in the foot with one he bought off of Ebay.

 

[Apollyon]

Hahahaha you aren't dumb at all, if I wasn't 18 when the game came out I would have no idea what it was. Ballistic knife - Wikipedia They are more of a toy than a real life weapon used on the streets, but I am sure some suburban ED has had to deal with some kid shooting himself in the foot with one he bought off of Ebay.

That made me think of Mac's shotgun ax on Agents of S.H.I.E.L.D!

 

[Groove]

Ash needs to get one of those. Perfect attachment to the “boomstick”!

 

[dpmd]

New-ish attending here just picked up a side gig at a medium sized community hospital without any trauma designation.

The general surgeons there typically want all trauma patients transferred to the nearest trauma center, which I agree with for the high risk cases. But I don't quite understand why general surgeons can't admit to manage the low risk cases themselves (for example stable low-grade splenic/liver lacs, or someone you'd rather be on the safe side keeping for observation for serial abd exams).

I suspect most non-trauma community EDs are similar to this, but just wondering if anyone out there has a different experience.

The trauma center is there to take care of these folks. Everyone involved in their care is used to it so they are helpful. Meanwhile at my non trauma center you have me, on call for 24 hrs at three different hospitals, in house at none of them. You have no massive transfusion protocol and in fact the very fastest you can get a bag of blood to hang is about 75 minutes and that is with someone hounding blood bank for it. The nurses will then only run it in over an hour. IR is available but the same guy is on call at those same three hospitals and usually is either pretty busy or at home asleep. Anesthesia is similarly either busy during the day or at home asleep. Same goes for the rest of the or team. Best case scenario I can go from calling to activate the or and cutting about 60 to 75 minutes later, or maybe the only call team will be an hour into a 5 hour spine or vascular case. The nurses are maxed on their ratios and it is hard to make sure my patients get timely pain meds let alone relying on the nurses to monitor their abdominal exam. I have neither the time nor the inclination to do multiple abdominal exams during the night. So basically any patient that can't go home needs to go to the trauma center because that is what it is there for. Because they usually have someone in house and all the ancillary stuff in case the bad thing that you are keeping the patient to monitor for happens.

 

[turkeyjerky]

Also a double-edged sword. Transfer an unstable splenic lac when you have a general surgeon on call, it's an EMTALA violation because your hospital had the capability to treat it.

I'm surprised at the number of transfers we get who are discharged from the ER because a physician isn't comfortable discharging them at the referring center. Some of these are discharged with a trauma surgeon seeing them. Some of the most notable are facial fractures (follow-up with OMFS/facial trauma next week without seeing in ER), peritonsillar abscesses (we drain them and discharge them, still baffled by the number of ER docs that don't drain these), etc.

Good points, However there's certainly another perspective, like others have mentioned--I can get a patient transferred to my local trauma center faster than I can get a surgeon to return a page in the middle of the night. Although, a strict interpretation of EMTALA often forces you to act against a patients best interests I think it's more appropriate (and in line with the legislative intent behind the statute) to operate with the patients best interests at heart, as long as it's in a non-discriminative manner.

On your second point, I've certainly done this before (with a priori knowledge of the impending discharge). It's extremely frustrating on both ends, but sometimes felt necessary (if only from from a a liability perpective) if you don't have any other way to secure followup for a condition that will require urgent outpatient surgery. Luckily my referral center has gotten better at being willing to page certain specialists for a phone conversation, but sometimes they refuse and just have us send the patient.

Docs who don't drain PTAs piss me off. I'm 3 years out and had to fight during training to get experience draining these. It's obviously within our scope of practice, but when there's a critical mass of docs scared to do it, it becomes difficult to either get trained in or keep doing it.

 

[scummie]

I work at a hospital with two surgeons who alternate call. Located in a city where all trauma gets routed to a Level 1 down the street but we occasionally get the drop off GSW etc. in the instances where I’ve had abnormal findings related to trauma such as an MVC, I just end up transferring.

Been out for about 7-8 months, never seen GS outside of business hours. Typically very unhelpful. Either they are way too sick or not sick enough to warrant an evaluation, much less an admission. Typically ends up turning into a transfer or a medical dump.

Also, I drain PTAs, something that we did in residency. Haven’t had any as an attending. I have found the older docs are more wary about this and don’t do as much.

 

[NSLDX]

That made me think of Mac's shotgun ax on Agents of S.H.I.E.L.D!

The best weapon for killing those soulless framework LMD's! Did you hear they were renewed for 2 more seasons at the same time! The new one can't come soon enough!

 

[plick]

Outcomes for trauma patients are much, much better at trauma centers. Ours will admit occasional rib fxs, pneumos in younger, healthier people, but splenic and liver lacs? No way. What if they go south? Then they have to transport them to a trauma center. You are observing them for complications that can't be handled at your center. What happens if the splenic lac bleeds out? Emergent splenectomy? No spleen salvaging surgery? A surgeon who hasn't dealt with the spleen in years?

Additionally, your surgeons are probably not compensated for trauma call.

It would be insane to admit a splenic or liver lac to a no trauma center. It's also insane you are referring to this as soon as helpfulness issue, not a quality of care or patient safety issue.

The premise of the question was regarding the patients you deem to be low risk for decompensation. During my ACS/trauma rotation at a level I, the vast majority of the admits that can be deemed low risk hardly ever needed any surgical interventions. And all those developed gradually; none of them were stable one minute and toxic the next minute.

I guess the bigger question has to do with the overutilization of specialty centers. My experience with working at smaller community hospitals is that the admitting hospitalist/surgeon overuse the "What if the patient goes bad?" argument to fend off as much admissions as possible. I've worked at places where the surgeons wants us to transfer every uncomplicated/partial SBO patients on anticoagulants (the excuse is if they need surgery and the anticoagulant is subsequently stopped a huge PE will kill the patient in the next 12 hours, therefore they need to be transferred to a center with vascular surgery and hematology and IR and etc).

Oh and yesterday our surgeon quickly admitted a 74 year old F with a splenic hematoma from an iatrogenic cause (s/p colonoscopy). The same surgeon wouldn't even come evaluate for possible observation a healthy 21 y/o M s/p minor trauma who had all negative workup (labs, CT, totally normal vitals throughout, looks great otherwise) but has some persistent mild nonspecific abd tenderness.... because such cases always requires a trauma center 100% of the time, always.

 

[dpmd]

The premise of the question was regarding the patients you deem to be low risk for decompensation. During my ACS/trauma rotation at a level I, the vast majority of the admits that can be deemed low risk hardly ever needed any surgical interventions. And all those developed gradually; none of them were stable one minute and toxic the next minute.

I guess the bigger question has to do with the overutilization of specialty centers. My experience with working at smaller community hospitals is that the admitting hospitalist/surgeon overuse the "What if the patient goes bad?" argument to fend off as much admissions as possible. I've worked at places where the surgeons wants us to transfer every uncomplicated/partial SBO patients on anticoagulants (the excuse is if they need surgery and the anticoagulant is subsequently stopped a huge PE will kill the patient in the next 12 hours, therefore they need to be transferred to a center with vascular surgery and hematology and IR and etc).

Oh and yesterday our surgeon quickly admitted a 74 year old F with a splenic hematoma from an iatrogenic cause (s/p colonoscopy). The same surgeon wouldn't even come evaluate for possible observation a healthy 21 y/o M s/p minor trauma who had all negative workup (labs, CT, totally normal vitals throughout, looks great otherwise) but has some persistent mild nonspecific abd tenderness.... because such cases always requires a trauma center 100% of the time, always.

With no IR I think admitting the spleen was a bad idea. I already gave my reasons why trauma patients requiring hospitalization should go to the designated trauma center, but I will add that the reason that the patients you saw on rotation didn't have an acute decompensation as the trigger for a trip to the or is because they had in house doctors and skilled nursing staff following them. Even then not all of them had a gradual decline but your limited experience on rotations may not have showed you that.

 

[turkeyjerky]

The premise of the question was regarding the patients you deem to be low risk for decompensation. During my ACS/trauma rotation at a level I, the vast majority of the admits that can be deemed low risk hardly ever needed any surgical interventions. And all those developed gradually; none of them were stable one minute and toxic the next minute.

I guess the bigger question has to do with the overutilization of specialty centers. My experience with working at smaller community hospitals is that the admitting hospitalist/surgeon overuse the "What if the patient goes bad?" argument to fend off as much admissions as possible. I've worked at places where the surgeons wants us to transfer every uncomplicated/partial SBO patients on anticoagulants (the excuse is if they need surgery and the anticoagulant is subsequently stopped a huge PE will kill the patient in the next 12 hours, therefore they need to be transferred to a center with vascular surgery and hematology and IR and etc).

Oh and yesterday our surgeon quickly admitted a 74 year old F with a splenic hematoma from an iatrogenic cause (s/p colonoscopy). The same surgeon wouldn't even come evaluate for possible observation a healthy 21 y/o M s/p minor trauma who had all negative workup (labs, CT, totally normal vitals throughout, looks great otherwise) but has some persistent mild nonspecific abd tenderness.... because such cases always requires a trauma center 100% of the time, always.

I'm pretty sympathetic to your position, and I think in a more rational system we'd operate more in line with your preference. IMHO this is one of the ways defensive medicine increases costs and resource utilization that isn't easily measured.

I hate the 'what if' argument. Once I had a hospitality try to refuse an admission bc the patient had an unrelated AAA (wasn't even big enough to be repaired either). We had a period of time when they wanted us to transfer every cholecystits case out cause GI on that week didn't do ERCPs--even when there was no suggestion of choledoolithiasis.

On the last case though, why even ask a surgeon to see the patient? Sounds like an automatic discharge to me.

 

[southerndoc]

Agree with you, except I still know some EM folks who do PTA drainage themselves. I, for one, love em. Possibly my favorite procedure.

All the docs where I work drain PTA's.

 

[TooMuchResearch]

All the docs where I work drain PTA's.

I haven't seen an ENT surgeon since I finished residency, except occasionally in the lounge at our mother ship

 

[deleted109597]

I guess the bigger question has to do with the overutilization of specialty centers. My experience with working at smaller community hospitals is that the admitting hospitalist/surgeon overuse the "What if the patient goes bad?" argument to fend off as much admissions as possible. I've worked at places where the surgeons wants us to transfer every uncomplicated/partial SBO patients on anticoagulants (the excuse is if they need surgery and the anticoagulant is subsequently stopped a huge PE will kill the patient in the next 12 hours, therefore they need to be transferred to a center with vascular surgery and hematology and IR and etc).

No. Specialty centers are how it should be. You don't want to deliver a baby at a hospital that does one a month. You don't want to be the 4th chole at BFE general for the year.
Getting good at something means doing it all the time. The only way that will happen is with specialty centers.
There's plenty of data that non-trauma hospitals have worse outcomes for trauma, because even though EMTALA exists, surgeons will keep the insured ones and ship the uninsured/CMS patients.

 

[evilbooyaa]

I've never played COD. However, I did try to research this, and got bupkus. Are you serious, or just playing at a GSW typo? I'm just a dumb ER doc, here!

Ballistic Knife

THROWING KNIFE - Call of Duty: WWII Wiki Guide - IGN

Ballistic knife was something that you would shoot at somebody, one-time shot, and if it hit them they died.

Throwing knife was like throwing a grenade but if it hit them they died.

But yeah, trauma at trauma centers.

 

[Perrin]

I work at a lvl 1 trauma center. If I get a call for a transfer, I almost always accept. If it sounds questionable, I ask them to talk to our trauma surgeon before accepting. I don’t want to be the doc that turned down a transfer that deteriorated out in the sticks. Our trauma surgeons are great. Pretty much anyone who gets transferred to us they will admit for observation without complaint.