New Respect For ER Techs and Triage Nurses

[uglyEMT]

Had a particularly crappy shift last night (nothing super bad or major just a long drawn out one) and twords the end I was given a new found respect for the Techs and Nurses.

Twords the end of the shift we have a head injury w/ neck pain call so of course its off to the nearest Trauma Center. Wasn't bad enough for Level 1 and a medivac so we ground transported to the nearest Level 2 (still is trying for 1 cert / don't know the business end of that so I digress). Just as we pull up we get hit with we are on full divert effective immediatly.... well when we called you it would have been nice to know.... Well I state my case for at least taking my patient. Intake nurse agrees but notifies us no beds were available and we probably would be in a hallway. Fine at least we are at diffinitive care and should be on our way.

Partner writes up the PCR while I stay with my patient awaiting the Triage Nurse to take over care. Nothing.. great shift change. OK no big deal in a little bit things will get better. Out of the blue it seemed two CPRs come crashing through the doors.. intake nurse is shocked and tried to say divert but tell that to two seperate crews cot surfing and one riding the lightning. She hits the OS button but very few hands come (come to find out later 4 nurses called in sick). The main ER Doc see me standing by my patient and just says here now (now I know how my dog feels) I tell my partner to stay with the patient and get to the Doc's side. Basically I was just another set of hands to help out with compressions and bagging. No big deal at least it isn't in the back of a moving rig. After a short time some RNs show up and I am out of the way back with my patient.

Again I go to the intake nurse and remind her we are still there. I get the drop the PCR in the box and go. Ummmm NO!!! I have a patient with a head injury, in full C-spine, on O2, in and out of it so NO I am not just leaving the patient in the hallway until I get a higher level of care. Guess at that point my patient advocacy balls got twisted and the CMA abandonment light went off. She says fine someone will be over soon. Told my partner to grab a cup of coffee we will be a while. Figured with two codes back to back Im at the bottom of the toteum pole.

Well fast foward 2 1/2hrs, an O2 tank later, several more sets of vitals, PMSes, and reassesments on my piece of tape and I finally get a Triage Nurse. This Nurse couldn't A)believe I would stay that long and have my rig OOS B)Not through a fit and C)continue with O2 therapy and keep treating my patient. She was actually impressed and got on things fast. Before I knew it we had a Doc on the way, CT/X-ray lined up and were allowed on our merry way. On the way out even got a thank you from a family member that just arrived.

Ok so where in there did I find new respect? Being in the ED almost 3hrs, watching a short staffed nursing staff do their thing, and basically teching my patient until higher care arrived made me realize what still goes on after we leave. Watching nurses take care of multiple patients at once without missing a beat, going from full divert to getting a trauma and two codes within minutes of each other and realizing it was necessary to take them and still do their thing. I have heard some ER Techs say they are just babysitters or laundry services and I thought that is how it really was. But staying with my patient for so long and still doing what I can for my patient, having to go from that to working alongside ED staff working a full code, back to my patient again made me realize just what is necessary to be a Tech or Triage Nurse. Yea I know there are probably long stretches of pure bordum (doesn't the same go for us in the "streets"?) but in that few hours (which I have never had to do before) in the ED where it was hectic I witnessed and was part of something I would probably never have been in and to see how everyone shined opened my eyes a little more.

So the next time I am dropping my patient off and I get a snippy Nurse or Tech, maybe it isn't them. Maybe it was a bad day 5 minutes before I got there. I will try to be more accomidating next time.

Sorry if this sounded a little rambling or all over the place. I have had 1hr rest in between my EMS shift and here now at my regular job.

[usmc_chris]

... Just as we pull up we get hit with we are on full divert effective immediatly.... well when we called you it would have been nice to know.... Well I state my case for at least taking my patient. Intake nurse agrees but notifies us no beds were available and we probably would be in a hallway. Fine at least we are at diffinitive care and should be on our way....

... Out of the blue it seemed two CPRs come crashing through the doors.. intake nurse is shocked and tried to say divert but tell that to two seperate crews cot surfing and one riding the lightning...

I agree that they do more than we think they do... I found that out during Paramedic clinical rotations! But what caught my eye that I wanted to reply was the above portions of your post, just looking for clarification. Do you mean to say that as you were rolling through the doors the triage RN was trying to tell you to go somewhere else? Sorry lady (or gentleman as the case may be) but once the patient hits the doors (actually some distance outside of the doors, just not sure the specifics) the patient belongs to you (the hospital as the generalized "you"), per EMTALA. Just curious about the way you worded this.

[usalsfyre]

Sorry lady (or gentleman as the case may be) but once the patient hits the doors (actually some distance outside of the doors, just not sure the specifics) the patient belongs to you (the hospital as the generalized "you"), per EMTALA. Just curious about the way you worded this.

300 yards, I believe.

Off topic, but "divert" really doesn't exist, outside of a hospital having to physically close it's doors for an emergency condition. As far as EMTALA is concerned, your arrival is the same as a patient walking in the ED doors.

[uglyEMT]

I agree that they do more than we think they do... I found that out during Paramedic clinical rotations! But what caught my eye that I wanted to reply was the above portions of your post, just looking for clarification. Do you mean to say that as you were rolling through the doors the triage RN was trying to tell you to go somewhere else? Sorry lady (or gentleman as the case may be) but once the patient hits the doors (actually some distance outside of the doors, just not sure the specifics) the patient belongs to you (the hospital as the generalized "you"), per EMTALA. Just curious about the way you worded this.

Chris yes as I rolled through the door litterly into the ED. Even though 15min prior during our transport to their facility I called inover H.E.A.R and told them what I had. If they said divert then, at that point, I would have made a different choice and went to the Level 1 even though it was farther away. I think it was the fact of it being middle of the night and apperently a crazy shift there for most of the ED Staff that it was said the way it was to us.

Off topic, but "divert" really doesn't exist, outside of a hospital having to physically close it's doors for an emergency condition. As far as EMTALA is concerned, your arrival is the same as a patient walking in the ED doors.

usalsfyre with long travel times in my area if an ED is filling up too much the ED usually calls MICOM and has them contact all the 911 dispatchers to notify all ambulance crews that they are on full divert so we wont even consider them in our disicion making process. We have several hospitals witht he same level of care within roughly the same travel time (albeit still 30 to 40 minutes) so we can plan ahead. In our case and that of the codes we happened to be there just when they made that call.

Edited June 2, 2011 by UGLyEMT

[usmc_chris]

Chris yes as I rolled through the door litterly into the ED. Even though 15min prior during our transport to their facility I called inover H.E.A.R and told them what I had. If they said divert then, at that point, I would have made a different choice and went to the Level 1 even though it was farther away. I think it was the fact of it being middle of the night and apperently a crazy shift there for most of the ED Staff that it was said the way it was to us.

usalsfyre with long travel times in my area if an ED is filling up too much the ED usually calls MICOM and has them contact all the 911 dispatchers to notify all ambulance crews that they are on full divert so we wont even consider them in our disicion making process. We have several hospitals witht he same level of care within roughly the same travel time (albeit still 30 to 40 minutes) so we can plan ahead. In our case and that of the codes we happened to be there just when they made that call.

Somebody wasn't thinking right! It happens to everybody at some point, though, especially if they were overwhelmed.

As to "diversion" systems. As usalsfyre said, in most areas, there is no such thing as true "diversion." Hospitals aren't allowed to turn away patients (unless they have some sort of really good reason, like the building is on fire... overcrowding isn't a good enough reason). The systems in place are courtesy requests that EMS attempt to take patients elsewhere. Of course, patients have the right to insist on going to whatever hospital they choose. And there are also protocol requirements, like trauma centers, stroke centers, hospitals with cath labs, etc.

In my region, about a year ago, they removed the system of hospital status we had. We have five hospitals in our county, with varying capabilities. This was done as a trial to "see what happened." They actually found that it improved drop times! As such, the system hasn't been re-introduced. What was happening is that hospitals were using the concept of diversion as a crutch, so that EMS patients would usually go somewhere else, so they didn't have to clear out the ED as quickly. Since they no longer have this crutch, the hospitals have streamlined processes to ensure that patients are adequately triaged and placed as soon as possible. I used to wait up to four hours for a bed at the local trauma center, my average drop times are less than an hour on the rare occasions I go there now, even for lower level medical problems.

[uglyEMT]

Everything you said is true to my area as well chris. It is a crutch they use and we accomidate as best as possible but untimatly it is up to the patient and the patients needs. If I need a stroke center, divert or no divert (minus fire or natural disaster) I am going there. Same goes for cath labs ect. The divert thing is used mainly for the 3am stubbed toe want meds kind of calls where we could use other local resources.

I guess its just the verbage in my area the way we use it. Its not really set in stone but is fround upon unless it is medically necessary.

[NYCEMS9115]

300 yards, I believe.

That is 3 football fields. Unless, you're referring to real Rural Areas. I believe it is once you enter the Hospital threshold. There are people who live less than 300yds from the hospital. Regardless, the EMS Providers are not relieved of their duties until properly relieved.

Content unchanged; added another point...

Edited June 4, 2011 by NYCEMS9115

[Richard B the EMT]

Someone translate the alphabet soup of EMTATA? I am guessing it means that any patient that presents, or is presented, at an ER MUST be seen in that facility, if only to be evaluated as to stability for transfer to another facility, in an old wording.

NYC system has the hospitals grouped in "Pods". If over a certain number of them request specific category "closing", all within that pod are "reopened to catchment area" in that category.

[JPINFV]

Someone translate the alphabet soup of EMTATA?

EMTALA: Emergency Medical Treatment and Active Labor Act. The gist is that every patient who presents to the ED requesting assistance must receive a medical screening exam, and if a life threatening condition or active labor is present, the patient must be stabilized to the best of the hospital's ability, and if specialty care is needed beyond the scope of the hospital, only then can the patient be transferred. This is all without regard to the patient's ability to pay.

[Richard B the EMT]

That was a bit more extensive than what I had thought. Thank you.