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Medical Forum / General / General / May 2005Stroke Victims Are Often Taken To Wrong Hospital
A 2000 survey showed that 66% of hospitals in North Carolina lacked any protocol for treating stroke. 82% couldn't identify patients with acute stroke. May 9, 2005 Stroke Victims Are Often Taken To Wrong Hospital Outdated Ambulance Rules, Inadequate ERs Make Dangerous Ailment Worse Lessons From Trauma Centers By THOMAS M. BURTON Staff Reporter of THE WALL STREET JOURNAL Christina Mei suffered a stroke just before noon on Sept. 2, 2001. Within eight minutes, an ambulance arrived. Her medical fate may have been sealed by where the ambulance took her. Ms. Mei's stroke, caused by a clot blocking blood flow to her brain, occurred while she was driving with her family south of San Francisco. Her car swerved, but she was able to pull over before slumping at the wheel. Paramedics saw the classic signs of a stroke: The 45-year-old driver couldn't speak or move the right side of her body. Had Ms. Mei's stroke occurred a few miles to the south, she probably would have been taken to Stanford University Medical Center, one of the world's top stroke hospitals. There, a neurologist almost certainly would have seen her quickly and administered an intravenous drug to dissolve the clot. Stanford was 17 miles away, across a county line. But paramedics, following county ambulance rules that stress proximity, took her 13 miles north, to Kaiser Permanente's South San Francisco Medical Center. There, despite her sudden inability to talk or walk and her facial droop, an emergency-room doctor concluded she was suffering from depression and stress. It was six hours before a neurologist saw her, and she never got the intravenous clot-dissolving drug. In a legal action brought against Kaiser on Ms. Mei's behalf, an arbitrator found that her care had been negligent, and in some aspects "incomprehensible." Today, Ms. Mei can't dress herself and walks unsteadily, says her lawyer, Richard C. Bennett. The fingers on her right hand are curled closed, and she has had to give up her main avocations: calligraphy, ceramics and other types of art. Kaiser declined to comment beyond saying that it settled the case under confidential terms "based on some concerns raised in the litigation." Stroke is the nation's No. 1 cause of disability and No. 3 cause of death, killing 164,000 people a year. But far too many stroke victims, like Ms. Mei, get inadequate care thanks to deficient medical training and outdated ambulance rules that don't send patients to the best stroke hospitals. Over the past decade, American medicine has learned how to save stroke patients' lives and keep them out of nursing homes. New techniques offer a better chance of complete recovery by dissolving blood clots and treating even more lethal strokes caused by burst blood vessels in the brain. But few patients receive this kind of treatment because most hospitals lack specialized staff and knowledge, stroke experts say. State and county rules generally require paramedics to take stroke patients to the nearest emergency room, regardless of that hospital's level of expertise with stroke. Stroke care is positioned roughly where trauma care was a quarter-century ago. By 1975, surgeons expert at treating victims of car crashes and other major accidents realized that taking severely injured patients to the nearest emergency room could mean death. So the surgeons led a push to make selected regional hospitals into specialized trauma centers and to overhaul ambulance protocols so that paramedics would speed the most severely injured to those centers. Now, in many areas of the U.S., accident victims go quickly to a trauma center, and trauma specialists say this change has saved lives and lessened disability. Eighty percent or more of the 700,000 strokes that Americans suffer annually are "ischemic," meaning they are caused by blockage of an artery feeding the brain, usually a blood clot. Most of the rest are "hemorrhagic" strokes, resulting from burst blood vessels in or near the brain. Although they have different causes, both result in brain tissue dying by the minute. Several factors have combined to prevent improvement in stroke care. In some areas, hospitals have resisted movement toward a system of specialized stroke centers because nondesignated institutions could lose business, according to neurologists who favor the changes. In addition, stroke treatment has lacked an organized lobby to galvanize popular and political interest in the ailment. Doctor Ignorance A big reason for the backwardness of much stroke treatment is that many doctors know little about it. Even emergency physicians and internists likely to see stroke victims tend to receive scant neurology training in their internships and residencies, according to stroke specialists. "Surprisingly, you could go through your entire internal-medicine rotation without training in neurology, and in emergency medicine it hasn't been emphasized," says James C. Grotta, director of the stroke program at the University of Texas Health Science Center at Houston. Many hospitals don't have a neurologist ready to deal with emergencies. As a result, strokes aren't treated urgently there, even though short delays increase chances of severe disability or death. Even if doctors do react quickly, recent research has shown that many aren't sure what treatment to provide. For example, a survey published in 2000 in the journal Stroke showed that 66% of hospitals in North Carolina lacked any protocol for treating stroke. About 82% couldn't rapidly identify patients with acute stroke. As with other life-threatening conditions, stroke patients are better off going where doctors have had a lot of practice addressing their ailment. A seven-year analysis of surgery in New York state in the 1990s showed that patients with ruptured blood vessels in the brain were more than twice as likely to die -- 16% versus 7% -- in hospitals doing few such operations, compared with those doing them regularly. A national study published last year in the Journal of Neurosurgery showed a similar disparity. Another major shortcoming of most stroke treatment, according to many neurologists, is the failure to use the genetically engineered clot-dissolving drug known as tPA. Short for tissue plasminogen activator, tPA, which is made by Genentech Inc., has been shown to be a powerful treatment that can lessen disability for many patients. A study published in 2004 in The Lancet, a prominent medical journal, showed that the chances of returning to normal are about three times greater among patients getting tPA in the first 90 minutes after suffering a stroke, even after accounting for tPA's potential side effect of cerebral bleeding that can cause death. But several recent medical-journal articles have found that nationally, only 2% to 3% of strokes caused by clots are treated with tPA, which has no competitor on the market. Some authors of studies supporting the use of tPA have had consultant or other financial relationships with Genentech. Skeptics of the drug point to these ties and stress tPA's side-effect danger. But among stroke neurologists, there is a strong consensus that the drug is effective. One reason why many patients don't receive tPA is that they arrive at the hospital more than three hours after a stroke, the time period during which intravenous tPA should be given. But many hospitals and doctors don't use tPA at all, even though it has been available in the U.S. since 1996. The dissolving agent's relatively high cost -- $2,000 or more per patient -- is a barrier. Medicare pays hospitals a flat reimbursement of about $5,700 for stroke treatment, regardless of whether tPA is used. Airport Emergency Glender Shelton of Houston had an ischemic stroke caused by a clot at Los Angeles International Airport on Dec. 30, 2003. In full view of other holiday travelers, Ms. Shelton, then 66, slumped over, and an ambulance was called. It was 4:45 p.m. By 5:55 p.m., she arrived at what now is called Centinela Freeman Regional Medical Center, four miles away in Marina del Rey. Hospital records show that doctors thought Ms. Shelton had suffered an "acute stroke." But she didn't get a CT scan, a recommended initial step, until 9 p.m. By then, she was already outside the three-hour window for safely administering intravenous tPA. Records also say she didn't receive the drug "due to unavailability of a neurologist until after the patient had been outside the three-hour time window." Ms. Shelton's daughter, Sandi Shaw, was until recently nurse-manager of the prestigious stroke unit at the University of Texas Health Science Center at Houston. Ms. Shaw says that at her unit, her mother would have had a CT scan within five minutes of arriving, and tPA probably would have been administered 30 or 35 minutes after that. Today, according to her daughter. Ms. Shelton often can't come up with words or relatives' names, can't take care of her finances, and can't follow certain basic commands in neurological tests. Kent Shoji, an emergency-room doctor at Centinela Freeman who handled Ms. Shelton's case, says, "She was a possible candidate for tPA," but a CT scan was required first. "The order was put in for a CT scan," Dr. Shoji says. "I can't answer why it took so long." A Centinela Freeman spokeswoman says, "We did not have 24/7 coverage with our CT scan, and we had to call a technician to come in. That's pretty common with a community hospital." The hospital has since been acquired by a larger health system and now does have 24-hour CT capability. 'Parochial Interests' A hospital-accrediting group has begun designating hospitals as stroke centers, but that is only part of what is needed, stroke experts assert. They say hospitals typically have to come together to create local political momentum to change state or county rules so that ambulances actually take stroke patients to stroke centers, not the nearest ER. New York, Maryland and Massachusetts are moving toward creating stroke-care systems, and Florida recently passed a law creating stroke centers. But in many places, short-term economic interests impede change, some doctors say. "There are still very parochial interests by hospitals and physicians to keep patients locally even if they're not equipped to handle them," says neurosurgeon Robert A. Solomon of New York-Presbyterian Hospital/Columbia. "Hospitals don't want to give up patients." The University of California at San Diego runs one of the leading stroke hospitals in the country. It and others in the area that are well prepared to treat stroke patients have sought for a decade to set up a regional system, but there has been little progress, says Patrick D. Lyden, UCSD's chief of neurology. "Some hospitals are resisting losing stroke business," he says. "We have the same political crap as in most communities. Paramedics still take people to the local ER." Among the opponents of the stroke-center concept during the 1990s was Richard Stennes, then ER director at Paradise Valley Hospital south of San Diego. In various public debates, Dr. Stennes recalls, he argued that many apparent stroke patients would be siphoned away from community hospitals even if they didn't turn out to have strokes. Also, he argued that tPA might cause more injury than it prevents. And then there was the economic issue: "Those hospitals without all the equipment and stroke experts," he says, "would be concerned about all the patients going to a stroke center and taking the patients away from us." Dr. Stennes has since retired. "All hospitals and clinicians try to deliver the right care to patients, especially those with urgent medical needs," says Nancy E. Foster, vice president for quality of the American Hospital Association, which represents both large and small hospitals. "Community hospitals may be equally good at delivering stroke care, and it would be important for patients to know how well prepared their local hospital is." Stroke experts aren't proposing that every hospital needs to specialize in stroke care but instead that in every population center there should be at least one that does. In Atlanta, Emory University's neuro-intensive care unit illustrates the special skills that make for top care. Owen B. Samuels, director of the unit, estimates that 20% to 30% of patients it treats received poor initial medical care before arriving at Emory, jeopardizing their futures or even lives. Brain hemorrhages, for example, are commonly misdiagnosed, even in patients who repeatedly showed up at emergency rooms with unusually severe headaches, Dr. Samuels says. The Emory unit has 30 staff members, including two neuro-critical care doctors and five nurse practitioners. A team is on duty 24 hours a day. The unit handles about two dozen patients most days, keeping the staff busy. On the ward, nearly all patients are unconscious or sedated, so it's eerily silent. Patients generally need to rest their brains as they recover from stroke or surgery. After a hemorrhagic stroke, blood pressure in the cranium builds as blood continues to seep out of the ruptured vessel. Pressure can be deadly, cutting off oxygen to the brain. Or escaped blood can cause a "vasospasm," days after the original stroke, in which the brain reacts violently to seeped-out blood. In the worst case, the brain herniates, or squeezes out the base of the skull, causing death. To avoid this, nurses at Emory constantly monitor brain pressure and temperatures. They put in drain lines. They infuse medicines to dehydrate, depressurize and stop bleeding. Since Emory launched the neuro-intensive unit seven years ago, 42% of patients with hemorrhagic strokes have become well enough to go home, compared with 27% before. Fewer need rehabilitation -- 31% versus 40% -- and the death rate is down. Damica Townsend-Head, 33, gave the Emory team a scare. After surgery last fall for a hemorrhagic stroke, her brain swelling was "really out of control," Dr. Samuels says, raising questions about whether she would survive. The staff put a "cooling catheter" into a blood vessel, which allowed the circulation of ice water to bring down the temperature in her blood and brain. They intentionally dehydrated her brain to lower pressure. A month later, she woke up and recovered with minimal disability. She still walks with a cane and tires easily, but her speech is normal and she hopes to return soon to work. "I consider her what we're in business for," Dr. Samuels says. Public Awareness The public's low awareness of stroke symptoms -- and the need to respond immediately -- can also hinder proper care. Ischemic strokes, those caused by clots or other artery blockage, cause symptoms such as muscle weakness or paralysis on one side, slurred speech, facial droop, severe dizziness, unstable gait and vision loss. People with this kind of stroke are sometimes mistaken for being drunk. In addition to intense head pain, a hemorrhagic stroke often leads to nausea, vomiting or loss of balance or consciousness. Still, many people with some of these symptoms merely go to bed in hopes of improving overnight, doctors say. Instead, they should go immediately to a hospital and demand a CT scan as a first diagnostic step. The well-funded American Heart Association, established in 1924, has made many people aware of heart attack symptoms and thereby saved many lives. In contrast, the American Stroke Association was started only in 1998 as a subsidiary of the heart association. The stroke association spent $162 million last year out of the heart association's $561 million overall budget. Justin Zivin, another University of California at San Diego stroke expert, says the stroke association "is a terribly ineffective bunch. When it comes to actual public education, I haven't seen anything." The stroke association counters that it is buying television and radio ads promoting awareness, similar to ones produced in 2003 and 2004. The group also sponsors research and education, including an annual international stroke-medicine conference. It's not just the general public that fails to recognize stroke symptoms. Often, emergency-room doctors and nurses don't, either. Gretchen Thiele of suburban Detroit began having horrible headaches last May, for the first time in her life. "She wasn't one to complain, but she said, 'I can't even lift my head off the pillow,' " recalls her daughter, Erika Mazero. Ms. Thiele, 57, nearly passed out from the pain one night and suffered blurred vision. When the pain recurred in the morning, she went to the emergency room at nearby St. Joseph's Mercy of Macomb Hospital. Ms. Mazero says that during the six hours her mother spent there, she was given a CT scan, but not a spinal tap, which could definitively have shown she had a leaking brain aneurysm, meaning a ballooned and weakened artery in her brain. After the CT, Ms. Thiele was given a muscle relaxant and pain medicine and sent home, her daughter says. Two months later, the blood vessel burst. Neurosurgeons at William Beaumont Hospital in Royal Oak, Mich., did emergency surgery, but Ms. Thiele suffered massive bleeding and died. Ali Bydon, one of the neurosurgeons at Beaumont, says a CT scan often is inadequate and that her condition could have been detected earlier with a spinal tap, also called a lumbar puncture. "Had she had a lumbar puncture and perhaps an operation earlier, it might have saved her life," says Dr. Bydon. "In general, a person who tells you, 'I usually don't get headaches, and this is the worst headache of my life,' is something that should alarm you." In addition, he says Ms. Thiele "absolutely" was experiencing smaller-scale bleeding in May that foreshadowed a more serious rupture. If doctors identify this kind of bleeding early, he says, chances of death are "minimal." But when a rupture occurs, he says, "25% of patients never make it to the hospital, 25% die in the hospital and 25% are severely disabled." A St. Joseph's hospital spokeswoman says the hospital has "very aggressive standards for treatment, and we met this standard," declining to elaborate. Determined Nurse Paramedics did the right thing after Chuck Toeniskoetter's stroke, but only because of some extraordinary intervention. Mr. Toeniskoetter, then 55, was on a ski trip Dec. 23, 2000, at Bear Valley, near Los Angeles. He had just finished a run at 3:30 p.m. when, in the snowmobile shop, he began slurring his words and nearly fell over. Kathy Snyder, the nurse in the ski area's first-aid room, quickly diagnosed stroke. She called a helicopter and an ambulance. Ms. Snyder says she knew the closest hospital with a stroke team was Sutter Roseville Medical Center in Roseville, Calif. The helicopter pilot was planning to take Mr. Toeniskoetter to a closer ER, but Ms. Snyder says she stood on the helicopter runners, demanding the patient go to Sutter. The pilot eventually relented. Mr. Toeniskoetter went to Sutter, where he promptly received tPA. Today, he has no disability and is back running a real estate-development business in the San Jose area. "Trauma patients go to trauma centers, not the nearest hospital," he says. "Stroke victims, too, require a real specialized sort of care." One-third of all strokes are suffered by people under 60, and hemorrhagic strokes in particular often strike young adults and children. Vance Bowers of Orlando, Fla., was 9 when he woke up screaming that his eyes hurt, shortly after 1 a.m. on Jan. 8, 2001. Malformed blood vessels in his brain were bleeding. He was in a coma by the time an ambulance delivered him at 1:57 a.m. to the nearest emergency room, at Florida Hospital East Orlando. Emergency-room doctors soon realized Vance had a hemorrhagic stroke. But neurosurgery isn't performed at that hospital. A sister hospital 14 minutes away by ambulance, Florida Hospital Orlando, did have neurosurgical capability. But in part because of administrative tangles, Vance didn't get to the second hospital until 4:37 a.m., more than two hours after his arrival. Surgery began at 6:18 a.m. "This delay may have cost this young man the possibility of a functional survival," Paul D. Sawin, the neurosurgeon who operated on Vance, said in a letter to the hospitals' joint administration. Florida Hospital, an emergency-medicine group and an ER doctor recently agreed to settle a lawsuit filed against them in Orange County, Fla., Circuit Court by the Bowers family. The defendants agreed to pay a total of $800,000, court records show. Monica Reed, senior medical officer of the hospital, says the care Vance received was "stellar" and that any delays weren't medically significant. Vance's stroke, not the care he received, caused his injuries, she said. Vance, now 13, survived but is mentally handicapped and suffers daily seizures, his mother, Brenda Bowers, says. Once a star baseball player, he goes by wheelchair to a class for disabled children. He speaks very slowly but not in a way that many people can understand. "He remembers playing baseball with all of his friends," his mother says, but they rarely come around any more. "He really misses all that." And there are differences in presentation, based on gender, further complicating the problem of receiving prompt, responsible treatment. "TwitteringOne" <mournenwould@aol.com> wrote in part: >And there are differences in presentation, >based on gender, further complicating the problem of receiving >prompt, responsible treatment. What differences might those be? -- Jim Chinnis Warrenton, Virginia, USA I'll have to get back to you. Take an aspirin, Call me next week. "TwitteringOne" <mournenwould@aol.com> wrote in part: >I'll have to get back to you. >Take an aspirin, >Call me next week. Take your time. -- Jim Chinnis Warrenton, Virginia, USA <snip> What's most scary about this , even though it's important to treat stroke, is the ambulance negligence. I'm a RN at a tertiary center in NY and just 3 days ago a coworker had a family member who was about 18 miles from our hospital, but only 13 from a troubled inferior community hospital, the pt specifically requested to come to our hospital, fearing that she was having an MI. The ambulance flatly refused to take her to our hospital telling her that it was against ambulance company protocol. The pt specifically asked if the ambulance driver felt the Dr.'s were better qualified to treat her where they were taking her as opposed to where she wished to go. The EMT answered "probably not". This is doubly troubling, since they now have opened themselves up for a negligence lawsuit, which my friend has said her grandmother will not pursue, but also more dangerously, if this happens again the pt is more likely to attempt to drive themselves to the facility they feel is more appropriate, rather than call for an ambulance. I realize the need for expedience in transport of a pt. but shouldn't common sense prevail in a case like this? It was clear the EMT felt the pt was justified in her preference, why not take her to the facility where she was going to receive superior care? btw, once the pt was signed off by the ED MD as stable she was transported to our facility for Cardiac Cath. > <snip> > [quoted text clipped - 13 lines] > her grandmother will not pursue, but also more dangerously, if this > happens again the pt is more likely to attempt to drive themselves to > the facility they feel is more appropriate, rather than call for an > ambulance. I realize the need for expedience in transport of a pt. but [quoted text clipped - 4 lines] > btw, once the pt was signed off by the ED MD as stable she was > transported to our facility for Cardiac Cath. if our health care is so screwed up such that people have to drive their loved ones to the right hospital capable of treating them, then maybe the medical community should publicize which is the correct hospital for people to go to.... now that you can't trust the ambulance companies anymore!!! >><snip> >> [quoted text clipped - 55 lines] > hospital for people to go to.... now that you can't trust the ambulance > companies anymore!!! This is not entirely what I meant, but you do have a valid point. I was not trying to imply that our ambulances can't be trusted, only that the EMT's and Paramedics exercise a more critical thinking approach to where they take their pt.s. A few extra seconds in the field to assess the pt. and decide that a longer ambulance ride to a superior facility is more beneficial than expedience for the sake of response numbers. >I was not trying to imply that our ambulances can't be trusted, only >that the EMT's and Paramedics exercise a more critical thinking approach >to where they take their pt.s. A few extra seconds in the field to >assess the pt. and decide that a longer ambulance ride to a superior >facility is more beneficial than expedience for the sake of response >numbers. The EMT stated the choice was dictated by company policy. It's difficult to exercise critical thinking and good judgment when you will lose your job for doing so. >>I was not trying to imply that our ambulances can't be trusted, only >>that the EMT's and Paramedics exercise a more critical thinking approach [quoted text clipped - 7 lines] > It's difficult to exercise critical thinking and good judgment when you will > lose your job for doing so. clarification, the EMT works for a volunteer Fire Dept. with an ambulance crew. You can't fire a volunteer. Besides anyone choosing to save a life over company policy has their head on straight. If I lose my job simply because I didn't follow company policy the company was not worth working for. >clarification, the EMT works for a volunteer Fire Dept. with an >ambulance crew. You can't fire a volunteer. Like hell you can't. I do it all the time. >Besides anyone choosing to save a life over company policy has their >head on straight. > >If I lose my job simply because I didn't follow company policy the >company was not worth working for. Let's try to keep the dramatics about saving lives within the realm of reason, okay? We're talking optimal treatment here, not immediate life or death. Even the best system has flaws, and the people who work in that system, be they paid or volunteer, have no choice but work within the system or get out. Or worse: be sued, stripped of their certification, or even prosecuted. Volunteers are by no means immune to those consequences. When a life is truly at stake, I won't hesitate to break regulations and do what I think is necessary. But my butt will be on the line to prove I made the right decision when I do that, so it's not a decision made lightly. "I thought she would be better off at Hospital A than Hospital B" is a pretty damned poor justification unless there's regulation, policy, or legislation in place to support my *opinion* that Hospital A is better. Basically, I agree with you that stroke patients would benefit from a system similar to that established for trauma patients, but until those systems exist and are sanctioned by governmental authority, it's just not practical to expect EMTs to ignore the regulations and policies that govern them. >> ...The EMT stated the choice was dictated by company policy. >> [quoted text clipped - 3 lines] >clarification, the EMT works for a volunteer Fire Dept. with an >ambulance crew. You can't fire a volunteer. Who told you that? Just because there's no paycheck doesn't mean that they can't be shown the door. LT >>>...The EMT stated the choice was dictated by company policy. >>> [quoted text clipped - 10 lines] > > LT yes, yes yes overstated for emphasis, the point wasn't the volunteer, the point was that the volunteer should be allowed to make a choice based on their assessment. >>>>...The EMT stated the choice was dictated by company policy. >>>> [quoted text clipped - 13 lines] >the point was that the volunteer should be allowed to make a choice >based on their assessment. I see. Then the point you tried to make had nothing to do with what you wrote. LT >>>>>...The EMT stated the choice was dictated by company policy. >>>>> [quoted text clipped - 19 lines] > > LT Oh please, not more of this crap. Why can't anyone have a discussion without someone picking apart semantics instead of just discussing the topic. The point I made had everything to do with what I wrote, you simply took one line of an entire cohesive discussion and chose to comment on it, then when explained to you, you belittled it. What's with you Larry? don't you have better things to do? >yes, yes yes overstated for emphasis, the point wasn't the volunteer, >the point was that the volunteer should be allowed to make a choice >based on their assessment. Which they do thousands of times per day all across the country. Lose the volunteer crap. It's irrelevant. >>yes, yes yes overstated for emphasis, the point wasn't the volunteer, >>the point was that the volunteer should be allowed to make a choice [quoted text clipped - 3 lines] > > Lose the volunteer crap. It's irrelevant. so is your comment, the volunteer crap was brought up by someone else. And the whole point to my original post was that these men and women AREN'T given the chance to make choices based on their assessments. If you aren't going to bother paying attention or add something helpful, why bother commenting at all? >> Lose the volunteer crap. It's irrelevant. >> >so is your comment, the volunteer crap was brought up by someone else. Your memory seems to be failing you. Here, allow me to refresh it for you. In Message-ID gOUfe.235$Bg4.96@fe10.lga you wrote: >clarification, the EMT works for a volunteer Fire Dept. with an >ambulance crew. You can't fire a volunteer. There is no mention of volunteers prior to that post. After all, how could there be? It was *your* story. None of us would have any way of knowing and no reason to ask. >And the whole point to my original post was that these men and women >AREN'T given the chance to make choices based on their assessments. If >you aren't going to bother paying attention or add something helpful, >why bother commenting at all? You don't remember what you said but you think I should pay attention? >>>Lose the volunteer crap. It's irrelevant. >> [quoted text clipped - 5 lines] >>clarification, the EMT works for a volunteer Fire Dept. with an >>ambulance crew. You can't fire a volunteer. Fine, thank you for correcting me, your comment is still irrelevant since my point had nothing to do with volunteers, but the fact that the ambulance crew's hands were tied by bureaucracy. > There is no mention of volunteers prior to that post. After all, how could > there be? It was *your* story. None of us would have any way of knowing > and no reason to ask. Ah more sarcasm, quite helpful and informative. >>And the whole point to my original post was that these men and women >>AREN'T given the chance to make choices based on their assessments. If >>you aren't going to bother paying attention or add something helpful, >>why bother commenting at all? > > You don't remember what you said but you think I should pay attention? Yes, because you are taking comments out of context, picking them apart then attacking the minutiae for , well no particular reason at all but to prove I was wrong about a point that you yourself said was irrelevant, seems like an awful lot of work for, um nothing...... >Fine, thank you for correcting me, your comment is still irrelevant >since my point had nothing to do with volunteers, but the fact that the >ambulance crew's hands were tied by bureaucracy. You're the one who interjected the irrelevance of volunteers into the thread. All I did was point out that irrelevance (which took some doing), and correct your distortions when you tried to deny your own words later. >> There is no mention of volunteers prior to that post. After all, how could >> there be? It was *your* story. None of us would have any way of knowing >> and no reason to ask. > >Ah more sarcasm, quite helpful and informative. That wasn't sarcasm. It was pure statement of fact and simple logic. >Yes, because you are taking comments out of context, picking them apart >then attacking the minutiae for , well no particular reason at all but >to prove I was wrong about a point that you yourself said was >irrelevant, seems like an awful lot of work for, um nothing...... I've taken nothing out of context, but you're correct that I have picked your statements apart and attacked the false and misleading ones. I don't consider false statements of fact to be minutiae. First you blamed EMS field personnel for something they have no control over (and, somehow, argued that being volunteers proved your assertions). Then, when shown the error of your thinking, you switched to blaming bureaucrats, which is exactly where we told you the blame lies in the first place. Instead of just shutting up and moving on, you revised your arguments time and time again, keeping the thread alive, apparently hoping we would forget your previous arguments, which are almost the opposite of your current ones. Dropping it and moving on would, indeed, be a grand idea. >>Fine, thank you for correcting me, your comment is still irrelevant >>since my point had nothing to do with volunteers, but the fact that the [quoted text clipped - 3 lines] > thread. All I did was point out that irrelevance (which took some doing), > and correct your distortions when you tried to deny your own words later. My goodness, your redundancy is maddening. >>>There is no mention of volunteers prior to that post. After all, how could >>>there be? It was *your* story. None of us would have any way of knowing [quoted text clipped - 3 lines] > > That wasn't sarcasm. It was pure statement of fact and simple logic. fact: There is no mention of volunteers prior to that post. sarcasm: After all, how could there be? It was *your* story. None of us would have any way of knowing and no reason to ask. >>Yes, because you are taking comments out of context, picking them apart >>then attacking the minutiae for , well no particular reason at all but >>to prove I was wrong about a point that you yourself said was >>irrelevant, seems like an awful lot of work for, um nothing...... > > I've taken nothing out of context, yes you did, the comment about the volunteers was irrelevant to the statement I was making. It was just an aside to point out that the EMT's I was discussing were volunteers. but you're correct that I have picked > your statements apart and attacked the false and misleading ones. in your opinion. In my opinion I haven't made any false or misleading statements. I simply made a mistake about one comment that I had previously made. I don't > consider false statements of fact to be minutiae. I haven't made any false statements of fact, well, except when I mis-stated that the volunteer comment was not mine. First you blamed EMS > field personnel for something they have no control over And when The discussion revealed that most EMT's hands were tied I revised my argument to the powers at fault. (and, somehow, > argued that being volunteers proved your assertions). Nope, never did, All I said was that volunteers couldn't be fired, never did I make any mention that they were to blame. Then, when shown the > error of your thinking, you switched to blaming bureaucrats, which is > exactly where we told you the blame lies in the first place. True, and what is wrong with this? When I realized that the EMT, who clearly believed he should be taking the pt, to the proper facility over the one he was dispatched to, whom should I blame? Have you never revised an assertion you had after realizing that your original logic was flawed? Instead of > just shutting up and moving on, Like you have? you revised your arguments time and time > again, No, only once. keeping the thread alive, The thread is alive because people wish to discuss it, sorry if that bothers you.If it is so troublesome, why continue to contribute? apparently hoping we would forget your > previous arguments, which are almost the opposite of your current ones. Not at all. My original argument was that the pt. should be brought to the facility best equipped to handle her diagnosis, it never changed, all that changed from my original post was the blame I placed on the ambulance driver. My original argument even touched on the true nature of the problem before I had all the details, when I stated: "The ambulance flatly refused to take her to our hospital telling her that it was against ambulance company protocol." It was at this point I should have realized it was the bureaucracy that tied the hands of the EMT. All my subsequent arguments stemmed from that bureaucracy and ny position that EMT's be allowed to deviate from certain protocols. None of which is, as you claim, almost opposite of my current positions, or my original one. > Dropping it and moving on would, indeed, be a grand idea. please do. >>><snip> >>> [quoted text clipped - 64 lines] >facility is more beneficial than expedience for the sake of response >numbers. More beneficial for who? The longer ride certainly makes the ambulance company healthier, but doesn't necessarily mean things are better for the patient. That''s why I think the original poster was off base - the ambulance is paid by the mile - they have no reason to go to the closest facility for expedience. >>>><snip> >>>> [quoted text clipped - 72 lines] > is paid by the mile - they have no reason to go to the closest > facility for expedience. yes they do, most ambulance companies in this area of NY are volunteer, they're not being paid. It's a company's response time that's at stake. if they deliver the pt later than they are supposed to it looks like the pt wasn't delivered to a hospital in a timely manner. >That''s why I think the original poster was off base - the ambulance >is paid by the mile - they have no reason to go to the closest >facility for expedience. They would here. Although there's a mileage fee, the base fee and ALS surcharge far outweigh it. Getting back in service quickly for another call is worth far more than a few extra billable miles, at least in urban systems where transports tend to be fairly short. I think the OP's point is perfectly valid. Where's he's off base is blaming the crew when it was probably a policy they have no control over. >[snip] >More beneficial for who? The longer ride certainly makes the [quoted text clipped - 4 lines] >is paid by the mile - they have no reason to go to the closest >facility for expedience. As in the rest of life, there are many competing interests at work in a situation like this. The local hospital wants the volume to stay alive, but so does the larger, tertiary hospital to pay for their advanced programs. The EMS service is best served by travelling as many 'loaded miles' as they can, but the individual medics usually want to spend as little time on each run as possible. Everyone wants to provide good care, but no one wants to spend any more than they have to in the process. Even the patient wants the best care available for their problem, yet really doesn't want to be involved in the situation in first place. What happens in the end is usually a result of compromises and resolutions of the many conflicts. If something goes wrong - absent some obvious or glaring issue - it's tough to point at any one aspect and single it out as the problem. LT > >[snip] > >More beneficial for who? The longer ride certainly makes the [quoted text clipped - 27 lines] > > LT I have been following this conversation with interest. May have missed a bit but.. Please tell me...are the practises (and regulations) national, state, or municipal? I assume you and Carey do not serve the same jurisdiction, or the same jurisdiction as the OP. Yet you speak as though there is one practise. Here ambulances and hospitals are part of universal health care--not for-profit. Even volunteer ambulance services would be under the umbrella of the jurisdiction healthcare agency. An ambulance cannot refuse anyone whether they can pay or not, cannot decide where they will take a patient, and would be in constant contact en route by an emerg physician in the scenario described. Zee >Please tell me...are the practises (and regulations) national, state, >or municipal? I assume you and Carey do not serve the same >jurisdiction, or the same jurisdiction as the OP. Yet you speak as >though there is one practise. The practices are municipal, county, or sometimes regional, but by no means national. There might be some on a state level, but I'm not familiar with them if there are. LT and I definitely do not serve the same jurisdiction. We're in different states. >Here ambulances and hospitals are part of universal health care--not >for-profit. Even volunteer ambulance services would be under the >umbrella of the jurisdiction healthcare agency. An ambulance cannot >refuse anyone whether they can pay or not, cannot decide where they >will take a patient, and would be in constant contact en route by an >emerg physician in the scenario described. It varies in the US. I have a lot of latitude in most cases where I take a patient (trauma being the exception), and we're not in constant contact with a physician. We contact them as needed. However, bypassing a closer facility has to be justifiable unless it's by patient choice. If the pt doesn't have a preference or can't inform me of one, then they'll go to the "nearest appropriate facility." Only with trauma do I have a clear-cut definition of what constitutes appropriate, so at least in my jurisdiction all serious medical patients will go to the nearest facility. Luckily, it's a pretty good hospital, but even if it weren't, I still wouldn't have much choice. > > <snip> > > [quoted text clipped - 36 lines] > maybe the medical community should publicize which is the correct > hospital for people to go to This is happening. Soon you will be able to compare hospitals on basic quality of care measures. > <snip> > [quoted text clipped - 21 lines] > btw, once the pt was signed off by the ED MD as stable she was > transported to our facility for Cardiac Cath. Both you and the person who posted the original article are missing a critical piece of information. The Hospital that the ambulance must take you to is not decided by the ambulance staff. Depending on who operates the ambulance the choice may be made by an insurance administrator, a medical control physician, a county emergency medical service committee, or even a state wide certifying organization. I volunteer on a public ambulance. It is owned and operated by the county government. There is a state wide certifying agency that has identified which hospitals are to be considered specialty referral centers and for what conditions. The counties present transport policy is that in the absence of an eligible specialty referral condition the choice of hospital may not add more than ten minutes to the transport when compared to the closest emergency department. The State agency recognizes trauma, including specific types of trauma such as hand and eye, and burns as specialty referral issues. Rape is not recognized, nor is special medical devices, non traumatic pediatrics, sickle cell anemia crisis, and many other conditions are not recognized. Public ambulances are operated for the best interest of the public rather than for the best interest of the individual patient. "The needs of the many outweigh the needs of the few or the one." The publics best interest is served by minimizing the time that their closest ambulance is tied up on another call. A much higher priority is placed on the first five minutes than the first five hours. The problem that many public EMS systems have is system abuse. People who have no health care use the ambulance and the Hill Burton amendment as their primary health care resource. Policies that require that patient or physician preference be given a higher priority than public safety are almost always abused. The District of Columbia has a policy of providing it's citizens transport to any hospital within the city boundary. I have answered mutual aid calls there were patients expected to be transported across the city at rush hour to a hospital they preferred and the families always become verbally abusive and sometimes physically threatening when informed that we are not permitted to do that. The city has given them the expectation that they can demand these choices and left their neighboring jurisdictions to cope with that when those residents cross the city line into Maryland or answer the cities calls for mutual aid. I don't want to get lost in a diatribe here but I do want you to understand that it is very seldom the ambulance staff that is making the choice. It has usually been made in advance for them by insurance, political, or financial interests. -- Tom H >> <snip> >> [quoted text clipped - 66 lines] > choice. It has usually been made in advance for them by insurance, > political, or financial interests. That's all well and good but I still feel a judgment call by the Paramedic or EMT should still prevail, especially in my area which is also covered by public ambulances, there are enough districts close enough to each other to facilitate tying up an ambulance if it means the pt has a better chance at survival by getting the right treatment, not necessarily the fastest. >>> <snip> >>> [quoted text clipped - 73 lines] > pt has a better chance at survival by getting the right treatment, not > necessarily the fastest. If your system allows you that latitude then fine but many do not. -- Tom H >> That's all well and good but I still feel a judgment call by the >> Paramedic or EMT should still prevail, especially in my area which is [quoted text clipped - 4 lines] > > If your system allows you that latitude then fine but many do not. Well yeah, that was my point, the systems need to allow that latitude. >>> That's all well and good but I still feel a judgment call by the >>> Paramedic or EMT should still prevail, especially in my area which is [quoted text clipped - 6 lines] > > Well yeah, that was my point, the systems need to allow that latitude. Bryan You seem to think I disagree with you. I don't! All I'm trying to say is that the forces that effect those decisions are well beyond the control of the field staff and are likely to remain so. Much more importantly the field staff are not to blame for the damnable politics and greed that actually shape those decisions. -- Tom Horne ><snip> >> Well yeah, that was my point, the systems need to allow that latitude. > [quoted text clipped - 4 lines] > importantly the field staff are not to blame for the damnable politics > and greed that actually shape those decisions. How did you get the impression I disagree with you? I said you made my point....... anyway, What I think is that you ARE partly correct: "the forces that effect those decisions are well beyond the control of the field staff and are likely to remain so." My point is that the Field staff should be given the leeway to make these kind of decisions. Especially if a Paramedic is involved in the situation. Paramedics are trained in Critical Thinking and would certainly be capable of a decision of this nature. >> Bryan >> You seem to think I disagree with you. I don't! All I'm trying to [quoted text clipped - 14 lines] > situation. Paramedics are trained in Critical Thinking and would > certainly be capable of a decision of this nature. Bryan If your going to try to make sense of this I will have to remind you that North American emergency service practices are guided by three hundred years of tradition uninterrupted by progress. If the paramedic could decide that the patient would be better off at a different facility then the closest hospital will be deprived of the opportunity to biopsy the patients wallet and only transfer them if the biopsy comes back negative for blue cross or other high pay out health insurance. On top of that a Maryland trauma patient might end up at a District of Columbia Hospital that is only ten minutes away by land rather than going by helicopter to Bethesda or Baltimore thus loosing money to another jurisdictions system that is run by a former protege of the Maryland systems founder who had the audacity to strike out on his own... OH NEVER MIND. -- Tom H > OH NEVER MIND. lol.... Oh, c'mon, Tom, go ahead and explain it. How hard can it be? >>> Bryan >>> You seem to think I disagree with you. I don't! All I'm trying to [quoted text clipped - 29 lines] > Maryland systems founder who had the audacity to strike out on his > own... OH NEVER MIND. I do understand, but in my case as presented all the hospitals were in the same county. True though, our point remains the same , it seems the ambulance companies care more about protocol and expedience that the actual care of the pt. >>>> Bryan >>>> You seem to think I disagree with you. I don't! All I'm trying to [quoted text clipped - 34 lines] > ambulance companies care more about protocol and expedience that the > actual care of the pt. You sir are one stubborn SOB. You insist on blaming the field staff and the providing organization for policies over which they have no control. You're right of Course You're right of Course You're right of Course You're right of Course You're right of Course You're right of Course You're right of Course Happy now. GO AWAY. I SAY GO AWAY BOY YA BOTHER ME. SCAT. -- Ton Horne <snip> >> I do understand, but in my case as presented all the hospitals were in >> the same county. True though, our point remains the same , it seems [quoted text clipped - 3 lines] > You sir are one stubborn SOB. You insist on blaming the field staff and > the providing organization for policies over which they have no control. Stubborn? maybe. But you are incorrect. the field staff and the providing organization most certainly DO have control, they just fail to exercise it. Big difference. > You're right of Course > You're right of Course [quoted text clipped - 4 lines] > You're right of Course > Happy now. No, sarcasm is most annoying the only one who derives joy from it is the provider. > GO AWAY. I SAY GO AWAY BOY YA BOTHER ME. SCAT. I'm sorry. I don't remember asking if I bothered you, you could always choose not to read my posts, or better yet choose not to respond........... BKM RN <snip> > Paramedics are trained in Critical Thinking Now this is a real can of worms here!! Critical Thinking? Check this: http://www.google.com/search?hl=en&lr=&oi=defmore&q=define:critical+thinking Perhaps the best one I found on the reference page was: "Critical thinking is a process that challenges an individual to use reflective, reasonable, rational thinking to gather, interpret and evaluate information in order to derive a judgment. The process involves thinking beyond a single solution for a problem and focusing on deciding what the best alternatives are." The problem is that many paramedics I know cannot or will not use their training and experience to properly assess a patient. I think they are fearful of having to defend themselves and defend their judgments and instead rely on the protocols to absolutely dictate treatment methods. I have been taught from the beginning that protocols are guidelines and if a treatment method falls outside the protocol but can be shown to have clinical significance, it is justified as long as it remains within the scope of practice. As for deviating from the nearest facility based on your assessment of the patient, your medical director should have a list of hospital capabilities and your deviation from the nearest facility should be predicated on your proper assessment.  SignatureGotta Go...It's Hot In Here, William Lyster-FF/NREMTB > <snip> > [quoted text clipped - 23 lines] > and your deviation from the nearest facility should be predicated on your > proper assessment. Bill You get it because you are a field provider. "your medical director should have a list of hospital capabilities" does kind of say it all. We are not permitted to make up rules as we go along. Bryan insists that we can and should. -- Tom Horne >> <snip> >> [quoted text clipped - 29 lines] > are not permitted to make up rules as we go along. Bryan insists that > we can and should. I get it too sir, you just choose to hide behind your incessant whining "stop blaming me." or "stop blaming those in the field." or "stop blaming the ambulance companies for being arrogant and shortsighted." Bill said: your medical director should have a list of hospital capabilities and your deviation from the nearest facility should be predicated on your proper assessment. This is exactly what I have been saying all along, no different. the problem is in the OP and my example this ISN'T what happened. Do you get it now? >I get it too sir, you just choose to hide behind your incessant whining >"stop blaming me." or "stop blaming those in the field." or "stop >blaming the ambulance companies for being arrogant and shortsighted." Well, you really should stop it. You seem unwilling to accept the reality that in the vast majority of cases there is absolutely *no objective basis* on which to justify bypassing a closer hospital for another in cases of stroke. >Bill said: your medical director should have a list of hospital >capabilities and your deviation from the nearest facility should be >predicated on your proper assessment. All hospitals within my coverage area offer stroke management and neurosurgery. Now, which ones do you think I should bypass, and on what basis? Sure, I know which one I'd want my relative at, but my personal opinion carries little weight at the department of health, and even less in court. Hell, even the hospitals being bypassed might file complaints once they learned what was happening. >>I get it too sir, you just choose to hide behind your incessant whining >>"stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 5 lines] > there is absolutely *no objective basis* on which to justify bypassing a > closer hospital for another in cases of stroke. Maybe, but the case I used as an example was for MI not stroke, and in that case there is an objective basis to justify bringing someone to a known cardiac facility over a community hospital. >>Bill said: your medical director should have a list of hospital >>capabilities and your deviation from the nearest facility should be [quoted text clipped - 6 lines] > court. Hell, even the hospitals being bypassed might file complaints once > they learned what was happening. That may very well be the case in your situation, it is not in all others. In my county people are routinely driven to closer hospitals solely for the purpose of expedience, even if a facility only a little farther away is the better choice. Again, I am not blaming the field personnel, I never did. I blame their superiors for not allowing them to make their own choices in these situations. >> Well, you really should stop it. >> [quoted text clipped - 5 lines] >that case there is an objective basis to justify bringing someone to a >known cardiac facility over a community hospital. Fine, change stroke to MI and you'll get the same story. All the hospitals in my district also offer cardiac cath, bypass, etc. Yet there is no established system (like there is with trauma) that allows me to justify bypassing a closer facility, even though I certainly would with my own family member. >That may very well be the case in your situation, it is not in all >others. In my county people are routinely driven to closer hospitals >solely for the purpose of expedience, even if a facility only a little >farther away is the better choice. Okay, why don't you put some meat behind this statement? Your *perception* is that it's purely for expedience. I have no idea what the reasons actually are -- since I know probably better than you how much EMS systems vary from one place to the next -- but you seem quite certain of yourself, so put it on the table. How do you know this is purely for expedience? >>>Well, you really should stop it. >>> [quoted text clipped - 11 lines] > bypassing a closer facility, even though I certainly would with my own > family member. Again this is your district, not mine. The pt I referred to was brought to a community hospital with no capability for CC that was 13 miles from her home with all symptoms of a possible MI while the tertiary facility whose known specialty is CC and Cardiothoracic surgery was 18 miles away. by the EMT's own admission to the pt. he felt they should be taking her to the our facility and not the community hospital. >>That may very well be the case in your situation, it is not in all >>others. In my county people are routinely driven to closer hospitals [quoted text clipped - 3 lines] > Okay, why don't you put some meat behind this statement? Your *perception* > is that it's purely for expedience. no the admission of the EMT was that it was for expedience. I have no idea what the reasons > actually are I do -- since I know probably better than you how much EMS systems > vary from one place to the next maybe, but obviously not in this case. -- but you seem quite certain of yourself, I am > so put it on the table. How do you know this is purely for expedience? answered above. >>I get it too sir, you just choose to hide behind your incessant whining >>"stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 16 lines] >court. Hell, even the hospitals being bypassed might file complaints once >they learned what was happening. Bryan, you should listen to Carey. Allow me to add that most EMS agencies don't have a good idea of a given hospital's specific capabilities. Hell, it's tough enough when working in the ER to keep up with what new docs have come on board the various services, what new equipment and techniques they're instituting 'upstairs', and about availability of resources at various hours of the day. And two final points; first, to say that paramedic programs teach 'critical thinking' is laughable. Second, medical care delivery systems should be planned, not cooked up on the fly by whatever medic is on shift at the moment. EMS is only one tiny portion of the greater system, and should confine it's input to those areas where they have some expertise. Determining in-hospital medical needs is not one of them. Larry, EMT-P >>>I get it too sir, you just choose to hide behind your incessant whining >>>"stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 36 lines] > > Larry, EMT-P Now you've done it. You have contradicted he who must be believed. He'll never let it go. For the patients arrival at a Hospital that he believes to be improper to not be the ambulance company's fault Bryan would have to be wrong. Now stop this foolishness and repeat after me. Bryan is always right. Bryan is always right. Bryan is always right. Bryan is always right. Bryan is always right. Bryan is always right. It will be so much easier if you don't try to confuse the all knowing Bryan with facts. Since he will never change his position that it has to be the fault of the ambulance provider there is no reason to invest your time in further argument. -- Tom Horne >>>> I get it too sir, you just choose to hide behind your incessant whining >>>> "stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 52 lines] > to be the fault of the ambulance provider there is no reason to invest > your time in further argument. Actually sir, he made his point quite sincerely without ridiculing me or the original poster, a case where I am much more inclined to agree with what he said as opposed to you and your sarcasm which is quite useless and offers no viewpoint but your own. Simply put, you are callous and sarcastic and are guilty of what you accuse me of, that you are always right even though I offer as many valid points as you do. It's funny but I notice that those who believe they are always right seem to accuse others of being guilty of the same. look in the mirror friend. >>>I get it too sir, you just choose to hide behind your incessant whining >>>"stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 21 lines] > Allow me to add that most EMS agencies don't have a good idea of a > given hospital's specific capabilities. This seems quite silly, wouldn't the EMS system need this information to properly do their job? Hell, it's tough enough when > working in the ER to keep up with what new docs have come on board the > various services, what new equipment and techniques they're > instituting 'upstairs', and about availability of resources at various > hours of the day. true, but that's more abstract than what we are talking about. this is simply which hospital is better to take the pt having a possible MI the known regional tertiary Medical Center that specializes in Cardiology or the community hospital in the boondocks that happens to be 6 miles closer. > And two final points; first, to say that paramedic programs teach > 'critical thinking' is laughable. I guess it depends on the program. the ones offered in my area do just that, and quite well I might add. I have a few friends that are paramedics and trust their judgment . > Second, medical care delivery systems should be planned, not cooked up > on the fly by whatever medic is on shift at the moment. again this is not really what I was suggesting. I don't want the EMT to set up an entire plan of care I just want him to be able to take his pt to the facility that he believes will provide the better care to the pt in a certain circumstance. I'm not advocating EMT's or paramedics arguing about the merits of hospital A over hospital B in every situation, but some cases are more cut and dried than others, and require a bit of common sense over a set rule for all circumstances. EMS is only > one tiny portion of the greater system, and should confine it's input > to those areas where they have some expertise. right like bringing the pt. to the correct hospital that care can be delivered at. Once again, it is not going to apply to every single situation, but in some circumstances the EMT or Paramedic should be allowed to overrule which hospital the pt is brought to based on the facts at hand. Determining > in-hospital medical needs is not one of them. > > Larry, EMT-P >>>>I get it too sir, you just choose to hide behind your incessant whining >>>>"stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 24 lines] >This seems quite silly, wouldn't the EMS system need this information to >properly do their job? I think that we all know who the trauma centers are and who has a cath lab or not. That's a minimal picture of a hospital's capabilities. One hopes that your EMS system is structured through policy so as to factor these things in when setting protocol. To leave these decisions to individual medics will give you broad inconsistency in application. How does one know that the medic on duty tonight knows anything about what hospital A can do vs. hospital B? I am not a fan of the "closest hospital" mindset, and I do advocate a "closest apropriae hosptal". But I do not agree that this should be a seat-of-the-pants decision by EMS. >Hell, it's tough enough when >> working in the ER to keep up with what new docs have come on board the [quoted text clipped - 6 lines] >known regional tertiary Medical Center that specializes in Cardiology or >the community hospital in the boondocks that happens to be 6 miles closer. These clear-cut cases should be alowed under your local protcol. If not, you should lobby those that formulate your protocols. >> And two final points; first, to say that paramedic programs teach >> 'critical thinking' is laughable. > >I guess it depends on the program. the ones offered in my area do just >that, and quite well I might add. I have a few friends that are >paramedics and trust their judgment . Any educational program that only lasts for 1000-1500 hours cannot teach critical thinking. >> Second, medical care delivery systems should be planned, not cooked up >> on the fly by whatever medic is on shift at the moment. [quoted text clipped - 6 lines] >situation, but some cases are more cut and dried than others, and >require a bit of common sense over a set rule for all circumstances. No problem. Incorporate the criteria into your local protocols. >>EMS is only >> one tiny portion of the greater system, and should confine it's input [quoted text clipped - 5 lines] >allowed to overrule which hospital the pt is brought to based on the >facts at hand. As above. LT >>>>>I get it too sir, you just choose to hide behind your incessant whining >>>>>"stop blaming me." or "stop blaming those in the field." or "stop [quoted text clipped - 37 lines] > "closest apropriae hosptal". But I do not agree that this should be a > seat-of-the-pants decision by EMS. excellent, now we're getting somewhere, a true discussion. I'm not advocating a seat of the pants decision in all cases, just the ability for the EMT to make the obvious decision without fear of reprimand. >>Hell, it's tough enough when >> [quoted text clipped - 10 lines] > These clear-cut cases should be alowed under your local protcol. If > not, you should lobby those that formulate your protocols. Something I will now look into, where should I start to lobby for this protocol, how can I enlist help from friends who are EMT's? What's the most likely governing body I should begin with ? >>>And two final points; first, to say that paramedic programs teach >>>'critical thinking' is laughable. [quoted text clipped - 5 lines] > Any educational program that only lasts for 1000-1500 hours cannot > teach critical thinking. I'm not sure I agree with that. I learned all of critical thinking skills while in LPN school. a 1600 hour program. It was far superior to anything I learned in RN school. >>>Second, medical care delivery systems should be planned, not cooked up >>>on the fly by whatever medic is on shift at the moment. [quoted text clipped - 8 lines] > > No problem. Incorporate the criteria into your local protocols. Yes, as above I will begin researching this. Since my initial post my friend's grandmother had a recurrence of the CP and instead of calling the ambulance, she called my friend to take her to our facility so she knew she would get the appropriate care. >>>EMS is only >>>one tiny portion of the greater system, and should confine it's input [quoted text clipped - 9 lines] > > LT thanks, it was nice to finally get a real opinion and discourse about what I was trying to discuss. >excellent, now we're getting somewhere, a true discussion. I'm not >advocating a seat of the pants decision in all cases, just the ability >for the EMT to make the obvious decision without fear of reprimand. The problem is that there is no measure for "obvious" with the exception of trauma and burns. They know where there are no services (in real life few and far between in general hospitals), but as to "best services" there are no guideposts for the most part. As things evolve there are often speciality hospitals (ie Heart Hospitals) popping up. But these are (and correct me if I am wrong those of you still on the street) are taken into account. Also, most are on the campuses of the same hospital the person would have been taken to anyway. -- Army Liason to the Office of Naval Contemplation >>excellent, now we're getting somewhere, a true discussion. I'm not >>advocating a seat of the pants decision in all cases, just the ability [quoted text clipped - 12 lines] > -- > Army Liason to the Office of Naval Contemplation So far only trauma and burns are on the specialty referral list in most jurisdictions. -- Tom Horne >>>excellent, now we're getting somewhere, a true discussion. I'm not >>>advocating a seat of the pants decision in all cases, just the ability [quoted text clipped - 15 lines] >So far only trauma and burns are on the specialty referral list in most >jurisdictions. Trauma centers, burn units, peds or pedi ICU, stroke centers, cath labs, neruosurgery. Absence of these services should all be reasonable indicators for bypass, circumstances considered. Of course, this should be codified into policy and not a maverick decision. LT >>excellent, now we're getting somewhere, a true discussion. I'm not >>advocating a seat of the pants decision in all cases, just the ability >>for the EMT to make the obvious decision without fear of reprimand. > The problem is that there is no measure for "obvious" with the > exception of trauma and burns. Stroke can be obvoius (weakness and slurred speech) as well as myocardial infarction (crushing chest pain radiating to the left arm, shortness of breath). > They know where there are no services > (in real life few and far between in general hospitals), but as to [quoted text clipped - 4 lines] > Also, most are on the campuses of the same hospital the person would > have been taken to anyway. But, in a community with just two hosptials, there may be one which is much better to treat the condition (i.e., one that is a stroke center or one that has a heart hospital). There other question I have is do we have any stats about how often a patient is taken to a hospital where the patient is taken to the wrong one? Jeff >>>excellent, now we're getting somewhere, a true discussion. I'm not >>>advocating a seat of the pants decision in all cases, just the ability [quoted text clipped - 24 lines] > > Jeff Who is going to define the hospital as wrong or right? If you get that part done then who is going to get them to admit that they were the wrong hospital when they will undoubtedly fight against not being classified as the right hospital for that purpose in the first place. -- Tom Horne Well we aren't no thin blue heroes, and yet we aren't no blackguards to. Just working men and women most remarkable like you. >>>>excellent, now we're getting somewhere, a true discussion. I'm not >>>>advocating a seat of the pants decision in all cases, just the ability [quoted text clipped - 29 lines] > hospital when they will undoubtedly fight against not being classified as > the right hospital for that purpose in the first place. Actually, what I am talking about is patients taken to hospitals that offer lower levels of services than other local hospitals. I am not talking about an individual case. The question I am really asking do we know how come this problem (patients taken to hospitals which are not as well prepared to treat an emergency situtation when there are other better qualified hospitals nearby)? Jeff > -- > Tom Horne > > Well we aren't no thin blue heroes, and yet we aren't no blackguards to. > Just working men and women most remarkable like you. >Actually, what I am talking about is patients taken to hospitals that offer >lower levels of services than other local hospitals. I am not talking about >an individual case. Again, what is a lower level of service and how do you decide which is lower. The EMS community already knows between non-existent and existent, and generally don't take people to where there are NO services. Beyond that, however, you get into validation and other concerns. >The question I am really asking do we know how come this problem (patients >taken to hospitals which are not as well prepared to treat an emergency >situtation when there are other better qualified hospitals nearby)? We don't. Because there are no objective measurements of better qualified except in burns and trauma. -- Army Liason to the Office of Naval Contemplation <snip> >>The question I am really asking do we know how come this problem (patients >>taken to hospitals which are not as well prepared to treat an emergency >>situtation when there are other better qualified hospitals nearby)? It's not up to you to decide if a hospital sucks or not. It's up to you to provide BLS and/or ALS interventions and treatment according to your training and your protocols. I imagine your protocols say something about transporting to the nearest facility. That's what you do. Unless it's a trauma alert, then you must (at least in FL), "transport or cause to be transported to the nearest state approved trauma center", that's verbatim from Florida Administrative Code 64E. That's it PERIOD. What happens when you decide to bypass the closest facility WITHOUT medical direction (either online or standing orders) and the patient takes a crap in your unit? I can think of one area where this problem of which you speak could in fact be a problem and that's in some parts of New Jersey where there are volunteer "First Aid Squads" that provide first response BLS care. In the parts of NJ where I have been, the ALS trucks were operated by the hospitals. So I imagine, if I am on an ALS transport unit that's run by St. Elsewhere Hospital, the patients I pick up are going to St. Elsewhere, regardless of whether or not St. Elsewhere is a Level 1 Stroke center or whatever. > We don't. Because there are no objective measurements of > better qualified except in burns and trauma. I don't think qualification is the appropriate term here. I think we are talking about the ability of a hospital to treat a given condition. The nurses and doctors may be qualified for brain surgery but if the hospital lacks the equipment necessary to perform such an operation, then it's a facility issue. My agency (a publicly funded Fire Rescue service) provides ALS treatment and transport in a large metropolitan area. We have a diversion program in our protocol that allows us to bypass facilities in the case of suspected stroke and heart attack. But we must go to the nearest stroke facility or hospital with a cath lab. Patients meeting trauma alert criteria are either flown or ground transported to the in-county Level I trauma center. Formerly, I worked in a rural area where the hospital wasn't much more than a glorified band-aid station. Not that the staff was crap, it's just that the hospital didn't have the facilities to do much. Every now and then we would transport a trauma patient there that didn't meet trauma alert criteria. The minute we wheeled in, the nurses would ask "why didn't you trauma alert them?" when they knew damn good and well the pt didn't meet criteria. The problem was that now they were stuck with a patient that needed to be transferred interfacility and that meant they would be required to make a bunch of phone calls to find a big city hospital that would take the pt. Hey look, I'm not in the business of wasting taxpayer dollars on a chopper ride for somebody just because the nurse at the local hospital doesn't want to deal with an interfacility transfer. My suspicion is that this "problem" is more of an issue with private providers that are transporting patients to their own facilities. If that's the case, we're not going to solve the problem here. Good luck and stay safe. SignatureGotta Go...It's Hot In Here, William Lyster-FF/NREMTB (working on P) <snip> > My agency (a publicly funded Fire Rescue service) provides ALS treatment and > transport in a large metropolitan area. We have a diversion program in our > protocol that allows us to bypass facilities in the case of suspected stroke > and heart attack. But we must go to the nearest stroke facility or hospital > with a cath lab. Patients meeting trauma alert criteria are either flown or > ground transported to the in-county Level I trauma center. Excellent, this is exactly what I had been talking about from my first original post. Every Ambulance company should have this diversion program. It is exactly what should have taken place when the pt had C/P and SOB, she should have been brought to our facility, the closest with a CC Lab. though not the closest hospital. >>Actually, what I am talking about is patients taken to hospitals that >>offer [quoted text clipped - 14 lines] > We don't. Because there are no objective measurements of > better qualified except in burns and trauma. There are objective measurements for MI and stroke care. The measurements include the number of patiented cared for in a year, the availability of certain services, like angioplasty, whether or not treatments, like tPA are giving within a certain time window to appropriate patients. These things can be measured and these measurements can be |
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