holding the wall

[truetiger]

Local ER, never. Big city hospitals, 10 mins max or we'll start asking for the charge nurse or DON.

 

[DrParasite]

DrParasite I see where you are coming from but from working in a high volume, urban 911 system it doesn't always work the perfect way you want it to work.

in my current system, our busiest units can do 20 jobs in 12 hours in the summer. power trucks (12 to 12) do between 12 and 18 year round. whats your definition of high volume urban 911?

My former system typically had one unit assigned to a municipality for duration of the shift, and rapid turnarounds were often done out of the ER for pending calls, and we averaged between 4 and 10 jobs in 12 hrs, with busy being 12+.

Our units have 10 minutes from the time of drop off until they can get assigned the next call, 20 if the ER is busy.

We have 4 hospitals in our area and every now and again we end up with the hospitals being overloaded. you can end up with 2 of them on critical care divert so that cuts our options in half if we have a patient who truly is sick.

so you go on the two that aren't on CC divert. but if they request an on divert hospital, notify the hospital in advance so they can make proper arrangements.

It's easy to say they need to build a bigger ER but where is that money going to come from to build it and staff it?

i didn't say build a bigger ER. I said the ER management needs to manage their beds, or put on more staff. whether it means discharging the patients who won't be admitted quicker, or admitting those who need beds, or cramming them in like sardines (which isn't preferable, but I did see an ER in NYC that did just that), the hospital needs to manage the flow.

Once we are on hospital property the patient is their "problem" if the 911 system gets so busy that we need to be pulled from the ER then so be it but then again it's not fair to the patient to be stuck in a hall bed and I doubt JACHO would be happy with patients being stuck in hall beds without the necessary resources to care for them.

100% right

edit: you also seem to be talking about an EMS system that utilizes stations. Where I work we don't, we run system status management, so units posted in outlying areas can be moved inward to cover the central areas.

which shortens the response time, but still stretches your EMS resources thin. instead of 1 ambulance per town, you end up with 1 ambulance covering 4 towns, and once that ambulance goes on a job, it gets even worse.

The patients are less acutely sick? Maybe. But that still doesn't put your acute stuffy nose above my exacerbated chf.

not for nothing, but if you have an exacerbated chf call, the facility should have probably called 911. had there been a shorter response the patient's chf might not have been exasperated. You really should get some 911 experience, especially in a system where you primarily treat only ALS patients, I think it will change you opinion.

We are important too. If we are holding a wall we are out of service for any stat transfers. (cath labs, strokes, sick pedis, trauma etc. We aren't all dialysis transfers and pulled out PEGs)

ehhh. while valid statement, the ER should be able to stable the as best they can until you get there. Plus you run schedules dialysis runs and pulled out pegtubes (which do get picked up by 911 when located at home).

My company's response area is huge, it can take more than an hour to get from one end to the other.

if you are responding L&S for an emergency and it's taking you 60 minutes, you either need more units better deployed or the caller should call 911 to get a quicker response.

If there is no staff to care for the patient then there isn't the staff and they're staying on the stretcher.

that's a hospital problem not mine. and as you said, what happens 30 minutes into you waiting for a bed, a call comes in for a stat transfer for a STEMI, trauma, etc? now you have to wait another 30-90 minutes, and the patient ends up suffering. golden hour is shot and with the STEMI, well time is muscle.

Maybe your company needs more ambulances if one being out of service is so devastating.

I could not agree with you more. However to paraphrase NVRob, where is that money going to come from for for the staffing and equipping of all those ambulances?

 

[Sasha]

in my current system, our busiest units can do 20 jobs in 12 hours in the summer. power trucks (12 to 12) do between 12 and 18 year round. whats your definition of high volume urban 911?

My former system typically had one unit assigned to a municipality for duration of the shift, and rapid turnarounds were often done out of the ER for pending calls, and we averaged between 4 and 10 jobs in 12 hrs, with busy being 12+.

Our units have 10 minutes from the time of drop off until they can get assigned the next call, 20 if the ER is busy.
so you go on the two that aren't on CC divert. but if they request an on divert hospital, notify the hospital in advance so they can make proper arrangements.i didn't say build a bigger ER. I said the ER management needs to manage their beds, or put on more staff. whether it means discharging the patients who won't be admitted quicker, or admitting those who need beds, or cramming them in like sardines (which isn't preferable, but I did see an ER in NYC that did just that), the hospital needs to manage the flow.100% rightwhich shortens the response time, but still stretches your EMS resources thin. instead of 1 ambulance per town, you end up with 1 ambulance covering 4 towns, and once that ambulance goes on a job, it gets even worse.not for nothing, but if you have an exacerbated chf call, the facility should have probably called 911. had there been a shorter response the patient's chf might not have been exasperated. You really should get some 911 experience, especially in a system where you primarily treat only ALS patients, I think it will change you opinion.ehhh. while valid statement, the ER should be able to stable the as best they can until you get there. Plus you run schedules dialysis runs and pulled out pegtubes (which do get picked up by 911 when located at home).if you are responding L&S for an emergency and it's taking you 60 minutes, you either need more units better deployed or the caller should call 911 to get a quicker response.
that's a hospital problem not mine. and as you said, what happens 30 minutes into you waiting for a bed, a call comes in for a stat transfer for a STEMI, trauma, etc? now you have to wait another 30-90 minutes, and the patient ends up suffering. golden hour is shot and with the STEMI, well time is muscle.I could not agree with you more. However to paraphrase NVRob, where is that money going to come from for for the staffing and equipping of all those ambulances?

Nursing homes don't call 911. Neither do home health care or hospice services. They call IFT. For everything. We had a call Saturday from a skilled nursing facility for possible internal bleed an a hgb of 4. All we can do is respond. We actually do not respond lights and sirens but I legitimately transport lights and sirens at least once every three shifts.

They may be at a hospital but if they have a heart attack they need a cath lab and only a cath lab will fix them. If they have a stroke only a stroke center will fix them. They can have their symptoms managed but they will continue to decline.

I did a short stent in 911 plus all my ride times. 90% of those calls were bs stuff that could have been driven themselves to an urgent care and managed just as well.

With IFT there's no one to throw the patient into a car and drive them. They are going to be waiting for us however long we take.

So don't downplay it like we can wait and you can't. I hate that. The only time I pitch fits in the ER is when some stupid stable fire medic gets a bed first when we were waiting with our patient first because "well they are 911." When they're going back to their station to eat lunch and watch the fights and we are holding an immediate response for ams or something like that.

 

[Bullets]

Ummm, 15 minute wait at University-Newark, a busy urban system, and one of 2 Level I trauma centers in NJ

I Couldn't imagine waiting hours, do ER not separate triage and main?

 

[Veneficus]

Nursing homes don't call 911. Neither do home health care or hospice services. They call IFT. For everything. We had a call Saturday from a skilled nursing facility for possible internal bleed an a hgb of 4. All we can do is respond. We actually do not respond lights and sirens but I legitimately transport lights and sirens at least once every three shifts.

They may be at a hospital but if they have a heart attack they need a cath lab and only a cath lab will fix them. If they have a stroke only a stroke center will fix them. They can have their symptoms managed but they will continue to decline.

I did a short stent in 911 plus all my ride times. 90% of those calls were bs stuff that could have been driven themselves to an urgent care and managed just as well.

With IFT there's no one to throw the patient into a car and drive them. They are going to be waiting for us however long we take.

So don't downplay it like we can wait and you can't. I hate that. The only time I pitch fits in the ER is when some stupid stable fire medic gets a bed first when we were waiting with our patient first because "well they are 911." When they're going back to their station to eat lunch and watch the fights and we are holding an immediate response for ams or something like that.

Sasha,

Do not dispair.

I have done high volume, "high performance,"urban EMS. It's called doing a full work up on everyone, needed or not. It does not increase the amount of high acuity patients.

Anyone who takes care of sick people can tell you it takes more resources and longer.

The only thing 20 jobs in 12 hours means to me from doing it myself is most of those people don't actually need an ambulance and you waste a lot of money performing the medical error of overtreating.

I remember running the entire early ACLS algorythms on arrest patients. (epi to mag sulfate, skipping no antiarrythmic or alternating epi in about 10 minutes. 15 including response time and first contact.)

Knowing what I know now, I am not fool enough to think I actually did those people any good though.

Nothing an enhanced public health sector couldn't do cheaper and more efficent, and could include SNFs.

 

[DrParasite]

Nursing homes don't call 911. Neither do home health care or hospice services. They call IFT. For everything. We had a call Saturday from a skilled nursing facility for possible internal bleed an a hgb of 4. All we can do is respond. We actually do not respond lights and sirens but I legitimately transport lights and sirens at least once every three shifts.

wow, one emergency transport every 3 shifts? I know people who transport 3 emergent patients every shift.

and I know nursing homes don't call 911. maybe you should educate those nursing homes to call 911 for emergent medical emergencies, and use IFT for stable patients? Remember, we are all supposed to be doing what's best for the patient, and more often than not, that means getting the most qualified person to the patient's side in the shortest amount of time.

They may be at a hospital but if they have a heart attack they need a cath lab and only a cath lab will fix them. If they have a stroke only a stroke center will fix them. They can have their symptoms managed but they will continue to decline.

yep, your right. maybe your IFT company should put on more units, so you always have one available in case those STAT cath or stroke patients come in?

I did a short stent in 911 plus all my ride times. 90% of those calls were bs stuff that could have been driven themselves to an urgent care and managed just as well.

ok, first off, the word is stint, not stent. secondly, did you work on a dual ALS unit, where you only saw ALS patients, and had BLS units handling BLS calls, or did you respond to everything?

911 abuse happens all too often. yes, ambulances are used as a taxi service. In theory, BLS handles BS while ALS will only deal with acutely sick patient. at least that's the theory anyway

With IFT there's no one to throw the patient into a car and drive them. They are going to be waiting for us however long we take.

but in IFT, if you are taking too long, they can always just call another IFT company.

So don't downplay it like we can wait and you can't. I hate that. The only time I pitch fits in the ER is when some stupid stable fire medic gets a bed first when we were waiting with our patient first because "well they are 911." When they're going back to their station to eat lunch and watch the fights and we are holding an immediate response for ams or something like that.

haha, that's pretty funny. you can wait, for the exact reason you just stated. maybe they are going back to their station, maybe they have another call pending. you really don't know.

you have a request for IFT for AMS, that's fine, but if there is a problem and you are unavailable or delayed, they can always call 911.

Ummm, 15 minute wait at University-Newark, a busy urban system, and one of 2 Level I trauma centers in NJ

10 minute is standard, and there are 3 Level 1s (RWJ, UMD, and Cooper).

I have done high volume, "high performance,"urban EMS. It's called doing a full work up on everyone, needed or not. It does not increase the amount of high acuity patients.

I disagree. the percentage of high acuity patients is about the same (between 10% and 20%), but because you are dealing with more patient contacts, you average more sick patients (same percentage, higher number).

Anyone who takes care of sick people can tell you it takes more resources and longer.

The only thing 20 jobs in 12 hours means to me from doing it myself is most of those people don't actually need an ambulance and you waste a lot of money performing the medical error of overtreating.

you are absolutely 100% correct. most people are either curbside pickups or walk in/walk out and drive the stable patient to the hospital, and leave them in triage.

Knowing what I know now, I am not fool enough to think I actually did those people any good though.

don't sell yourself short. they needed a ride to the hospital, and you provided it to them. that's that they wanted, and you did it for them.

 

[JPINFV]

at least that's the theory anywaybut in IFT, if you are taking too long, they can always just call another IFT company.

...because 911 systems can't call another company too? You know... like mutual aid or something. Heck, I'm willing to bet that the IFT companies in the area would be willing to sign a mutual aid contract for when there isn't enough 911 units on the road for their call volume.

 

[Fish]

In San Diego we were always given beds over IFT patients, even if our patient was stable, why? because we had calls responding and needed to go.

The service I work for now tries to maintain an Ambulance for every 20k people so there is always a unit available and a minor bed delay would not be a big deal, the service I used to work for had 2 Ambulances covering a district of 150k.

 

[DrParasite]

...because 911 systems can't call another company too? You know... like mutual aid or something.

sure.... call a company from further away who doesn't know the area. not only that, but 911 companies typically have a monopoly on a geographic area, and no other services operate in that area. IFT companies, on the other hand, go anywhere, and you can often find multiple ambulance companies in the same geographic areas. plus just because a company is stationed in an area, doesn't mean their ambulance isn't 50 miles away. very different than a 911 ambulance that covers a particular geographic area. QUOTE=JPINFV;369292]Heck, I'm willing to bet that the IFT companies in the area would be willing to sign a mutual aid contract for when there isn't enough 911 units on the road for their call volume.[/QUOTE]you'd lose that bet. many IFT companies don't want to do 911 because it isn't guaranteed money. there is little to no profit in 911 (most private 911 companies take a loss on 911 and make up the difference in IFT). plus an IFT can refuse a run if the patient doesn't have a way to pay, a 911 service can't do that.

 

[frdude1000]

I do street EMS in suburban MD near D.C. We usually wait around 15 min for a bed. We have a hospital alert tracker that tells us which hospitals are full/not accepting Priority II/III pts, when EKG beds are all full, etc. If we wait 30 min and a bed is not available after asking again, we are to contact our EMS supervisor. Most of the time we can get in and out quick....friday nights usually have a line of BLS pt's at the charge nurse desk.

 

[JPINFV]

you'd lose that bet. many IFT companies don't want to do 911 because it isn't guaranteed money. there is little to no profit in 911 (most private 911 companies take a loss on 911 and make up the difference in IFT). plus an IFT can refuse a run if the patient doesn't have a way to pay, a 911 service can't do that.

Yet where I worked just about every IFT company either had a 911 contract or a backup contract. Also, just because the 911 unit is supposed to cover area "x" doesn't mean it's available either. However, with an appropriate mutual aid contract with IFT companies, the 911 service can always request that an IFT service stations a unit in the mutual aid area until additional 911 units become available. Does your system not engage in planning and system development with other resources in the area?

 

[JPINFV]

plus an IFT can refuse a run if the patient doesn't have a way to pay, a 911 service can't do that.

911 services can refuse if the patient doesn't have an emergency ("paramedic initiated refusal"). The question is, does the service trust their paramedics enough to do it, and if not why not? Not being up to the game is different than not being able to play the game.

 

[Joe]

some interesting points brought up that i never thought of hahaha. if we go to level 0 then units are called up from another area about 30 miles south. we do have an ift company on backup for 911 but they are very seldom used in my experiance. lets be real for a second.. if the ift company is doing a transfer to er all that means to me is that pt needs the er just as bad as the next bls call that comes in. is it frustrating waiting behind an ift company because both our pts need er but they got there first? yea but we both need to be here. me being on a 911 rig doesnt give me some higher authority. we all have the same la county emt patch on our right arm... if an als call comes in then i dont mind them line jumping.

 

[the_negro_puppy]

We call it ramping and it is an everyday occurence here.
Longest wait is only 4 hours, but we have to wait 30min to 1 hour on an almost daily basis

Heres a pic from a bad day at our 2nd largest hospital, 20 ambulance crews, pretty much no-one left to respond

 

[Cup of Joe]

Now which one was mine again? :rofl:

 

[Sasha]

wow, one emergency transport every 3 shifts? I know people who transport 3 emergent patients every shift.

and I know nursing homes don't call 911. maybe you should educate those nursing homes to call 911 for emergent medical emergencies, and use IFT for stable patients? Remember, we are all supposed to be doing what's best for the patient, and more often than not, that means getting the most qualified person to the patient's side in the shortest amount of time.
yep, your right. maybe your IFT company should put on more units, so you always have one available in case those STAT cath or stroke patients come in?ok, first off, the word is stint, not stent. secondly, did you work on a dual ALS unit, where you only saw ALS patients, and had BLS units handling BLS calls, or did you respond to everything?

911 abuse happens all too often. yes, ambulances are used as a taxi service. In theory, BLS handles BS while ALS will only deal with acutely sick patient. at least that's the theory anywaybut in IFT, if you are taking too long, they can always just call another IFT company.
haha, that's pretty funny. you can wait, for the exact reason you just stated. maybe they are going back to their station, maybe they have another call pending. you really don't know.

you have a request for IFT for AMS, that's fine, but if there is a problem and you are unavailable or delayed, they can always call 911.
10 minute is standard, and there are 3 Level 1s (RWJ, UMD, and Cooper).
I disagree. the percentage of high acuity patients is about the same (between 10% and 20%), but because you are dealing with more patient contacts, you average more sick patients (same percentage, higher number).
you are absolutely 100% correct. most people are either curbside pickups or walk in/walk out and drive the stable patient to the hospital, and leave them in triage.
don't sell yourself short. they needed a ride to the hospital, and you provided it to them. that's that they wanted, and you did it for them.

Doesn't matter what you tell a nursing home they likely aren't going to call 911. Even if our call taker is strongly urging them (due to contracts we can't refuse an immediate response transport and tell them to call 911) to reconsider considering our eta is xx minutes based on the complaint

They can call another IFT company, violate their contract and still wait for txp.

You know people who do 3 emergent transports every shift? Nice. I know 911 medics who do nothing but neck pain, stuffy noses, tummy aches and broken toes with the occasional legitimately emergent call. I know 911 medics who will go three shifts without turning a wheel.

And I would argue IFT medics and emts are more qualified to deal with nursing home patients emergencies anyway as they are more familiar and comfortable with the chronic disease processes and equipment you will run into at the nursing homes. Just like 911 medics are more qualified for trauma (i will freely and unabashadly admit I suck at trauma beyond stuff like hip fractures because we don't get those calls)

I am not trying to turn this into a one is better than the other, honestly just trying to prove a point that IFT is just as important.

My favorite off load problem:

"Oh you're here! We were just going to call you guys to take bed 17 here's the paperwork let's get him moved over."
"uhm... First we have to get rid of the patient currently on the stretcher...."
"Oh... You can put him in bed 17 as soon as you take that guy."

 

[Niccigsu]

1 of our local EMS providers has a designated "holding the wall" guy (he's an older EMT) that is stationed @ the Emergency Department to specifically wait with patients for a room. That way it frees up the transporting EMT's without abandoning the patient when there isn't anyone available to transfer care to at the moment.

 

[Jon]

In Philadelphia itself, I think I've babysat a patient in the ED for 30-40 minutes on RARE occasions. Usually it's brutally obvious that our patient isn't nearly as sick as the ones getting priority. It's frustrating, but I also understand.

In the suburbs, on a rare bad day, it's 10-15 minutes before I get a bad Usually I'll have the patient in a bed an a report given in ~5 minutes from hitting the door.

 

[Tigger]

I swear most of the nursing homes we service would rather just have the patient die then call 911. It apparently generates too much paperwork and the very vast majority of the time we can get a truck to a contracted facility just as fast as the city can. And before anyone asks our operations people do have a sit down meeting with the facility's staff to explain to them what the contract entails and when they should be calling 911.

Also I would imagine that most major cities have mutual aid contracts with the private companies in the city. Almost every private will take roll over 911 calls if they have a unit available since they stand a better chance of making money by taking the call then just having the truck parked. Our contract is no obligation, if we don't have a unit available we don't get penalized, if we do we make money (sometimes).

Even cities that contract 911 ambulance service frequently mandate that that the contracted provider nominate a "mutual aid partner" that is another private.

 

[MedicBender]

I've been diverted from a hospital once due to a full ER. The rest of the time we go straight to a room. When I was in Maryland it wasn't uncommon to wait 20-30 min at the bigger hospitals.

I usually call a head to try and give the ER enough time to get a bed together. When I arrive at some of the hospitals around here they already have a room assignment when we pull up.