Motorcycle Crash 60 Miles From Definitive Care

He meets physiologic and anatomic triage criteria: hypotension with tachycardia, altered mental status, unstable pelvis, and a mangled extremity. Those criteria exist to route patients past facilities that cannot provide definitive hemorrhage control.

The Level III can resuscitate but cannot do damage-control laparotomy or pelvic packing. A 12-minute ground trip to a hospital without a surgeon converts a 22-minute air transport into a prolonged secondary transfer during the most lethal window. Total time to the Level I by air is approximately 37 minutes from now versus 62 by ground; air is the right call.

Justification is not just distance - it is capability and time. Document the criteria met, the helicopter request time, and the receiving facility's acceptance.

Caveats to state explicitly: if he arrests or becomes unstable in a way that precludes the flight, the Level III is the correct diversion. Keep the sheet but reposition the binder over the greater trochanters, not the iliac crests, and reassess distal pulses. Prevent hypothermia - remove wet clothing, warm blankets, warmed fluids - because a cold, coagulopathic patient loses the benefit of the faster transport.

Prepare for a patient who will need blood, an operating room, and a warm room - in that order.

• Massive transfusion protocol activated before arrival, with a resupply plan. Expect a 1:1:1 balanced resuscitation; ensure a rapid infuser and fluid warmer are primed.
• Calcium at the bedside: citrate in stored blood chelates calcium, and ionized hypocalcemia worsens coagulopathy and contractility.
• Tranexamic acid drawn up if he is within 3 hours of injury - the benefit window is early and the drug is cheap; the decision should be made in the first minutes, not after the CT.
• OR notification and a room with pelvic and extremity instrumentation available; anesthesia and the trauma surgeon in-house.
• FAST probe, pelvic binder check, and a warm room - ambient temperature is a resuscitation variable in a wet patient at 4°C.
• Blood bank, radiology, and the charge nurse told what is coming so CT and the OR do not collide.
• A pre-briefed role assignment so the handoff happens once, out loud, with the EMS crew and then the flight crew.

Anticipate the sequence: blood and binder first, then CT or straight to OR depending on response.

The review should separate the patient's outcome from the system's performance.

Data elements: scene arrival and departure times, mechanism and triage criteria met, percentage of triage criteria documented, mode of transport and request-to-launch interval, level of destination, time to first blood product, time to definitive hemorrhage control, and whether the receiving center accepted on first call.

Systems questions to ask:

• Did the field crew document the criteria that justified air transport, or did they default to the nearest facility? Undertriage is the most common and most consequential error in rural trauma.
• Was the helicopter requested at the same time as the ground unit, or after assessment? Concurrent dispatch is a protocol decision, not an individual one.
• Does the region have a written destination policy for patients meeting physiologic criteria, with a feedback loop to EMS?
• Is there a documented handoff between the field and flight crews?

Change levers: field triage education with case review, a regional destination protocol, and a loop-closure letter to the EMS agency. Report through the trauma registry so the benchmark is measurable, and keep the review in the performance-improvement structure so it is protected and non-punitive.