Columns, Commentary, Operations

Transporting Patients to Appropriate Receiving Destinations

You and your partner find Mark, a 48-year-old male, sitting at the dining room table complaining of difficulty breathing and weakness. His skin is pale and clammy. He appears lethargic and is struggling to breathe.

He looks at you as you enter the room and responds by thanking you for coming. As you begin to assess Mark, you note that his skin is warm and his pulse rate is fast.

Your partner applies oxygen and you see Mark’s pulse oximetry increase from 91% to 95%.

Mark tells you he had a cancerous tumor surgically removed from his lung and was released from the hospital a few weeks ago. He denies any complications from the procedure and says he has been feeling good until this morning when he woke up feeling weak and a little shorter of breath than normal. He has an appointment next week to follow up with his doctor. 

Mark said he initially attributed his shortness of breath to “a flare-up of his COPD,” and was going to wait to talk to his physician but the weakness is something different and Mark is concerned.

Your partner reports Mark’s blood pressure is 94/42 mmHg with a pulse of 107, respirations of 32 with a SpO2 of 95% on oxygen. His lung sounds are absent on the lower right side.

The surgical scar appears to be healing well and Mark has no complaint of pain. You help Mark to your stretcher and begin transporting.

During transport, you establish an IV and begin to administer fluid. Soon into transport Mark becomes less responsive. His pulse rate has increased to 126 and his blood pressure is now 88/38 mmHg. His respiratory rate remains about 30. 

Due to the drop in Mark’s blood pressure and his altered level of responsiveness, you gently put down the head of the stretcher putting Mark in a supine position.

When you lay Mark back on the stretcher, you notice his jugular veins remain flat. Consulting with your partner you decide that transport to City Hospital is most appropriate because of their sepsis program, even though Metro-General Hospital is closer.

During transport, you continue administering fluid and notify City Hospital you’re transporting a patient to them who needs the septic alert team.

At the ED, Mark had a tympanic temperature of 102 degrees F and receives aggressive IV fluids resuscitation and antibiotics to treat his sepsis, which was later determined to be caused by Streptococcus pneumoniae that had spread from a pneumonia infection secondary to his pneumonectomy. The EMS crew made the correct decision for treatment and transport.  Mark responded to treatment and was released 10 days later.   

Discussion

This case offered the EMS team a couple of challenging decision points. Mark wasn’t doing well and had a significant pulmonary history. He was in respiratory distress and was progressing into shock. His pulmonary history and absent lung sounds created suspicion for a pneumothorax and his progressing shock could be attributed to the development of a tension pneumothorax.

On exam, however, the EMS crew recognized his pulse pressure was widening. The diastolic value wasn’t moving up as it typically would with a tension pneumothorax. In addition, it was noticed that in a supine position, Mark’s jugular veins were flat, which again is inconsistent with a tension pneumothorax.

Mark was in septic shock, caused by the widespread immune response to the bacterial infection resulting in vessel dilation and leakage of fluid from the blood vessels. Fluid boluses to manage his pressure and transport to a facility with capabilities to quickly manage sepsis was indicated. 

It’s important for EMS to differentiate between various medical conditions, as findings can direct prehospital treatment as well as help determine patient destination. Emergency medicine is progressing rapidly and there are many aggressive treatment paths that can have positive impacts on patients. A patient who is experiencing a myocardial infarction can be taken emergently to the cardiac cath lab and have the vessel occlusion removed. Similarly, patients experiencing strokes can receive fibrinolytics medications or catheterization to remove the clots in their cerebral blood vessels. There are pediatric centers, burn centers, trauma centers and centers that specialize in the management of sepsis. Many hospitals have multiple specialty teams available. Even if a rural area doesn’t have a specialty hospital, odds are good that that facility has transfer agreements with specialty centers in surrounding cities and can provide initial treatment and then transfer the patient, commonly by air, to the specialty center.

Conclusion

EMS is in a position to be the initiator of specialty center destination. In large cities with multiple hospitals, EMS should transport patients to the closest, most appropriate facility based on patient condition, even if this requires passing a closer facility. Where there are hospitals with multiple specialty services, EMS may be asked to activate a specific team, such as the stroke or cardiac team.

In rural communities, EMS can communicate with the local hospital and by letting the hospital know of patient condition, help start the interfacility transport process from the field. EMS is, and should be, considered part of the healthcare team. 

EMS providers should strive to recognize conditions requiring specialty centers and work as patient advocates to get patients to an appropriate facility as timely as possible.