Would you transport or wait for EMS?

[Anonymous M4]

Theoretical question.

A previously healthy young family member comes to you and says "I've been shot." Indeed, he has a single wound to the RUQ. It's 11 PM and you are 12 min to a level I center. Do you call 911 to pick him up, or do you put him in the car and drive him yourself?

Just interested to hear what people would do.

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[gutonc]

Theoretical question.

A previously healthy young family member comes to you and says "I've been shot." Indeed, he has a single wound to the RUQ. It's 11 PM and you are 12 min to a level I center. Do you call 911 to pick him up, or do you put him in the car and drive him yourself?

Just interested to hear what people would do.

If you take him there it will be 12 min before he gets there. If EMS does it will be 12 minutes + however long it takes them to get there + however long they dick around while they're there. If he's walky-talky right now, grab him and run.

 

[Anonymous M4]

So does that quicker transport trump the availability of IV fluids/ O2 whenever EMS get there?

 

[deleted109597]

Yes. Plenty of literature supports that.

 

[The White Coat Investor]

One benefit of using EMS is EMS has the trauma team assembled when they get there. The homeboy transport doesn't. So you'd have to call down there and have them call a trauma code en route or there would be a certain delay assembling the team, perhaps even more delay than calling EMS originally would involve.

 

[rescue1]

I believe there was an older study on survival rates of multisystem trauma victims brought in by ALS EMS, BLS EMS, and POV. As I recall, the lowest mortality was in the POV, followed by BLS, with the highest mortality by ALS.

 

[neusu]

One benefit of using EMS is EMS has the trauma team assembled when they get there. The homeboy transport doesn't. So you'd have to call down there and have them call a trauma code en route or there would be a certain delay assembling the team, perhaps even more delay than calling EMS originally would involve.

This is the bigger reason to use EMS. Perhaps if you work at, or at least know the number for, the nearest trauma center you could give a heads up. Nonetheless, EMS response time is often rather quick.

 

[Croooz]

Depends on where I live.

 

[Anonymous M4]

Depends on where I live.

Like... High income vs low income neighborhood? What are you factoring in there?

 

[CraftyMed]

The "depends on where I live" likely relates to EMS response time. The average time that most agencies aim for is 7mins. Are you close to a station? Are you going to be the 3min response? Or the 12min response? Is your area staffed by volleys? Or a full-time paid service?

There are too many unknowns in this "hypothetical" situation. And if you waited to see what people on SDN had to say about it, your family member is already dead

 

[emd123]

Yes. Plenty of literature supports that.

Scoop and run.

 

[Apollyon]

And if you waited to see what people on SDN had to say about it, your family member is already dead

Like, this is an "SDN is not for medical advice" thread?

I just have an (admittedly amusing) image in my mind of some dude with a shot in the gut, minimally bleeding but certainly not well appearing, and the family member sitting at the computer, anxiously awaiting replies.

 

[Croooz]

Like... High income vs low income neighborhood? What are you factoring in there?

EMS response time. I've lived in low income neighborhoods where the response time was far better than where I live now. Might have to do with volunteer houses versus salaried EMS...or perhaps the experience of EMT's with GSW vs those whose routine calls are for emergent splinters.

When I did as your hypothetical situation suggests, I spent 6+ hours answering questions at the police station and another couple months having to deal with being called whenever someone else was shot in my area. So while I got my friend to the ER and he survived not sure I did any better than EMS could have. As they say no good deed goes unpunished. Thanks to that I definitely would give the idea of transporting any other friend a long second thought. My BIL or SIL I would give them bus fare....

 

[Anonymous M4]

The "depends on where I live" likely relates to EMS response time. The average time that most agencies aim for is 7mins. Are you close to a station? Are you going to be the 3min response? Or the 12min response? Is your area staffed by volleys? Or a full-time paid service?

There are too many unknowns in this "hypothetical" situation. And if you waited to see what people on SDN had to say about it, your family member is already dead

So this was a real situation I faced in my preclinical years. In the heat of the moment, I didn't know if EMS (esp in my low income neighborhood) would be able to get there and get him to the hospital before he bled out. So I put him in the car. By the time we got the ED he was sweating and altered, and I had to get someone to help me carry him in. But the ED guys stabilized him, and he was in the OR within 45 minutes and out of the hospital in 10 days. So it ended well, but I have always wondered if my gut was right. I was scared half to death and didn't consider calling 911 or the hospital to let them know we were coming. All I could think to do was drive and reassure my (understandably freaking out) family member. But he looked so bad by the time we got there that I sometimes wonder if EMS would have been safer.

 

[Anonymous M4]

EMS response time. I've lived in low income neighborhoods where the response time was far better than where I live now. Might have to do with volunteer houses versus salaried EMS...or perhaps the experience of EMT's with GSW vs those whose routine calls are for emergent splinters.

When I did as your hypothetical situation suggests, I spent 6+ hours answering questions at the police station and another couple months having to deal with being called whenever someone else was shot in my area. So while I got my friend to the ER and he survived not sure I did any better than EMS could have. As they say no good deed goes unpunished. Thanks to that I definitely would give the idea of transporting any other friend a long second thought. My BIL or SIL I would give them bus fare....

Right. The cops definitely had some questions.

 

[Rendar5]

So this was a real situation I faced in my preclinical years. In the heat of the moment, I didn't know if EMS (esp in my low income neighborhood) would be able to get there and get him to the hospital before he bled out. So I put him in the car. By the time we got the ED he was sweating and altered, and I had to get someone to help me carry him in. But the ED guys stabilized him, and he was in the OR within 45 minutes and out of the hospital in 10 days. So it ended well, but I have always wondered if my gut was right. I was scared half to death and didn't consider calling 911 or the hospital to let them know we were coming. All I could think to do was drive and reassure my (understandably freaking out) family member. But he looked so bad by the time we got there that I sometimes wonder if EMS would have been safer.

I doubt EMS would've been safer. Homeboy ambulance service tends to produce equivalent or better outcomes when it comes to penetrating trauma. There are only a few rare circumstances where the ambulance crew can save the patient (no, intubation is not one of them, field intubations of penetrating trauma produce poorer outcomes iirc): tension pneumothorax and external exasanguination. Everything else is cured by either ED airway establishment, open thoracotomy, blood products, or OR activation, all of which is done once the patient gets to the hospital .

 

[alpinism]

So does that quicker transport trump the availability of IV fluids/ O2 whenever EMS get there?

The most current trauma research (to be fair it changes every 5-10yrs) suggests improved outcomes following hypotensive resuscitation using normal room air. IV fluids and O2 have never never been proven to decrease morbidity or mortality. In this situation, barring any massive blood loss, there isn't much EMS could do anyway but delay transport.

I believe there was an older study on survival rates of multisystem trauma victims brought in by ALS EMS, BLS EMS, and POV. As I recall, the lowest mortality was in the POV, followed by BLS, with the highest mortality by ALS.

I doubt EMS would've been safer. Homeboy ambulance service tends to produce equivalent or better outcomes when it comes to penetrating trauma. There are only a few rare circumstances where the ambulance crew can save the patient (no, intubation is not one of them, field intubations of penetrating trauma produce poorer outcomes iirc): tension pneumothorax and external exasanguination. Everything else is cured by either ED airway establishment, open thoracotomy, blood products, or OR activation, all of which is done once the patient gets to the hospital .

This.

 

[Siggy]

The cynical answer revolves around whether you can use a car besides your own for the transport.

 

[Anonymous M4]

The cynical answer revolves around whether you can use a car besides your own for the transport.

Lol. No exit wound, no blood on the upholstery. Or are you talking about ditching the car before the cops show up?

 

[ihearttriangles]

Haha. As a former paramedic I've spent an embarrassing amount of time pondering this very scenario. Personally, there is no way in hell I would activate EMS if I was shot. I would get someone to drive me to the local trauma center and on the way there call 911 and have them contact the trauma hospital and inform them of my impending arrival. 911 dispatch is usually surprisingly competent. I say "surprising" cause most of them sit around all day eating donuts and gossiping, but anyway I digress.
The problem with EMS is that so many things have to happen: you gotta call, a dispatcher has to dispatch, PD has to show up to "secure the scene", EMS has to stop flirting with ED nurses get in the ambulance and drive on over, there will inevitably be some delay at scene, then you got to radio in to some bitchy base hospital nurse and get the "ok" to come to their hospital. So, I'm thinking even if you're a mile or two from the trauma center this is still all gonna take 20-25 minutes.
But, on the flip side, and I saw this happen a few times, homeboy ambulance can seriously screw the pooch. In all likelihood they can't distinguish a trauma center from a pharmacy and may either drop off the pt at CVS or an urgent care (thus necessitating EMS activation) or drive around aimlessly for quite some time, realize they are lost and then call 911. Or, probably worse, they loose their head and drive like a maniac and crash their car into a pole with homeboy laying in the backseat without a seat belt who is now more effed up, and guess what, now you gotta activate EMS.
But, in the end in both situations you don't make the platinum 10 but probably make the golden 60.

 

[CraftyMed]

Like, this is an "SDN is not for medical advice" thread?

I just have an (admittedly amusing) image in my mind of some dude with a shot in the gut, minimally bleeding but certainly not well appearing, and the family member sitting at the computer, anxiously awaiting replies.

I'm glad someone got the joke. Even more interesting is that the OP is saying this was a real-life scenario for him/her.

 

[Anonymous M4]

I'm glad someone got the joke. Even more interesting is that the OP is saying this was a real-life scenario for him/her.

I thought it was a funny image too. If that had been the case, I would not consider myself too well suited for Emergency Medicine. Like I said, I made a reasonably educated decision (I.e one hole. Bleeding. Needs trauma center 8 miles away. Probably no traffic. Transport) that was thankfully successful. My hand was somewhat forced, as my relative was going to try to drive himself if I didn't, and I was reasonably sure that he would not make it and crash on the way. I wondered if I did him any disservice by not getting EMS on board. So I asked. I hope never to be in that situation again, but l think the ideas here can also apply to other emergent situations.

I did cringe a little because the image put forth did stir up the actual memory of my minimally bleeding but certainly not well appearing relative, but I also laughed.

"When the Doctor and the Undertaker meet in the street, they wink" read sthg like that once

 

[Siggy]

Lol. No exit wound, no blood on the upholstery. Or are you talking about ditching the car before the cops show up?

Blood on the upholstery. It's important to use your on-scene resources... all of your on-scene resources.

 

[diphenyl]

Homeboy ambulances are the reason I stopped smoking. They always seemed to roll up in the ambulance bay when I took a smoke break. Most of the times they didn't even break before they pushed the homeboy out. Can't even take a 5 min break man.

 

[Chip N Sawbones]

Like, this is an "SDN is not for medical advice" thread?

I just have an (admittedly amusing) image in my mind of some dude with a shot in the gut, minimally bleeding but certainly not well appearing, and the family member sitting at the computer, anxiously awaiting replies.

Some Dude doesn't get shot, he's the guy that shoots innocent SOCMOBbers. Even ignorant premeds like me know that!

It is still a funny image, though.