Ongoing Hospital(s) Discussion

[wolfwyndd]

If the pt does not have a choice or can not decide, then offer closest ED.

It is bad practice to refer one ED over another. If a pt asks your opinion, just explain that you can not offer it. Give them the options and let them choose!

That might be great advice for the area where you are, but around here, our hospitals run the gambit from 1st class to . . . . . . . I wouldn't take my DOG there.

You are right about protocols in some respect. Serious trauma's get taken the the trauma center. Beyond that, it's open to patient choice. So what happens when someone just 'driving through' has a medical emergency? They aren't going to be able to know what hospitals are around. If someone asks us what hospital WE RECOMMEND, we'll tell them what we think based on their chief complaint, signs and symptoms. NOT based on what kind of EMS room the hospital has. IMO some of our northern area hospitals would be able to take care of a sprained ankle, but I certainly wouldn't take someone having a suspected MI to them.

 

[reaper]

That might be great advice for the area where you are, but around here, our hospitals run the gambit from 1st class to . . . . . . . I wouldn't take my DOG there.

You are right about protocols in some respect. Serious trauma's get taken the the trauma center. Beyond that, it's open to patient choice. So what happens when someone just 'driving through' has a medical emergency? They aren't going to be able to know what hospitals are around. If someone asks us what hospital WE RECOMMEND, we'll tell them what we think based on their chief complaint, signs and symptoms. NOT based on what kind of EMS room the hospital has. IMO some of our northern area hospitals would be able to take care of a sprained ankle, but I certainly wouldn't take someone having a suspected MI to them.

That is where you should have policies in place. You would take MI's or STEMI's to the hospitals that are setup to handle them.(ie: Cath Lab)

We have two hospitals that deal with Chestpain. The rest are smaller ED's and are not equipped to handle them. The Pt's are told that they have a choice between the two that do take them.

 

[EMSLaw]

You take the patient to the closest appropriate facility, if the patient isn't capable of making the choice themselves. I wasn't advocating anything else, just making an observation. And I have had patients ask which hospital to go to - I generally tell them which two are closest, unless they need a trauma, stroke, or other specialized hospital.

Here's an interesting scenario that I had that lead to a lot of debate among my squad - your patient on a 911 call, who is apparently stable, asks to go to a hospital where his doctor is. It's in another part of the state, 1.5 hours one-way. You only have two rigs on, and this will obviously take one out of service for the rest of the night. Do you take him, bypassing, by a conservative estimate, 15 closer hospitals?

 

[wolfwyndd]

So the question is what have hospitals done for you as an EMS provider that you especially appreciated?

We actually have TWO hospitals in the area that offer boatloads of continuing education classes for either free, or really, really, really cheap. I took an 8 hour continuing education class last summer for 10.00. THAT is what I am most appreciative of.

Beyond that I really appreciate the EMS break rooms at some of the hospitals. Some are really awesome, some are. . . . . . well, I can have a free soda.

As for being appreciative of the nurses. Eeeehh. Isn't it part of their job to take over patient care when we show up with a patient? It depends on what hospital I take my patient too. Some of them would rather we not ever set foot in THEIR hospital. I actually once had a nurse close the door in my face after I helping move the patient over into the bed before I could give them my report. Then again I've also had nurses meet me at the door with help that was needed, but unasked for. It varies from hospital to hospital AND from shift to shift.

 

[VentMedic]

I never take anything for granted.

Our Hospitals are actually growing. They are building on and hiring. A lot of that comes from the management of them!

Who owns these hospitals?

Sutter, Tenet, CHW, HCA, Baptist Heathcare, JMH, Lee County, NHS, Cleveland Clinic and Mayo are all cutting back. The only large corporate hospital system that is doing reasonably well is the SDA but they have also done some cutting. Kaiser is doing decent but they are streamlined to the bare bone as it is. Even with Sutter (CA) showing a profit, it has a couple of hospitals that should be taken out of service and others that will be if they are not retrofitted. It doesn't help matters that some union is always striking either although the past 6 months have shown less of that. The smaller hospitals that are independent and functioning as a district based off taxes from their residents have really offered up some horror stories for cutbacks. The California hospitals are struggling because their state is broke. Florida also isn't far behind in that problem.

Also, let's not forget that many FDs and ambulance stations are equiped better than most homes with elaborate kitchens, outdoor grills, TVs and computers. They may also enjoy having only one or two calls per 24 hours where as the hospital staff might be lucky to get their 15 minute break in 12 hours.

As for being appreciative of the nurses. Eeeehh. Isn't it part of their job to take over patient care when we show up with a patient? It depends on what hospital I take my patient too. Some of them would rather we not ever set foot in THEIR hospital. I actually once had a nurse close the door in my face after I helping move the patient over into the bed before I could give them my report. Then again I've also had nurses meet me at the door with help that was needed, but unasked for. It varies from hospital to hospital AND from shift to shift.

That is also going to vary with what type of ambulance crew you are following. If they were jerks and just slammed narcan as they were entering the ED for a laugh, don't expect a warm loving reception.

 

[reaper]

You take the patient to the closest appropriate facility, if the patient isn't capable of making the choice themselves. I wasn't advocating anything else, just making an observation. And I have had patients ask which hospital to go to - I generally tell them which two are closest, unless they need a trauma, stroke, or other specialized hospital.

Here's an interesting scenario that I had that lead to a lot of debate among my squad - your patient on a 911 call, who is apparently stable, asks to go to a hospital where his doctor is. It's in another part of the state, 1.5 hours one-way. You only have two rigs on, and this will obviously take one out of service for the rest of the night. Do you take him, bypassing, by a conservative estimate, 15 closer hospitals?

That is dependant on your agencies policies. We do not transport outside the county, unless to a burn center. Now, we may transport a Trauma to the level 1 center in the next county, if it is closer to where we are.

 

[EMSLaw]

That is dependant on your agencies policies. We do not transport outside the county, unless to a burn center. Now, we may transport a Trauma to the level 1 center in the next county, if it is closer to where we are.

Policies are all well and good, but we can all agree that you don't treat a patient without his or her consent, yes?

Well, if your patient does not consent to go to hospital X, and instead wants to go to more distant hospital Y, what are your options? You could transport your patient against their will to hospital X, or not transport at all, which is arguably abandoning the patient.

Our SOPs are similar, by the way. Since we are on a county border, though, we generally will transport to one of two reasonably nearby EDs (approximately 20-25 minutes) or to a Trauma Center (25-30 minutes). At the discretion of the crew chief, we will sometimes transport to a large hospital that is slightly further away (35 minutes) if the patient requests it.

 

[reaper]

Who owns these hospitals?

Sutter, Tenet, CHW, HCA, Baptist Heathcare, JMH, Lee County, NHS, Cleveland Clinic and Mayo are all cutting back. The only large corporate hospital system that is doing reasonably well is the SDA but they have also done some cutting. Kaiser is doing decent but they are streamlined to the bare bone as it is. Even with Sutter (CA) showing a profit, it has a couple of hospitals that should be taken out of service and others that will be if they are not retrofitted. It doesn't help matters that some union is always striking either although the past 6 months have shown less of that. The smaller hospitals that are independent and functioning as a district based off taxes from their residents have really offered up some horror stories for cutbacks. The California hospitals are struggling because their state is broke. Florida also isn't far behind in that problem.

Also, let's not forget that many FDs and ambulance stations are equiped better than most homes with elaborate kitchens, outdoor grills, TVs and computers. They may also enjoy having only one or two calls per 24 hours where as the hospital staff might be lucky to get their 15 minute break in 12 hours.



That is also going to vary with what type of ambulance crew you are following. If they were jerks and just slammed narcan as they were entering the ED for a laugh, don't expect a warm loving reception.

These are owned by Cooperations. One corp owns two of the hospitals in the county and the other one owns 6 of them. They have a very good management systems over their hospitals and they are always growing. They both have brand new hospitals that were built within the last year. There is no cuts going on here.

Far as the station issues. Some of the FD's stations are nice, that we station at. But our EMS only stations are bare bones with normal stuff. Bedrooms, Kitchen, bathroom and living room. No luxury items. Most of the TV's or kitchen equipment is provided by the employees. The county provides them, but we may bring our own, to have something better. I do not expect the county to provide these things on tax payers dime!

 

[reaper]

Policies are all well and good, but we can all agree that you don't treat a patient without his or her consent, yes?

Well, if your patient does not consent to go to hospital X, and instead wants to go to more distant hospital Y, what are your options? You could transport your patient against their will to hospital X, or not transport at all, which is arguably abandoning the patient.

Our SOPs are similar, by the way. Since we are on a county border, though, we generally will transport to one of two reasonably nearby EDs (approximately 20-25 minutes) or to a Trauma Center (25-30 minutes). At the discretion of the crew chief, we will sometimes transport to a large hospital that is slightly further away (35 minutes) if the patient requests it.

It is explained to the pt that we do not transport outside of the county. They have a choice of multiple hospitals inside the county borders. If they insist on going to the other hospital, then they can sign a refusal and drive themselves. It is not pt abandonment.

Do not know how your service runs. We are not a taxi service for them. If they need to be treated, then they have the option to go to an ED in the county.

 

[EMSLaw]

It is explained to the pt that we do not transport outside of the county. They have a choice of multiple hospitals inside the county borders. If they insist on going to the other hospital, then they can sign a refusal and drive themselves. It is not pt abandonment.

Do not know how your service runs. We are not a taxi service for them. If they need to be treated, then they have the option to go to an ED in the county.

I didn't reveal all the details, either. The patient was two-weeks postop from a heart transplant. He was having s/o/b and wanted to be transported to the transplant center because of possible rejection issues.

With regards to refusing to transport and instead getting an RMA - If you browbeat the patient into signing the RMA because you won't transport them, then that hardly qualifies as an informed waiver of their rights.

 

[reaper]

I didn't reveal all the details, either. The patient was two-weeks postop from a heart transplant. He was having s/o/b and wanted to be transported to the transplant center because of possible rejection issues.
So now we allow the Pt's to dictate treatment plans? How do you know that this was a rejection issues and not something else? Why not transport to the closer appropriate facility and allow them to determine what is wrong with the pt?
With regards to refusing to transport and instead getting an RMA - If you browbeat the patient into signing the RMA because you won't transport them, then that hardly qualifies as an informed waiver of their rights.

How is it not an informed waiver of their rights? They have the right to be transported to an appropriate facility for treatment. If they choose not to be transported, then they have that right and are made aware of the complications that may arise from said decision.

 

[VentMedic]

So now we allow the Pt's to dictate treatment plans? How do you know that this was a rejection issues and not something else? Why not transport to the closer appropriate facility and allow them to determine what is wrong with the pt?

Would you also not transport a STEMI a few more minutes to a hospital that is a cardiac center? Heart muscle is heart muscle regardless of the reason they are losing it.

Time is of importance with these patients. Our transplant physicians get extremely disgusted when one their heart or lung transplant patients sits in a little general ED getting numerous tests and still the appropriate tests are not done either because of lack of knowledge of the ED physician or because their lab does not have the capability. It may also take up to 12 hours to get that patient transferred due to all the arrangements that must be made with the ambulances and finding the right crew. You might as well just shoot the patient and kill them quicker. What a waste for a patient to go through the transplant process and then have an EMT determine if he lives or dies because they don't want to drive a few minutes to the more appropriate facility. Of course, the other thing worst would be getting stuck in a truck with a disgruntled EMT(P) who must do the transport.

 

[EMSLaw]

It was a difficult situation. The question was whether he needed stabilization at a closer ED, or whether he could be transported. And, also, whether we would be permitted to take him that far.

We were called back to the residence about two weeks later (for a different patient), and he had been transported up to the transplant center and seemed to be doing much better.

 

[reaper]

Would you also not transport a STEMI a few more minutes to a hospital that is a cardiac center? Heart muscle is heart muscle regardless of the reason they are losing it.

Time is of importance with these patients. Our transplant physicians get extremely disgusted when one their heart or lung transplant patients sits in a little general ED getting numerous tests and still the appropriate tests are not done either because of lack of knowledge of the ED physician or because their lab does not have the capability. It may also take up to 12 hours to get that patient transferred due to all the arrangements that must be made with the ambulances and finding the right crew. You might as well just shoot the patient and kill them quicker. What a waste for a patient to go through the transplant process and then have an EMT determine if he lives or dies because they don't want to drive a few minutes to the more appropriate facility. Of course, the other thing worst would be getting stuck in a truck with a disgruntled EMT(P) who must do the transport.

Yep, just jump on the "disgruntled medic" route! Never once said that the transport would not be done for "not wanting to do it".

The scenario described taking a pt 1.5 hours out of county, with only two units in entire county. Your job is to make a decision for the best of all, not just one. That is why policies are written for this reason.

If there is an appropriate facility in the area, that can treat this pt or transfer them out. then that is the choice that is made. It is not our problem if the ED Dr cannot consult and make appropriate decisions.

If they work for a private service that can provide a unit to to do transport then that is fine.

These are decisions that must be made and cannot be fathomed,if you have never worked for rural services that have these restraints.

 

[VentMedic]

It is really difficult to watch a transplant patient whom you may have seen at various stages of their initial, pre, during and post op phase die because they got stuck in some hospital and where the transport capabilities of EMS is inadequate. We've seen hearts so badly damaged needlessly because of lengthy stays in another ED. We've seen transplanted lungs totally trashed because some facility did not have the right equipment to intubate and ventilate. It is not a perfect world and recipients do know the risks but many of these patients are stuck in a hospital that is practically at the back door of the appropriate hospital but just had the misfortune of getting a Paramedic who had an attitude problem and wanted to show the patient they weren't about to tell them anything about what is the appropriate treatment for them.

These are decisions that must be made and cannot be fathomed,if you have never worked for rural services that have these restraints.

I have worked both in the hospital and prehospital as well as flight. That is why I know it is so important to get the patient to the appropriate facility if at all possible. We have one area where it is 50 miles either way to a hospital. If the patient decides to have a baby has 49.9 miles on the side where there is no L&D, they get taken to that facility because it is the closest by 1/10th of a mile. Then, a team from the other facility or one from Miami or Orlando must travel 2x the distance to pick up the mother and maybe the baby.

 

[reaper]

Always the medic with an attitude problem!

That pt had the choice to move closer to a transplant facility. When you choose to live in a rural area, then you take those chances, that the EMS system is not setup as big as a city's would be.

Not everyone works in a big city and has the resources to do what may be best for that pt. They must do what is appropriate and hope for the best.

These are decisions that must be made and are tough calls to make. Not just done because of Lazy,Disgruntled medics with attitude problems did not want to be burdened with a transport.

 

[Medic744]

We take the pt to the nearest appropriate facility no matter what but some do have better perks than others. If I wasnt lactose intolerant I would be really upset that we dont transport to the hospital with the ice cream bin (like the one you see at convience stores) filled with every kind of goodie that the Nestle company makes. I just get excited when HFD has made a fresh pot of coffee.

 

[VentMedic]

Always the medic with an attitude problem!

That pt had the choice to move closer to a transplant facility. When you choose to live in a rural area, then you take those chances, that the EMS system is not setup as big as a city's would be.

Not everyone works in a big city and has the resources to do what may be best for that pt. They must do what is appropriate and hope for the best.

These are decisions that must be made and are tough calls to make. Not just done because of Lazy,Disgruntled medics with attitude problems did not want to be burdened with a transport.

Have you read some of the threads lately or attended any of the major conferences to listen to some of the bi...ing that goes on in this profession?

Did you even bother to read my previous post about how some of the decision making to transport to one facility vs another can come down to a few feet on the wrong side of the line?

There are also areas where protocols are inadequate as well as the education and training. Look at the thread we just had about medical needs children. No the parents can't ride. No the child can't take their vent. No the child can not have a vascular access device. And no we are definitely not taking your kid to the children's hospital that is a mile away.

Maybe you should look at some of the things you do from a patient's point of view. Yes, most transplant candidates do try to relocate close to a city where their primary doctors will be. However, not everyone plans on having a catastrophic illness in a place that works with the plans of the EMS providers. Personally I think the patients should be given a list of areas that has EMS providers who are more qualified and dedicated to patient care than others. Learning the difference between an EMT-B and P should be essential. They should also be aware if the ambulance company or FD runs a medic mill just to have warm bodies fill positions.

We do provide serious training to most of our patients and their families from neo, pedi, transplant recipients and those with devices like LVADs to not rely on EMS if at all possible and make arrangements as early as possible or have their case manager arrange for a specialty team transport.

 

[EMSLaw]

The scenario described taking a pt 1.5 hours out of county, with only two units in entire county. Your job is to make a decision for the best of all, not just one. That is why policies are written for this reason.

Only two ambulances in town, at least, but our township is over 100 square miles.

One thing we did consider later was calling for a private ambulance to meet us and take him to where he wanted to go.

 

[VentMedic]

Originally Posted by reaper
The scenario described taking a pt 1.5 hours out of county, with only two units in entire county. Your job is to make a decision for the best of all, not just one. That is why policies are written for this reason.

Only two ambulances in town, at least, but our township is over 100 square miles.

One thing we did consider later was calling for a private ambulance to meet us and take him to where he wanted to go.

These areas might need a contract made between other services to cover while their truck is on a transport. FDs do this. Even SFFD (San Francisco) will use AMR as a backup when their trucks are busy.

Your responsibility is to one patient and if you do not know what is best, that is what your medical control is there for to advise you.

It would also be a waste to watch a patient die waiting 12 - 24 hours for an IFT to be arranged while you were watching TV at the station and that one patient was your only call for the 24 hours. Yeah the "what if" factor of getting a real cool trauma and heaven forbid we have to do an IFT with some "medical" patient is always an issue and is often used as an excuse. You have decided that the patient in front of you is not worth saving because the "what if" call that might happen.

Rural areas must have plans A and B in place even if it is stopping by the rural hospital to pick up one of their staff members to accompany them to the next hospital. There are times when a helicopter can not fly due to weather. Rural areas again should have other options to get the patient to the more appropriate facility. Yes, that may mean taking one of your ALS trucks with a hospital staff member who can at least access the vascular access device or establish an airway that you are not allowed to.
The more progressive rural systems do have their acts together and do work with the hospitals and external resources to do what is best for their patients. Some may even have early activation of a trauma system or an agreement with the ED to get a helicopter in the air.