holding the wall

[DrParasite]

Hell, a DNR is just a request, why not just ignore every DNR that meets criteria because, hey, it's just a request no one is going to physically stop you.

hmmm, I always thought that a DNR was a legal document written and signed by the patient and their doctor, enforceable by the courts. It took a 2nd year med student to tell me that they were just a request and didn't need to be followed because no one is physically going to stop you.

Didn't you just say it's just a request? Why even have reasons to begin with. If it's just a request, couldn't you just say, "We came here because we wanted to. You know... save the company gas money and put less miles on the ambulance."

yes, I did, because it is only a request. We try to accommodate the hospital's request, but if we can't, oh well, not going to lose sleep over it, nor will I lose any sleep because the ER staff is unhappy that we brought a patient to them while on divert. And just so you are happy, nor will my supervisors, upper management, or local EMS regulatory agency.

BTW, when a hospital goes on divert, do they close their walk in entrance? no, they keep accepting patients, they just all need to wait a little longer. That's why a divert is a request and a courtesy, they can't actively refuse to accept a patient (something about EMTALA and dumping patients if I remember correctly).

What are you going to do to stop the hospital from treating someone on your gurney anyways?

well, I could always say "STOP!!!! do not touch MY patient!!!" would be extremely over dramatic, and not all that productive, but I COULD do it. Not that I would, especially for a simple, quick life saving intervention.

But if the hospital wants to put the patient on a 12 lead monitor, starts 2 IVs and start pushing medications, maybe even putting in an advanced airway, I'm gonna say "hold it, lets put him on one of your beds, then you can do whatever you want, and we can get out of your way." and most of the time, it will get done. and if it doesn't, that's when you get your supervisors to call their supervisors and document everything to follow up to prevent it from happening again.

Why draw the line there? So they don't have a bed ready now, everything else gets delayed instead of getting imaging studies and labs cooking?

I guess it's a differences in the importance your hospitals view EMS. In NJ anyway, might not be the same out west.

Also, if you permit all the work to be done with the patient on your cot, it means that your time and your equipment is not as valuable as theirs. meaning, why should they even try to get a bed for you when they can just have you babysit the patient until they get around to it? yes the work needs to be done, but it needs to tie up a hospital resource, not an EMS resource.

it has nothing to do with EMT, paramedic, IFT, 911, uneducated EMS or EMS that requires a Masters degree. it has to do with the fact that the ambulance does not belong in the ER in a holding pattern with no end in sight. 911 trucks need to be available to answer 911 calls, IFT trucks need to be available to answer IFT calls.

But if you accept the fact that you can be put in the holding pattern, than that means you have a very low opinion of yourself/your job and your role in the over all system, and you have accept that the ER's time and resources are more valuable than your own.

I might not be very educated when compared to some of the doctors, but at least I got enough self worth to know that my time isn't there just to be wasted by others. shame others in the profession don't have that same amount of self worth.

 

[Bullets]

Nonetheless, FDNY is still the primary EMS provider even in areas served by volunteer companies. My understanding of the volunteer EMS outfits is that they are no longer dispatched by FDNY and buff calls. Event though these neighborhoods are far from FDNY units, they are still served by FDNY.

I'm thinking more about neighborhoods served by hospital based EMS. If FDNY is not covering those areas period, those neighborhoods should be getting a tax break (in theory) as the the municipality is failing to provide a service. In this case it has nothing to do with call volume, as clearly there is enough population to justify the existence of a hospital.

Actually those areas out on the barrier, reedy point, breezy point, are served by volunteer EMS agencies, a few are part of the volunteer FD and have provided medical coverage for the area long before FDNY reorganized. Its a system that worked so FDNY kinda left them alone. There is only one bridge out to that area, and you have to go through a gate and past a security guard and all that

 

[JPINFV]

hmmm, I always thought that a DNR was a legal document written and signed by the patient and their doctor, enforceable by the courts. It took a 2nd year med student to tell me that they were just a request and didn't need to be followed because no one is physically going to stop you.

Yet, look at all of the places that will gleefully ignore otherwise valid DNR orders/requests simply because they aren't on the proper colored paper. Opps, sorry, you're a hospice patient with an otherwise valid DNR order written into the chart and going to a hospice facility? Well, you don't have our DNR form, so we're just going to ignore it. So, which is it. Is a DNR a legal order or is it not. If it's a legal order, than all of the systems that limits ambulance crews to just the out-of-hospital forms must be breaking the law somehow.

yes, I did, because it is only a request. We try to accommodate the hospital's request, but if we can't, oh well, not going to lose sleep over it, nor will I lose any sleep because the ER staff is unhappy that we brought a patient to them while on divert. And just so you are happy, nor will my supervisors, upper management, or local EMS regulatory agency.

Similarly, I doubt the hospital staff is going to lose sleep over forcing the crew who ignored the divert to hold the wall. I imagine it isn't too hard to find patients in the lobby that are sicker than your patient.

You're also missing the entire point of a pattern of ignoring the divert status. There's a difference between one patient and flat out continually ignoring it. I stand by my statement that a crew or company that shows such a pattern will garner the attention of the hospital staff, which will garner the attention of both the company (especially if the company has a contract for that facility) and the local EMS authority. Why is the policy on divert status any less important than all of the other policies out there governing the EMS system?

BTW, when a hospital goes on divert, do they close their walk in entrance? no, they keep accepting patients, they just all need to wait a little longer. That's why a divert is a request and a courtesy, they can't actively refuse to accept a patient (something about EMTALA and dumping patients if I remember correctly).

Comparing someone who hasn't accessed the emergency medical system to someone who is currently in the emergency medical system is comparing apples to oranges. Of course it's ironic to discuss dumping patients in a conversation about trying to justify EMTs dumping patients because they don't want to be a team player.

But if the hospital wants to put the patient on a 12 lead monitor, starts 2 IVs and start pushing medications, maybe even putting in an advanced airway, I'm gonna say "hold it, lets put him on one of your beds, then you can do whatever you want, and we can get out of your way." and most of the time, it will get done. and if it doesn't, that's when you get your supervisors to call their supervisors and document everything to follow up to prevent it from happening again.I guess it's a differences in the importance your hospitals view EMS. In NJ anyway, might not be the same out west.

If you're coming into a facility on divert, what makes you think that a bed is available to treat your patient? I've never had a patient be treated on my gurney, but I also haven't ignored diversion status either. Besides, what makes you think that the hospital supervisors care what the ambulance supervisor thinks when the ED is already packed with patients and on divert?

Of course out West (since you want to make this a geographical issue) doesn't have a problem with unlicensed providers working on ambulances.

Also, if you permit all the work to be done with the patient on your cot, it means that your time and your equipment is not as valuable as theirs. meaning, why should they even try to get a bed for you when they can just have you babysit the patient until they get around to it? yes the work needs to be done, but it needs to tie up a hospital resource, not an EMS resource.

But if you accept the fact that you can be put in the holding pattern, than that means you have a very low opinion of yourself/your job and your role in the over all system, and you have accept that the ER's time and resources are more valuable than your own.

I might not be very educated when compared to some of the doctors, but at least I got enough self worth to know that my time isn't there just to be wasted by others. shame others in the profession don't have that same amount of self worth.

Strange, the same could be said about a crew who thinks that divert status doesn't apply to them. What makes your patient more important than all of the other patients in the saturated ED? Your time is more important than the hospital staff's time dealing with numerous other patients because you want to dump your patient on them instead of following your system's policy regarding divert? A policy that was made in consultation with both the system administrators, the hospitals, and the ambulance services? I'd rather have a lower sense of worth than an over-inflated sense of self worth where I think I know more than everyone else involved with the system combined.

Shame on those who thinks that they're the only people that matter in a system.

I wonder what would happen if EMS providers suddenly had to start regularly treating multiple sick patients for hours at a time instead of one patient for 20 minutes. I'm willing to bet the "I'm the center of the universe" attitude would quickly change.

 

[Handsome Robb]

.
Also, if you permit all the work to be done with the patient on your cot, it means that your time and your equipment is not as valuable as theirs. meaning, why should they even try to get a bed for you when they can just have you babysit the patient until they get around to it? yes the work needs to be done, but it needs to tie up a hospital resource, not an EMS resource.

it has nothing to do with EMT, paramedic, IFT, 911, uneducated EMS or EMS that requires a Masters degree. it has to do with the fact that the ambulance does not belong in the ER in a holding pattern with no end in sight. 911 trucks need to be available to answer 911 calls, IFT trucks need to be available to answer IFT calls.

But if you accept the fact that you can be put in the holding pattern, than that means you have a very low opinion of yourself/your job and your role in the over all system, and you have accept that the ER's time and resources are more valuable than your own.

This is a ridiculous statement...we are all on the same team, working towards a common goal, that goal being good patient care.

Healthcare isn't a perfect system anywhere in the world. Sure something may look good on paper but paper isn't the real world.

So if I'm reading what you said above correctly your saying by allowing a nurse to pull labs before we get a room in hope to expedite the patient's stay in the ER and eventually clearing a bed more quickly I have no respect for the value of my equipment or myself? If myself and a nurse push a med before the patient is assigned a room because the system, as a whole, is overloaded I have a poor opinion of myself and my job? That's asinine.

Sure units need to be available to answer calls in the system but even if they are able to answer those calls what good is it if there's nowhere for us to take those patients to? Just some food for thought.

 

[DrParasite]

Yet, look at all of the places that will gleefully ignore otherwise valid DNR orders/requests simply because they aren't on the proper colored paper. Opps, sorry, you're a hospice patient with an otherwise valid DNR order written into the chart and going to a hospice facility? Well, you don't have our DNR form, so we're just going to ignore it. So, which is it. Is a DNR a legal order or is it not. If it's a legal order, than all of the systems that limits ambulance crews to just the out-of-hospital forms must be breaking the law somehow.

I know I am probably in the minority, but if i had a DNR, I would want to make it as accurate as possible. that means using the state DNR form, for out-of-hospital if the patient will be transported out of hospital, and if hospital and hospice if appropriate. but thats just me.

Similarly, I doubt the hospital staff is going to lose sleep over forcing the crew who ignored the divert to hold the wall. I imagine it isn't too hard to find patients in the lobby that are sicker than your patient.

probably right, but when I start calling for the hospital administration to come down and explain to my patient why they are waiting, a bed will be found. and while I haven't had to do that, I know of supervisors who have went to the ER and made that request. it's called advocating for your patient.

You're also missing the entire point of a pattern of ignoring the divert status. There's a difference between one patient and flat out continually ignoring it. I stand by my statement that a crew or company that shows such a pattern will garner the attention of the hospital staff, which will garner the attention of both the company (especially if the company has a contract for that facility) and the local EMS authority. Why is the policy on divert status any less important than all of the other policies out there governing the EMS system?

you can stand by your statement, but your statement is still wrong. maybe an IFT company can get in trouble (since that seems to be where all your experience is), but 911 services don't.

the divert status is a hospital request, it isn't an EMS policy. I could explain it more, but if you don't understand that concept, than it is a moot point.

Comparing someone who hasn't accessed the emergency medical system to someone who is currently in the emergency medical system is comparing apples to oranges. Of course it's ironic to discuss dumping patients in a conversation about trying to justify EMTs dumping patients because they don't want to be a team player.

ahhh, not a team player... yeah, that's me. the guy who wants to get back out there and pick up the next GSW victime, heart attack, or asthma attack, and take them to the hospital, instead of holding a wall for 1-4 hours. yep, not a team player :rofl:

If you're coming into a facility on divert, what makes you think that a bed is available to treat your patient? I've never had a patient be treated on my gurney, but I also haven't ignored diversion status either. Besides, what makes you think that the hospital supervisors care what the ambulance supervisor thinks when the ED is already packed with patients and on divert?

well, when you aren't going to make any noise, they won't care. if you just wait their quietly, hospital supervisors won't care. maybe the hospitals I have dealt with are just more EMS friendly than others, or just practice good customer service whether it be from a patient or a fellow healthcare provider.

Of course out West (since you want to make this a geographical issue) doesn't have a problem with unlicensed providers working on ambulances.

ouch, a zinger!!! you know, with a small percentage of FD ambulances or rural ambulances in the sticks do doesn't represent the majority, so your cheap shot doesn't phase me at all,nor does it even apply to me.

Strange, the same could be said about a crew who thinks that divert status doesn't apply to them. What makes your patient more important than all of the other patients in the saturated ED? Your time is more important than the hospital staff's time dealing with numerous other patients because you want to dump your patient on them instead of following your system's policy regarding divert? A policy that was made in consultation with both the system administrators, the hospitals, and the ambulance services? I'd rather have a lower sense of worth than an over-inflated sense of self worth where I think I know more than everyone else involved with the system combined.

yes, back this the divert thing. if you can't understand that it's a courtesy, not a requirement, than I won't waste any more time wit you.

My patient is more important because I have done my job, and brought them to the ER. if the staff say put him in triage, he goes into triage. if the staff say put him in a bed, he goes in a bed. either way, my job (what I'm paid to do, and what my boss tells me to do) is to pick up sick people and take them to the hospital. Once they are in the hospital, they are the hospital's problem (and yes, overcrowding sucks, but that's a hospital flow problem, not an EMS problem).

I wonder what would happen if EMS providers suddenly had to start regularly treating multiple sick patients for hours at a time instead of one patient for 20 minutes. I'm willing to bet the "I'm the center of the universe" attitude would quickly change.

first off, usually those sick patients are focused 100% by a doctor or nurse until they are stabilized. Then they are consistently monitored by a nurse or by a machine (which is monitored by a nurse) for changes, and if there are any life threatening changes the patient again gets 1:1 care.

if a nurse is handling too many sick patients at the time time, than the hospital needs to hire more nurses. I am pretty sure there are nursing standards that say how many patients can be assigned to a nurse. either way, it's a hospital issue, not an EMS one.

This is a ridiculous statement...we are all on the same team, working towards a common goal, that goal being good patient care.

absolutely right, in theory anyway. we also play different roles, ambulance people pick up the people and drop them off in the ER, while the ER people deal with the people we drop off. but if the ER is preventing you from leaving the ER, then they are preventing you from providing good patient care to the other people who need your help, which is preventing you from doing your job. so how is delaying access to the EMS system considered god patient care? ditto delaying getting a comfy bed for the patient (ambulance cots as a whole generally suck when compared to a hospital bed). We won't even go into the detrimental effects of having a patient on a backboard for an extended period of time.... So again, if the people on your "team" are preventing you from providing good patient care to others who need your help, and are forcing your patients to remain on a ambulance cot and/or long spine board longer than the need to, are they really striving to provide good patient care?

So if I'm reading what you said above correctly your saying by allowing a nurse to pull labs before we get a room in hope to expedite the patient's stay in the ER and eventually clearing a bed more quickly I have no respect for the value of my equipment or myself? If myself and a nurse push a med before the patient is assigned a room because the system, as a whole, is overloaded I have a poor opinion of myself and my job? That's asinine.

so let me ask you this: if the nurse can do all that work with the patient on your cot, why should he or she work on getting you a bed at all? why not just leave the patient on your cot? the patient gets treated, the hospital gets it's tests done, and it doesn't tie up a hospital bed at all. there is absolutely no reason for the hospital to get you a bed at all.

Sure units need to be available to answer calls in the system but even if they are able to answer those calls what good is it if there's nowhere for us to take those patients to? Just some food for thought.

the patients need to go somewhere, and the system (in its current state) has EMS take them to the ER. You can like it, you can hate it, you can disagree with it, or you can think it can be done better; but regardless of what anyone thinks, that's the systems we have to deal with. Are the ER's overworked with non-emergent patients? absolutely. But they can't turn them away, despite that they would like to. They do make them wait, but they do get seen, and if a critical patient walks in the door, they do get to jump the line and get seen.

Maybe I am looking at the issue wrong. Maybe the issue is in other areas the ER staff just doesn't care. Maybe EMS needs to build better relationships with the ER management so they will care what people think?

I can't speak for anyone else, but I have gone out with nurses in a purely social setting. We have all gone drinking after a long shift, and EMS was invited to their christmas party. We treat them with respect, and they treat us with respect. Maybe it's because of this that despite being overworked and understaffed, we still rarely wait more than 20 minutes for a bed (and usually it's because they are actively trying to find a bed for us). We are friends, we work to help them, and they in turn work to help us. We understand their roles in the healthcare system, and they understand ours. maybe that's why we don't have hour+ long waits to turn over a patient.

One last example: I had a run in with an L&D nurse a few years ago. She completely ignored me, ignored everything I had to say, and then sent me down to the ER with my patient (which didn't bother me all that much except that I didn't know the way through the hospital). Anyways, I made it to the ER, and the nurse (who only knew me professionally, I doubt she even remembered my name) saw I was visibly frustrated. After we transferred the patient to a bed, she asked what was bothering me and I told her. She then brought me to the nursing director of the ER, who asked what was wrong, and I told her. She then picked up her cell phone, dialed a number, and told me to repeat what I told her. So I did. I later learned that the person she called was the director of the L&D department who wasn't happy to hear what I had to say. The original nurse was reeducated on interacting with other healthcare providers (she didn't think she did anything wrong), which I didn't care about, but the department policies were changed to be more EMS friendly (and more patient friendly, which me very happy).

and the only reason anything was done was because I said something about it, and the ER staff respected EMS (as a general whole, not an individual provider) to listen to a complaint to make the system better for all involved.

btw, that nursing director has since moved on to another position, but I have met the new ER director, have her name, email and phone number, and she knows me, and has my contact information. and yes, we have communicate issues and they tend to be resolved to everyone's benefit.

 

[JPINFV]

I know I am probably in the minority, but if i had a DNR, I would want to make it as accurate as possible. that means using the state DNR form, for out-of-hospital if the patient will be transported out of hospital, and if hospital and hospice if appropriate. but thats just me.

So, how many extra DNR forms are you willing to fill out for 15 minute transports when every place else allows for a simple order written in the chart. When EMS requires a special document, maybe EMS is the problem and not everyone else.

probably right, but when I start calling for the hospital administration to come down and explain to my patient why they are waiting, a bed will be found. and while I haven't had to do that, I know of supervisors who have went to the ER and made that request. it's called advocating for your patient.

I highly doubt that most hospital administrators care just as your supervisors don't care about divert status.

you can stand by your statement, but your statement is still wrong. maybe an IFT company can get in trouble (since that seems to be where all your experience is), but 911 services don't.

Let's stop playing stupid games. Put up your local policy that says that the ambulance crew can decide on their own to ignore divert status. Here's three separate county wide policies on divert status. Notice that there is no option for an ambulance crew to unilaterally ignore divert status regardless of the use of the term "request." When the decision is made at the system and base hospital level, it isn't a "request" for the crew anymore.

http://www.ochealthinfo.com/docs/medical/ems/P&P/310.96.pdf

Regardless of the use of the term "request," notice that none of the decision making regarding the "request" is done at the ambulance level. The lowest it goes is the base hospital.

Another county:
http://www.remsa.us/policy/5310.pdf

Again, no option for paramedics to simply ignore trauma diversions "just because."

Another county:
http://www.sdcounty.ca.gov/hhsa/programs/phs/documents/EMS-PolicyProtocol_Manual_2011.pdf
Pg 39-42

Again, note, all decisions regarding diversion are made at the base hospital level.

Now show me where in your protocols you're allowed to make the decision at the ambulance level to dump patients on an ED.

the divert status is a hospital request, it isn't an EMS policy. I could explain it more, but if you don't understand that concept, than it is a moot point.

It very much is an EMS system policy. See above for three separate policies made at the EMS level regarding divert status.

ahhh, not a team player... yeah, that's me. the guy who wants to get back out there and pick up the next GSW victime, heart attack, or asthma attack, and take them to the hospital, instead of holding a wall for 1-4 hours. yep, not a team player :rofl:

So your potential patients are more important than the patient in front of you? There are no other calls. Also, if your call volume is so high, why aren't there more units on the road? Why is the hospital required to bend over backwards because of your service's failure to plan?

well, when you aren't going to make any noise, they won't care. if you just wait their quietly, hospital supervisors won't care. maybe the hospitals I have dealt with are just more EMS friendly than others, or just practice good customer service whether it be from a patient or a fellow healthcare provider.

The hospitals I've ever had a regular problem with I can count on one hand. Let me rephrase that, I can think of 1 hospital that had regular issues. So my question is why are you constantly making noise? Furthermore, you are not the hospital's customer in any sense of the term.

ouch, a zinger!!! you know, with a small percentage of FD ambulances or rural ambulances in the sticks do doesn't represent the majority, so your cheap shot doesn't phase me at all,nor does it even apply to me.

Ambulance out in the sticks? What's wrong with a state that can't even get one single office/authority/what-have-you providing umbrella oversight even if there are regions? Why does it not surprise me that a state that can't even require all ambulances to have an EMT on it can't draw up a unified policy regarding diversion?

yes, back this the divert thing. if you can't understand that it's a courtesy, not a requirement, than I won't waste any more time wit you.

My patient is more important because I have done my job, and brought them to the ER. if the staff say put him in triage, he goes into triage. if the staff say put him in a bed, he goes in a bed. either way, my job (what I'm paid to do, and what my boss tells me to do) is to pick up sick people and take them to the hospital. Once they are in the hospital, they are the hospital's problem (and yes, overcrowding sucks, but that's a hospital flow problem, not an EMS problem).

Since I've already posted links in this post, it's only a courtesy for states that can't provide reasonable oversight to the EMS system.

Yep, it doesn't matter if the hospital can't currently take care of the patient. You did your job, even if it is ultimately to the detriment of the patient, and many other patients. After all, the only thing that matters is your ability to be a horizontal taxi service, right?

first off, usually those sick patients are focused 100% by a doctor or nurse until they are stabilized. Then they are consistently monitored by a nurse or by a machine (which is monitored by a nurse) for changes, and if there are any life threatening changes the patient again gets 1:1 care.

...because the number of sick patients in an ED currently under diversion for saturation can't possibly out number the number of nurses and physicians on duty. That's almost like it being impossible for the number of calls to exceed the number of ambulances currently on duty, right? Of course the solution isn't to bring patients to a non-saturated hospital. That's just crazy talk.

if a nurse is handling too many sick patients at the time time, than the hospital needs to hire more nurses. I am pretty sure there are nursing standards that say how many patients can be assigned to a nurse. either way, it's a hospital issue, not an EMS one.

...because the hospital hires psychics to determine when exactly their capacities will be overwhelmed. Additionally, adding more nurses and physicians doesn't expand the number of beds in the ED. Capital investments like expanding a building aren't exactly as simple as hiring an extra nurse.

 

[systemet]

In a past life, I have reported to work, been driven by a supervisor to the ER, and waited for an entire shift with a succession of different patients until being picked up at the ER (late), and driven back to the station. My personal best on a single patient is 8 hours.

I have worked in re-direct systems where a guy with multiple torso stab wounds, in sight of the trauma center, gets driven across town to another trauma center, because "they're on redirect".

I've worked in systems where you park the ambulance on scene, because by the current bizarre incarnations of whatever redirect policy is in place, driving in any direction would be completely counterproductive because the combination of hospitals going on redirect and off-redirect meant you'd just have to turn around again.

--------------------------

There is a series of problems. I'm not sure how this works out in the US.

(1) Shortage of discharge beds. If there's no long-term care / nursing home / whatever for the ER patient to go to... where do they go.. nowhere. They stay in the ER.

(2) Failure of other hospital services to admit 24 hours. Some of the medical wards just aren't taking new admits at 0300. And, hey, they're busy, and they deserve a quiet night sometimes. But the spill over is, the patient stays in the ER.

So now you have....

(3) Lack of ER resources, due to 30-50% of beds being occupied by "emergency admitted inpatients". These patients are assigned to another service, but occupying a bed in the ER, or a nearby hallway, receiving orders from said services, and generally consuming ER resources doing time-consuming tasks ordered by an MD from another service.

Then you have a problem.

(4) Triage back up. There's 100 people in the waiting room. Some of these people are sick. Some are old people with a convincing story for a possible MI. Some are kids that needing working up. Some have serious pathology. And in comes an ambulance.

(5) Lack of incentive to accept EMS patients. So a bed opens up. And the triage RN has been worrying for the last 2 hours about an 80 year old with indigestion. Maybe they've had time to do a quick 12-lead in a corner somewhere, and seen that there's no STEMI. But they'd love a troponin, and it's been an hour since the last ECG. And EMS has a homeless person, intoxicated, and incontinent of feces.

What choice does the RN make? Well, the patient in the waiting room is probably sicker, so they go in, right. And EMS waits, because the incontinent homeless guy can't sit upright in a chair. And this repeats, all night. Because everyone else is sick. And he's intoxicated and incontinent. And if he was a 30 year old stockbroker, maybe the triage RN might care more. But maybe not.

But let's say he's intoxicated, but ambulatory. He could go to chairs, but then he's going to mouth people off, and cause problems. Sure there's security, but they cause as many problems as they solve. So he stays with EMS, because at least there, someone will correct his behaviour without having five people jump on him.

Or, let's say, the two patients are the same. There's a vague cardiac rule-out patient with EMS, and one of the same acuity waiting in chairs. The RN can free up the ambulance crew, or take the patient in chairs. Which action is most legally defensible? Sure, it looks bad if the ambulance waits an hour or two, gets a positive 12-lead, and the patient subsequently dies. Or enzymes show a NSTEMI a few hours later. But how bad does it look if the person in chair drops after a 4 hour wait? At least the ambulance patient is getting periodic repeat 12-leads, and if they develop anginal symptoms, EMS can do initial treatment.

(6) EMS becomes surge nursing support. The hospital doesn't have enough beds. No one's getting discharged, plenty of people are getting admitted, but none of them are physically moving upstairs. The hospital isn't paying the paramedic's wages, they're not answerable to the city taxpayer. They have no incentive to ensure ambulances are available for local 911 care. That becomes the city's problem. That's who the taxpayer is turning to if there's no one to answer 911. [Even if EMS is part of the healthcare system -- a paramedic is still cheaper than an RN, and how important is the ER in terms of hospital departments? And then how important is EMS? Neither are a priority compared to say the pediatric neuro ICU].

/ end rant.

---------------------

As an aside, in a life past, I have also been the transfer medic. One of two ALS cars on at night for stat transfers / CCT for a million people. Sitting, waiting in the ER, with a pediatric patient with a leg fx, giving periodic pain control, sitting and listening to the triage RN telling the emergency crew that as soon as patient transfer takes their cardiac to the cathlab, they'll be a bed opening up, not realising that the crew that's going to do that job, is waiting to drop off their low acuity patient before anything else can get done.

------------------------

I'm not sure what my original point was, nor am I completely convinced that this is anything more than pointless whining.

As I saw it, at least, the problem was that the entire system was chronically underfunded, and the ER's had nowhere to send their patients, and nowhere to put them. It wasn't that anyone was being lazy. Just that you can't magically make another long-term care bed appear, free up an emergency bed, clear the triage backlog, prioritise EMS, and generally fix things.

 

[Veneficus]

divert, the forest from the trees

Once I was stationed at a busy station, on a single unit (of 2 stationed there), 12-14 ALS calls for 12 hours was the average shift, but it could get busier, plus any number of dynamic posting (aka system status management) and complete BS calls.

Just down the street was a small hospital, non trauma center, non cardiac center, 1 surgical suite and a whopping 4 bed ICU. But they did have a 6 bed ED (2 acute beds that actually had monitors) with a waiting room with another 8 chairs.

Now and again, a sick person would actually walk in the front door. Where they would find 1 doctor, 1 nurse, and one "nursing" tech (aka nursing student).

On a bad night, when only 1 anesthesia intensivist was in the hospital outside of the ED, with an on call surgeon who had 45 minutes to get there, 2 or more sick people would actually wander in.

Rather than pull the intensivist from the ICU, they would call our station on the non-emergent line to see if there was a unit in station and if so, ask if we could come and help.

I am proud to say we went out of our way to help.

It didn't earn the very reputable EMS company any money, in fact it cost them money. (the official line not written in policy was: do what you can whenever you can to help)

It definately put extra stress on the other unit at the station and likely extra stress on the units in the area.

So why did we do it?

Because a person, who can also be described as a patient was in need. Because some very capable providers who were part of the continuum of care required extra people in order to provide the best they could to this person in time of need.

It was not, and everywhere today is not, about the hospital; not about EMS.

It is about people we call patients. Not to save lives, but to prolong them, hopefully at some level of quality. Healthcare is a team effort, you can be a valuable player or the weak link. But universally when it is about your needs and not the team's, you are the weak link, even if you don't think so.

Every country I know of has doctors and nurses and hospitals.

Not every country has modern EMS. (or even EMS at all) So in the grand scheme of things, EMS is the bonus it isn't required.

In the US, what is the purpose of EMS?

To help the patient out of the hospital as an extension of a physician.

Part of the responsibility of a physician is to direct patients to the best care that can be provided. Sometimes that means overlooking said physician's pride, ego, or financial incentives.

But moreover, most physicians I know want to do what is best for a patient. Many times that means sending them somewhere else or engaging the help of other doctors.

Divert status is a way of a doctor saying "We are so overwhelmed patients coming to us will not receive the best care. Take them somewhere they could receive better or appropriate level care."

The reasons for this "status" are many. But the bottom line is the patient for whatever reason will not receive the best care they could and in fact are entitled to get at that facility at that time.

If a tornado came down and wiped out most of the hospital, would you still taker patients there? If the tornado hit a hospital in a neighboring area would you take patients from your MCI there?

Of course not, because the hospital cannot provide adequete care right?

When a hospital has no more beds, no more equipment, no more staff, it doesn't matter if the deficit comes from being wiped out by a tornado or from treating too many patients. The resources are simply used. There are no more, and the divert status may allow time to get this "internal" disaster in order.

On a really bad day, any given hospital in the world can be so overwhelmed that it may take days to put itself back in order.

Whether it is a polite request, policy, or order, it is a moot point.

A doctor somewhere, somehow, for some reason has asked you to take patients to better help. As an extension of that physician, you have should make every effort to honor that.

On rare occasion a patient may be so bad, that you absolutely need the doctor's help immediately. That is just a reality of life. But that is the exception, not the rule.

When deciding on those exceptions, Keep in mind the patient may need something the doctor doesn't have. (like an available OR) In those cases, the doctor can do no more than you can. In fact, since he can't drive the patient somewhere else, he can actually do less.

Since there are many barriers to sending a sick patient away from an ED, taking a patient to an overwhelmed ED that cannot help does harm to the patient.

EMS that harms patients is worse than no EMS at all.

Anyone can provide Sh***y care, it does not make a superior provider. It is certainly not something to be proud of.

Providing Sh***y care because of hubris, delusional self importance, self righteousness, or spite is definately not acceptable from any member of the healthcare or public safety community.

I think because of the organizational stressors put on dispatchers they often lose sight of reality. (particularly when response times are concerned.)

It does not good to get sunbstandard help in 8 minutes than needed help in 15.

When there are more people requesting help than resources that can help, while simply dispatching an ambulance removes the blinking light from their screen, it doesn't actually translate to needed help or even help at all. It is at best potentially helpful and at worst the hallucination of help. (perhaps better described as "virtual help", since it exists on computer but not reality)

 

[DrParasite]

So, how many extra DNR forms are you willing to fill out for 15 minute transports when every place else allows for a simple order written in the chart. When EMS requires a special document, maybe EMS is the problem and not everyone else.

as many as are needed.

the hospital needs the order written on the hospital chart, EMS needs it on the EMS form. and I bet the nursing home needs the DNR written on the proper nursing home documentation. It's not about EMS requiring a special document, it's about the healthcare agency doing what is required by it's policies.

if EMS requires a special form (that is standardized statewide), is it that hard for the nurse/hospital rep to fill it out, so the other agency (in this case EMS) can follow their protocols, just as the hospital has to follow theres?

I highly doubt that most hospital administrators care just as your supervisors don't care about divert status.

I guess our administrators just respect us more than your administrators respect you.

Let's stop playing stupid games. Put up your local policy that says that the ambulance crew can decide on their own to ignore divert status.

there is no policy, because there is no need for one. Diverts are a courtesy, not a law.

Now show me where in your protocols you're allowed to make the decision at the ambulance level to dump patients on an ED.

page 1 of the EMT text book: your job is to pick people up and take them to the ED. look it up yoruself

Also, if your call volume is so high, why aren't there more units on the road? Why is the hospital required to bend over backwards because of your service's failure to plan?

I agree with you 100% more. there should be more units on the road, but as you said "...because the [ambulance agencies] hires psychics to determine when exactly their capacities will be overwhelmed." Not only that, but an ambulance not on a run doesn't make money, nor does an ambulance that chronically transports uninsured or underinsured patients. and we all need to make money to pay the bills.

The hospitals I've ever had a regular problem with I can count on one hand. Let me rephrase that, I can think of 1 hospital that had regular issues. So my question is why are you constantly making noise? Furthermore, you are not the hospital's customer in any sense of the term.

your right, I'm not a customer, I'm a fellow healthcare provider, and my agency is a fellow healthcare agency.

Ambulance out in the sticks? What's wrong with a state that can't even get one single office/authority/what-have-you providing umbrella oversight even if there are regions? Why does it not surprise me that a state that can't even require all ambulances to have an EMT on it can't draw up a unified policy regarding diversion?

There is no written policy, because none is needed. we can avoid hospitals on divert, but if the patient requests, the family requests, the patient needs immediate hospital care or any other reason given, the patient can and will be transported to the hospital even if it's on divert. it's a courtesy, not a law. and yes, my state's DOH has a few issues, and the NJFAC is a worthless.... never said i agree with anything they say, and I have openly said I wish they were gone.

Since I've already posted links in this post, it's only a courtesy for states that can't provide reasonable oversight to the EMS system.

nothing to do with reasonable oversight, but I can see discussing this with you is like teaching a pig to sing.

...because the hospital hires psychics to determine when exactly their capacities will be overwhelmed. Additionally, adding more nurses and physicians doesn't expand the number of beds in the ED. Capital investments like expanding a building aren't exactly as simple as hiring an extra nurse.

and yet, you expect ambulance companies to do just that.....

whatever, I'm done trying to teach this pig to sing.

There is a series of problems. I'm not sure how this works out in the US.

(1) Shortage of discharge beds. If there's no long-term care / nursing home / whatever for the ER patient to go to... where do they go.. nowhere. They stay in the ER.

(2) Failure of other hospital services to admit 24 hours. Some of the medical wards just aren't taking new admits at 0300. And, hey, they're busy, and they deserve a quiet night sometimes. But the spill over is, the patient stays in the ER.

So now you have....

(3) Lack of ER resources, due to 30-50% of beds being occupied by "emergency admitted inpatients". These patients are assigned to another service, but occupying a bed in the ER, or a nearby hallway, receiving orders from said services, and generally consuming ER resources doing time-consuming tasks ordered by an MD from another service.

Then you have a problem.

(4) Triage back up. There's 100 people in the waiting room. Some of these people are sick. Some are old people with a convincing story for a possible MI. Some are kids that needing working up. Some have serious pathology. And in comes an ambulance.

(5) Lack of incentive to accept EMS patients. So a bed opens up. And the triage RN has been worrying for the last 2 hours about an 80 year old with indigestion. Maybe they've had time to do a quick 12-lead in a corner somewhere, and seen that there's no STEMI. But they'd love a troponin, and it's been an hour since the last ECG. And EMS has a homeless person, intoxicated, and incontinent of feces.

What choice does the RN make? Well, the patient in the waiting room is probably sicker, so they go in, right. And EMS waits, because the incontinent homeless guy can't sit upright in a chair. And this repeats, all night. Because everyone else is sick. And he's intoxicated and incontinent. And if he was a 30 year old stockbroker, maybe the triage RN might care more. But maybe not.

But let's say he's intoxicated, but ambulatory. He could go to chairs, but then he's going to mouth people off, and cause problems. Sure there's security, but they cause as many problems as they solve. So he stays with EMS, because at least there, someone will correct his behaviour without having five people jump on him.

Or, let's say, the two patients are the same. There's a vague cardiac rule-out patient with EMS, and one of the same acuity waiting in chairs. The RN can free up the ambulance crew, or take the patient in chairs. Which action is most legally defensible? Sure, it looks bad if the ambulance waits an hour or two, gets a positive 12-lead, and the patient subsequently dies. Or enzymes show a NSTEMI a few hours later. But how bad does it look if the person in chair drops after a 4 hour wait? At least the ambulance patient is getting periodic repeat 12-leads, and if they develop anginal symptoms, EMS can do initial treatment.

(6) EMS becomes surge nursing support. The hospital doesn't have enough beds. No one's getting discharged, plenty of people are getting admitted, but none of them are physically moving upstairs. The hospital isn't paying the paramedic's wages, they're not answerable to the city taxpayer. They have no incentive to ensure ambulances are available for local 911 care. That becomes the city's problem. That's who the taxpayer is turning to if there's no one to answer 911. [Even if EMS is part of the healthcare system -- a paramedic is still cheaper than an RN, and how important is the ER in terms of hospital departments? And then how important is EMS? Neither are a priority compared to say the pediatric neuro ICU].

/ end rant.

---------------------

As an aside, in a life past, I have also been the transfer medic. One of two ALS cars on at night for stat transfers / CCT for a million people. Sitting, waiting in the ER, with a pediatric patient with a leg fx, giving periodic pain control, sitting and listening to the triage RN telling the emergency crew that as soon as patient transfer takes their cardiac to the cathlab, they'll be a bed opening up, not realising that the crew that's going to do that job, is waiting to drop off their low acuity patient before anything else can get done.

------------------------

I'm not sure what my original point was, nor am I completely convinced that this is anything more than pointless whining.

As I saw it, at least, the problem was that the entire system was chronically underfunded, and the ER's had nowhere to send their patients, and nowhere to put them. It wasn't that anyone was being lazy. Just that you can't magically make another long-term care bed appear, free up an emergency bed, clear the triage backlog, prioritise EMS, and generally fix things.

everything you just said applies to the US, and is 100% accurate.

It's a hospital flow problem, and not a problem that should be pushed onto EMS providers.

 

[JPINFV]

You say there is no law or policy, yet I just posted three separate links to divert policies. As such, there is nothing else to discuss as you are refusing to recognize anything outside of NJ exists.

 

[DrParasite]

Divert status is a way of a doctor saying "We are so overwhelmed patients coming to us will not receive the best care. Take them somewhere they could receive better or appropriate level care."

yes, and you would be surprised how many times an ER has no beds available but they will refuse to go on divert. The doctors want them to, the nurses want them to, but hospital administration refuse to.

If a tornado came down and wiped out most of the hospital, would you still taker patients there? If the tornado hit a hospital in a neighboring area would you take patients from your MCI there?

internal disasters like a tornado are a little different. or a HazMat spill in the ER. or a power outage hospital wide killing the A/C on a hot summer night. During an internal disaster, a hospital CAN refuse to accept a patient, and the ER can close it's doors.

When a hospital has no more beds, no more equipment, no more staff, it doesn't matter if the deficit comes from being wiped out by a tornado or from treating too many patients. The resources are simply used. There are no more, and the divert status may allow time to get this "internal" disaster in order.

I'm sorry, but not enough resources is not an internal disaster. it's a problem, but not an internal disaster.

A doctor somewhere, somehow, for some reason has asked you to take patients to better help. As an extension of that physician, you have should make every effort to honor that.

On rare occasion a patient may be so bad, that you absolutely need the doctor's help immediately. That is just a reality of life. But that is the exception, not the rule.

When deciding on those exceptions, Keep in mind the patient may need something the doctor doesn't have. (like an available OR) In those cases, the doctor can do no more than you can. In fact, since he can't drive the patient somewhere else, he can actually do less.

Since there are many barriers to sending a sick patient away from an ED, taking a patient to an overwhelmed ED that cannot help does harm to the patient.

I think I might have misspoken, or misunderstood. I am not advocating going to a hospital that is on divert just because you can. They are a courtesy, but the hospital is overwhelmed, it generally won't do anyone any good, and the wait time will be longer.

HOWEVER, we do transport to hospitals on divert all the time, for the following reasons:

-Pt choice
-Trauma
-Cardiac arrest if they arrest en route unless its traumatic in origin.
-Inability to obtain an airway/Airway obstruction.
-Severe shock
-Imminent delivery with abnormal presentation.
-Uncontrolled hemorrhage

by FAR, the most common reason is pt (or family) choice. In fact, that is often asked of the patient before getting a hospital's divert status. That means if hospital A is on divert, but the patient wants to go to hospital A, guess where they are going? Ditto a SNF patient whose charts says take to hospital A. Despite being on divert, that's where they are going.

I think because of the organizational stressors put on dispatchers they often lose sight of reality. (particularly when response times are concerned.)

It does not good to get sunbstandard help in 8 minutes than needed help in 15.

When there are more people requesting help than resources that can help, while simply dispatching an ambulance removes the blinking light from their screen, it doesn't actually translate to needed help or even help at all. It is at best potentially helpful and at worst the hallucination of help. (perhaps better described as "virtual help", since it exists on computer but not reality)

I agree. the politicians put too much emphasis on response times, citizens put too much emphasis on getting an ambulance there quickly (when in most cases, a few extra minutes won't matter), and dispatchers are forced to hurry crews out of the hospital because they have jobs pending.

But until all EMS units end up 100% government funded, and staffed to the level to handle the routine peak call volume 24/7 (like the city FD's are in most urban cities), it won't change.

 

[usalsfyre]

Sticking your fingers in your ears, closing your eyes and screaming "not my problem" at the top of your lungs isn't a good way to garner support to fix things.

If your no different than a patient arriving via the front door (i.e. ignoring divert) than why do you have a specialized entitlement to a bed faster than the patient who walks in the door with a similar complaint? Do you tell you patients not to call to get in quicker?

Your sending mixed messages.

 

[usalsfyre]

But until all EMS units end up 100% government funded, and staffed to the level to handle the routine peak call volume 24/7 (like the city FD's are in most urban cities), it won't change.

What city FDs are you around? I've yet to see a major urban FD that staffed appropriately.

 

[JPINFV]

I think I might have misspoken, or misunderstood. I am not advocating going to a hospital that is on divert just because you can. They are a courtesy, but the hospital is overwhelmed, it generally won't do anyone any good, and the wait time will be longer.

HOWEVER, we do transport to hospitals on divert all the time, for the following reasons:

-Pt choice
-Trauma
-Cardiac arrest if they arrest en route unless its traumatic in origin.
-Inability to obtain an airway/Airway obstruction.
-Severe shock
-Imminent delivery with abnormal presentation.
-Uncontrolled hemorrhage

Courtesy. You keep using that word. I don't think it means what you think it means. It's not a courtesy if there are a limited and set number of reasons why it wouldn't apply. That makes those reasons exemptions, and the presence of exemptions does not automatically make something a courtesy that the provide has the option of simply ignoring.

 

[DrParasite]

If your no different than a patient arriving via the front door (i.e. ignoring divert) than why do you have a specialized entitlement to a bed faster than the patient who walks in the door with a similar complaint? Do you tell you patients not to call to get in quicker?

Your sending mixed messages.

you are right. patients should be seen in the same order of need, whether they come by ambulance or POV. That is how the system is supposed to work.

that means, if you bring in an ambulatory patient, they go to triage and wait in chairs. if you are sick, you get a bed immediately and get a monitor, etc. if you are non-ambulatory, you get a bed and wait to be seen. that's how the system is supposed to be.

But the ambulance should not be tied up. If the patient has to wait due to no staff, so be it, but it is inappropriate to keep the ambulance there and prevent it from responding to other emergencies because the ER lacks staff or is overwhelmed by patients. The ambulance should be available to answer the next call, not holding the wall because of a lack of beds.

or maybe I have just been spoiled by NJ's amazing hospital ERs.

What city FDs are you around? I've yet to see a major urban FD that staffed appropriately.

FDNY, Philly FD, Newark FD, Syracuse FD (back when I was in college), and I could name another dozen or so smaller urban FDs in the NYC metro area. And almost every FD has more units than their city's EMS department, despite EMS answering 4x as many calls.

The way I judge staffing is how often a department needs to call outside mutual aid to assist with routine calls. Not the 3 alarm fires, not the building collapse with people trapped, I am talking about the majority of the calls. Most departments don't call M/A for every call, and handle their own calls in their own jurisdiction with their own departmental resources that are dedicated to accomplishing that job.

Unfortunately, many EMS systems can't say the same.

 

[Handsome Robb]

I know I am probably in the minority, but if i had a DNR, I would want to make it as accurate as possible. that means using the state DNR form, for out-of-hospital if the patient will be transported out of hospital, and if hospital and hospice if appropriate. but thats just me.
probably right, but when I start calling for the hospital administration to come down and explain to my patient why they are waiting, a bed will be found. and while I haven't had to do that, I know of supervisors who have went to the ER and made that request. it's called advocating for your patient.
you can stand by your statement, but your statement is still wrong. maybe an IFT company can get in trouble (since that seems to be where all your experience is), but 911 services don't.

the divert status is a hospital request, it isn't an EMS policy. I could explain it more, but if you don't understand that concept, than it is a moot point.
ahhh, not a team player... yeah, that's me. the guy who wants to get back out there and pick up the next GSW victime, heart attack, or asthma attack, and take them to the hospital, instead of holding a wall for 1-4 hours. yep, not a team player :rofl:
well, when you aren't going to make any noise, they won't care. if you just wait their quietly, hospital supervisors won't care. maybe the hospitals I have dealt with are just more EMS friendly than others, or just practice good customer service whether it be from a patient or a fellow healthcare provider.
ouch, a zinger!!! you know, with a small percentage of FD ambulances or rural ambulances in the sticks do doesn't represent the majority, so your cheap shot doesn't phase me at all,nor does it even apply to me.yes, back this the divert thing. if you can't understand that it's a courtesy, not a requirement, than I won't waste any more time wit you.

My patient is more important because I have done my job, and brought them to the ER. if the staff say put him in triage, he goes into triage. if the staff say put him in a bed, he goes in a bed. either way, my job (what I'm paid to do, and what my boss tells me to do) is to pick up sick people and take them to the hospital. Once they are in the hospital, they are the hospital's problem (and yes, overcrowding sucks, but that's a hospital flow problem, not an EMS problem).
first off, usually those sick patients are focused 100% by a doctor or nurse until they are stabilized. Then they are consistently monitored by a nurse or by a machine (which is monitored by a nurse) for changes, and if there are any life threatening changes the patient again gets 1:1 care.

if a nurse is handling too many sick patients at the time time, than the hospital needs to hire more nurses. I am pretty sure there are nursing standards that say how many patients can be assigned to a nurse. either way, it's a hospital issue, not an EMS one.
absolutely right, in theory anyway. we also play different roles, ambulance people pick up the people and drop them off in the ER, while the ER people deal with the people we drop off. but if the ER is preventing you from leaving the ER, then they are preventing you from providing good patient care to the other people who need your help, which is preventing you from doing your job. so how is delaying access to the EMS system considered god patient care? ditto delaying getting a comfy bed for the patient (ambulance cots as a whole generally suck when compared to a hospital bed). We won't even go into the detrimental effects of having a patient on a backboard for an extended period of time.... So again, if the people on your "team" are preventing you from providing good patient care to others who need your help, and are forcing your patients to remain on a ambulance cot and/or long spine board longer than the need to, are they really striving to provide good patient care? so let me ask you this: if the nurse can do all that work with the patient on your cot, why should he or she work on getting you a bed at all? why not just leave the patient on your cot? the patient gets treated, the hospital gets it's tests done, and it doesn't tie up a hospital bed at all. there is absolutely no reason for the hospital to get you a bed at all.
the patients need to go somewhere, and the system (in its current state) has EMS take them to the ER. You can like it, you can hate it, you can disagree with it, or you can think it can be done better; but regardless of what anyone thinks, that's the systems we have to deal with. Are the ER's overworked with non-emergent patients? absolutely. But they can't turn them away, despite that they would like to. They do make them wait, but they do get seen, and if a critical patient walks in the door, they do get to jump the line and get seen.

Maybe I am looking at the issue wrong. Maybe the issue is in other areas the ER staff just doesn't care. Maybe EMS needs to build better relationships with the ER management so they will care what people think?

I can't speak for anyone else, but I have gone out with nurses in a purely social setting. We have all gone drinking after a long shift, and EMS was invited to their christmas party. We treat them with respect, and they treat us with respect. Maybe it's because of this that despite being overworked and understaffed, we still rarely wait more than 20 minutes for a bed (and usually it's because they are actively trying to find a bed for us). We are friends, we work to help them, and they in turn work to help us. We understand their roles in the healthcare system, and they understand ours. maybe that's why we don't have hour+ long waits to turn over a patient.

One last example: I had a run in with an L&D nurse a few years ago. She completely ignored me, ignored everything I had to say, and then sent me down to the ER with my patient (which didn't bother me all that much except that I didn't know the way through the hospital). Anyways, I made it to the ER, and the nurse (who only knew me professionally, I doubt she even remembered my name) saw I was visibly frustrated. After we transferred the patient to a bed, she asked what was bothering me and I told her. She then brought me to the nursing director of the ER, who asked what was wrong, and I told her. She then picked up her cell phone, dialed a number, and told me to repeat what I told her. So I did. I later learned that the person she called was the director of the L&D department who wasn't happy to hear what I had to say. The original nurse was reeducated on interacting with other healthcare providers (she didn't think she did anything wrong), which I didn't care about, but the department policies were changed to be more EMS friendly (and more patient friendly, which me very happy).

and the only reason anything was done was because I said something about it, and the ER staff respected EMS (as a general whole, not an individual provider) to listen to a complaint to make the system better for all involved.

You are a bigger idiot than I originally thought.

"once they are in the hospital they are the hospital's problem"? What the hell happened to patient advocacy? While your statement is technically true it shows how :censored::censored::censored::censored:ty your attitude and compassion for your patients truly is. I hope that myself, my family members or my friends have the misfortune of landing themselves in the back of your ambulance.

You're constantly saying "my, me, I". It's not all about you, it's about the patient.

 

[technocardy]

The longest I've ever waited with a patient has been maybe 15 minutes. Typically when we walk into the ER we stop at the triage nurses station on the EMS side and give our verbal assessment. Once that is done, we are assigned to a part of the ER (A-E). We get into the respected area we've been assigned with our bed (oh yeah, dispatch will make sure they have a bed ready for us if we don't personally patch through to the hospital). We transfer the pt to the bed then walk over to that ER area nurses station, give another more in-depth report of the pt, give them our paper work and head out. We've never had to sit and wait past the first nurse’s station. If the pt is critical (CTAS 1, or majority of CTAS 2) then they're put right into a trauma/resus room and the second report is given to the team. (That's at the hospital I typically run too). If it's to the trauma centre then it's almost the same deal, however it's a quick stop at the nurses’ station, then roll into the trauma bay where the who fam damily is waiting.

We use too have a thing called "paramedic hallway" which was a special team of paramedics who would hang out in the EMS hallway with a backlog of pts, so if the ER was full, or they weren't serious enough too been seen right away then 2 things could happen.

1. The medics who brought the pt in can get right back out onto the streets and
2. The pt would continue to get focused assessments and treatments until a bed was available

There are 2 sides to every situation. Obviously it can get frustrating to sit in an ER with your colleagues coming and going, bring in and dropping off pts, etc etc. However if a pt is brought in via personal ride, 911, or IFT and they are to be seen quicker than you, then that's the way it is. It sucks, and I'm not saying OP is whining or anything but that is the way it is. Yes the argument exists that for every minute you sit in the ER with a pt, that’s another minute your service and coverage area is a unit short. Can the service bring over an IFT unit that's just sitting in some hall? Cross coverage? I know they're not all ideal solutions to the problem but they are temporary solutions that can provide a band aid fix until you return to the streets.

There is only so much we can do, the ER staff can do, and our services can do. Let’s face it, the population is getting older and sicker and we just cannot keep up with the demand so problems will exists.

Possible solutions? Well if things aren't running smoothly between EMS and ER staff that might be a good place to start. Sit down with supervisors, ER dept. staff, the doc that signs your protocols and help to make things more streamlined than they currently are. If you see something that's broken or not running at 100% efficiency then heck, let’s do everything we can to get it there. For you, the ER staff, but more importantly the patients.

/soapbox

 

[the_negro_puppy]

When hospitals are on divert we are not allowed to go there unless we have a category 1 pateint (cardiac arrest, STEMI, serious trauma, head injury). They will not let us in the door. Sometimes due to miscommunication we go to hospitals on divert, and the patients refuse to be driven elsewhere, get off our stretcher and walk into the waiting room with chest pain and are seen straight away :wacko:h34r:

 

[SkaMedic]

While there is no mandated diversion except in the case of an internal disaster, hospitals that request diversion usually do so for good reason. If we are all on the same team, we should act responsibly and professionally doing our best to honor this request. In California, hospitals cannot go on diversion for BLS patient; they must accept all BLS patients. If I am transporting a BLS patient, I try not to a hospital on diversion because I know I'm going to hold up a wall or my patient is just going to sit in the waiting room (I will tell my patient this and usually agree to go to a different hospital). Additionally, I am just adding to the saturation of the ED on diversion. There is, however, absolute diversion of ALS patients here. If a hospital is on diversion, you CANNOT bring an ALS patient. If you were to disregard the diversion I guarantee your "self worth" would be the last thing you would have to worry about.

Dr. Parasite: it seems that in New Jersey if a hospital is on diversion it is true that you can still bring those patients who request to go to an ED that is on diversion but you must inform the patient of the hospital's diversion status and advise them that there will be an extended wait time. If the patient still wants to go to that hospital, you should advise the ER.

Here is a link to the diversion guidelines (true, they are not policies) for New Jersey by New Jersey's hospital association

njha.com/Publications/Pdf/DivertGuidelines2009.pdf

 

[Amberlamps916]

4 hours at Intercommunity-Citrus Valley hospital in Covina........