The Trouble with Transfers

Douglas J.E. Schuerer, MD FACS

Director of Trauma
Department of Surgery
Section of Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Disclosure
I have no disclosures.
Department of Surgery
Acute and Critical Care Surgery
Transfer 1
21 y.o. female volleyball team captain for local college
Hit by truck while driving a scooter
Arrived to your Level 3 trauma center at 1514
GCS 4
Intubated on arrival
HR120 BP 128/65
Department of Surgery
Acute and Critical Care Surgery
Transfer 1
After primary survey what would you do next?

A) CXR, pelvis x-ray
B) CT Head
C) A and then transfer
D) CT Head, chest, abdomen, pelvis, face
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Transfer 1
What would you do now?
A) Call neurosurgery
B) Call orthopaedics
C) CT angio of the Head and neck
D) Transfer to a Level 1 center
Department of Surgery
Acute and Critical Care Surgery
Transfer 1
What timeline would you
work for your transfer?




How much should be done at
your center?


Does it matter if you have
neurosurgery available?
Department of Surgery
Acute and Critical Care Surgery
Transfer 1
Ortho consult
NS consult
Mannitol
Lasix
CT angio of the head and
neck
Pelvic films

Arrived 1514
Note to transfer at 1700
Report called to RN at
1759
Departed 1902
Arrived BJH 1958

Department of Surgery
Acute and Critical Care Surgery
Transfer 1
Arrives with heparin
infusing on pressure bag
into femoral A-line
OSH called to make sure
we know she got 3-4
doses of contrast


Department of Surgery
Acute and Critical Care Surgery
Transfer 1
What would you do next? Right craniectomy
ICP control
Pelvis fixed 5 days later
when ICP improved
1 week MRI showed
diffuse injury

What now?
Department of Surgery
Acute and Critical Care Surgery
Transfer 2
You are an EMS provider and a come upon this scene:
MVC vs. Truck, high speed, significant intrusion.
Called 1911, Arrived on scene at 1940
4 victims
56 y.o female, complains of leg pain. HD stable
55 y.o. male, complains of abdominal tenderness, HD
stable
27 y.o. obviously pregnant female, mild cramping
28 y.o. male, no apparent injuries
Who goes where?
Department of Surgery
Acute and Critical Care Surgery
Transfer 2
A) All to a level 1
B) All to nearest hospital
C) Older 2 to Level 1, younger to nearest hospital
D) Pregnant and abdominal pain to Level 1, others to
nearest hospital

Department of Surgery
Acute and Critical Care Surgery
Transfer 2
More info
Family just picked up at
airport. Parents in town to
help with baby. Mom is 39
4/7 weeks.

Any differences?

How should they be leveled?


Department of Surgery
Acute and Critical Care Surgery
Transfer 2
2 older patients are directly transferred to the Level 1
center.
Both arrive about 2030.
Female is made a Level 1 as her BP dropped below 90.
Male is a level 2.

Turns out female has only a breast hematoma, no
intervention needed.
Male has mesenteric hematoma. Requires laparotomy,
resection and ostomy.

Pregnant female is taken to local hospital.

Department of Surgery
Acute and Critical Care Surgery
Transfer 2
What next?
A) Watch her in your ED for contractions fro 6 hours and then
discharge?
B) Call nearest OB available hospital and call for transfer?
C) Call a trauma venter and ask for transfer to a trauma center?
D) Call a trauma center and ask for OB?


Department of Surgery
Acute and Critical Care Surgery
Transfer 2
OSH called OB. Mentioned minor trauma but asked for
direct transfer to OB floor for further monitoring.


MD:
What is your protocol for such a case?

What imaging will they need?

Where is this best done?
Department of Surgery
Acute and Critical Care Surgery
Transfer 2
Patient transported directly to
OB. Arrives 2150.
FHT initially 120, but within
15 minutes decrease to 90s.
What to do now?


Department of Surgery
Acute and Critical Care Surgery
Transfer 2
STAT c-section
Baby with poor outcome
Mom had an abruption posteriorly

What imaging is needed now?
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
You are on call watching the newest civil disobedience
going on in your city.
You see that the riot police cleared out part of the crowd to
get to a protester who had been shot.
You wonder why you do not hear more as you are the
closest Level 1 center.
You drift off to sleep as your night is not so bad for a
change
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
Your partner is at a small community hospital that is not a
trauma center, just north of the disturbance.
At that hospital:
Surgeons are not in house
ED is busy but not ready for trauma

At 0119 a car drops off a victim of shooting.
Complains of GSWs to the left flank, mid axillary line and
the left leg.
Initial vitals. SBP 40, HR 107
Awake and following commands.
What do we do?
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
A) Scream and run away
B) IVs, CXR, fluids
C) FAST (including chest), IVFs
D) IV, intubate, CXR, extremity films

Department of Surgery
Acute and Critical Care Surgery
Transfer 3
Will you transfer the patient?

What absolutely needs to be done first?



Department of Surgery
Acute and Critical Care Surgery
Transfer 3
IVFs started
CXR obtained
Pelvis film obtained
Extremity film obtained
Triple lumen placed in groin

Department of Surgery
Acute and Critical Care Surgery
Do we need all of the other films?
Do we need to intubate?
What kind of line?
Department of Surgery
Acute and Critical Care Surgery
Post intubation film
He is then sent to your Level 1 center.
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
Arrives at 218
91/75, 72, Intubated
Got 2 units PRBCs en route
GSW to the left flank and the left calf.
You get a CXR:
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
What next?
A) Thoracotomy
B) Chest tube and FAST
C) Sternotomy
D) Laparotomy
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
Taken to the OR
Laparotomy, abdomen packed
Pericardial window done through the diaphragm, grossly positive
? What to do now?

Sternotomy
Hole in the right atrium at AC junction
Cardiac repair, PEA arrest with cardiac message and
recovery

Department of Surgery
Acute and Critical Care Surgery
Transfer 3
In abdomen:
Shattered kidney
Bleeding spleen
Gastric injury
Distal esophagus injury

What do you do?
Damage control?

Kidney and spleen removed, stomach and esophagus
repaired, chest tube placed, packed open
Eventual return to OR in 2 days to close abdomen.
EBL 3 liters Got 14 PRBCS, 6FFP, 1plt
What do the MD think about that resuscitation?
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
But what about the bullet?

Department of Surgery
Acute and Critical Care Surgery
Pre and Post op films
What would you do next?
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
A) Bypass and bullet removal
B) TEE
C) VIR for removal
D) CT scan to localize
Department of Surgery
Acute and Critical Care Surgery
CT, TTE and intracardiac echo all done.
CT says in RV, echoes say in pericardium.
What do you think?
Department of Surgery
Acute and Critical Care Surgery
Transfer 3
Taken to OR by CTS
No bullet on exploration
Put on bypass, bullet was in the LV
Removed and recovered

Out of ICU post injury day 7.
Poor pulmonary toilet
UGI day 7 showed no leak
Diet started, tubes slow to come out.
DC home post injury day 14.

Department of Surgery
Acute and Critical Care Surgery
Transfer 4
You are at a non-trauma center but the only major hospital
in a county south of a large metro center.
You get a construction worker who fell 25-60 feet.
Arrives at 1350.
GCS 5, Denies complaints
HR 103, BP 118/45

Department of Surgery
Acute and Critical Care Surgery
Transfer 4
What are your priorities?
A) Intubate
B) IVS and fluid
C) Blood
D) Above and xrays
Department of Surgery
Acute and Critical Care Surgery
CXR
Department of Surgery
Acute and Critical Care Surgery
Pelvis x-ray
Department of Surgery
Acute and Critical Care Surgery
Transfer 4
When should you consider transfer?

When should this person have flown over this hospital to a
Level 1 center?
Department of Surgery
Acute and Critical Care Surgery
Transfer 4
1411: Intubated
1420: Triple lumen line placed
1425: Discussing transport and helicopter called
1451: Helicopter arrived
1531: Patient arrives at your hospital

Department of Surgery
Acute and Critical Care Surgery
Transfer 4
Was this a timely response and transfer activation?
A) Yes
B) No
Department of Surgery
Acute and Critical Care Surgery
Transfer 4
Should this person have a pelvic binder?

Should a triple lumen have been placed, it delayed the
transfer phone call?

Patient received 8 units of PRBCs en route, his temp was
94.4 at the OSH.
What should the patient have received?
A) Crystalloid only
B) Exactly the same amount of PRBCs and FFP?
C) That blood and as much FFP as they could get form the blood bank
D) Why waste all that blood, he is dying anyway?


Department of Surgery
Acute and Critical Care Surgery
Transfer 4
What would you do at your trauma center?
Your INR just came back at 3.
BP is hanging at 80-90 with resuscitation.



Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Also a small liver laceration
Head CT was negative
Department of Surgery
Acute and Critical Care Surgery
Transfer 4
Binder placed
Resuscitation tried to correct coagulopathy
Scan to see if head injury and decide VIR vs OR.
Patient did poorly.
Department of Surgery
Acute and Critical Care Surgery
Transfer 5
OSH says, we have a lady hear with a GSW to the right
flank. We operated on her and packed her liver then
embolized it.
When she comes she is stable, open abdomen.
VIR records demonstrate common hepatic coil embolization

What now?
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Department of Surgery
Acute and Critical Care Surgery
Transfer 6
At the Level 3 center, she is found to also have a SAH.
The spine surgeon determines he cannot care for the C2
fracture and ortho cannot take care of the tib/ fib fracture.
Patient transferred to Level 1 center for further care.
Arrives at 1303.

Good trauma system?


Department of Surgery
Acute and Critical Care Surgery
Does she need any other studies?
Department of Surgery
Acute and Critical Care Surgery
CT Angio
Department of Surgery
Acute and Critical Care Surgery
Questions?