Is Having More Ambulances The Solution?

[JaxSage]

funny, I can do everything that you said you can do. I can put an iv in anywhere that there is a vein, I can decide whether or not to c-spine someone, I can decide whether or not to RSI some poor chap and many other things. I can also spike and hang blood without a nurses OK.

Can you with 100% certainty say that all your paramedics are smart enough to know the difference that the knee pain that has been going on for weeks or years is not this time a blood clot?

Can you for 100% certainty say that the menstrual bleeding is not a miscarriage? Or one of the other pregnancy complications that I can't for the life of me think of right now.

I'm still leary of letting every paramedic in any system have the ability to refuse transport.

Let's discuss children now, child has a fever that started yesterday? Are you sure that all your paramedics in your system can differentiate between pneumonia or bronchitis, or RSV?

Sorry to disagree but I'm going to have to continually be leary of letting every medic in any system do this. The ones who are competent and educated can do this but by the logic that begs to happen here, can you be 100% sure that all your medics are as educated as you say you are?

just disagreeing

Ruff, I never said that ALL of the medics on the job were competent or educated enough to make the decision to deny transport. Like I said in my last post, some medics have misused their judgments when denying someone transportation. I believe that most of us on the job do a good job when it comes to making that type of decision. However, Ruff, our protocol concerning this matter is more geared towards those who obviously don't need an ambulance (e.g. paper cuts, the sniffles, etc.). If we come across a patient with a questionable problem, then we transport. If there is any doubt in mind, we transport. If it's obvious that this person needs a clinic and not an ER, then we refuse.

To answer your question, I suppose none of us could be 100% certain that a person's paper cut won't lead to respiratory failure and that a person's knee pain that he has been having for twenty years isn't a possible blood clot. If we're going to second guess every ridiculous problem that is obviously ridiculous, then we might as well stop complaining whenever a patient, especially a frequent flyer, calls us for what seems to be a bogus concern...because you just never know.

It's fine to disagree. Not everybody would agree with this policy of ours. But with a lack of ambulances, a lack of resources, and a high call volune with the number of people in our county, we can't afford to just take everybody to the hospital. Ultimately, the citizens in the county will pay dearly for that. Whenever I would tell people that if you call 911 you may or may not get an ambulance, they think that's just scary. Read the news and see how many people died because they couldn't get an ambulance because one wasn't available. I think that this fact wouldn't really hit home until one of our loved ones needs an ambulance...and knowing that there's a possibility that one may not show up.

By the way, we don't have forms for patients to sign when we refuse them...for the obvious reason that patients won't sign them if they don't agree with our decision. We do have forms for patients to sign when THEY refuse EMS and when we think they ought to go to the hospital with us.

[reaper]

Sounds to me that there needs to be some changes in the way your county manages EMS!

I work a county with a population of over 500k. We run between 15-19 trucks. We do not deny transport to anyone and still manage to cover the county just fine.

For what you have described as your "guidelines" on this. There is no way I would be caught dead, tied up in that system. Because when the poop hits the rotors, everyone is going to get hit by it!

[Just Plain Ruff]

Jax thanks for the clarification. I agree with you, not everyone in every system are competent enough to be allowed to do this.

As for the people who call for the paper cut, how many of those do we as a collective system get? I'd be surprised if it is more than 1% of the call volume, I'd be more inclined to believe it was less than 1/10 of one percent.

I am still uncomfortable in allowing this type of practice. It just seems rife for abuse as well as chock full of possibility to get my butt in a ringer if the patient comes back in a lawsuit.

I am by no means lawsuit shy nor am I a very conservative medic but I don't feel comfortable refusing transport to anyone. They called I transport, sure it's a you call we haul type of mentality but they perceive it as their emergency and as long as the patients are not educated to know better, which 97% of patients are not, then if they want to go, I'll take em.

Jax, I really wasn't trying to start any crap with you, just pointing out my thoughts and ramblings.

[crazyemt5150]

Ok so I'm all for denying pt's transportation when its not needed but will your protocol save your ass when you make the wrong field impression. I don't know if you guys heard of the crew that responded to a call and arrived on scene and determined that the pt was just suffering from heart burn, told the pt to take some tums and go to sleep that all his vitals were normal. Guess what a couple of hours later the guy died from a massive heart attack. The crew is now being sewed for neglect and a failure to perform duties. I honestly think that it is easier to go ahead and just transport a pt to the hospital you will have the same paper work no matter what. Cause i don't know about you guys but i don't feel like loosing my license anytime soon

[JaxSage]

Sounds to me that there needs to be some changes in the way your county manages EMS!

I work a county with a population of over 500k. We run between 15-19 trucks. We do not deny transport to anyone and still manage to cover the county just fine.

Good for your guys, then. It's not the case with us. Perhaps your county doesn't get ten EMS calls within two minutes like it is in my county. Literally, the busiest times of the day are at lunch time and during the 5:00 rush. It's very common for five or more calls to go out within two minutes. It's very common for almost all of our trucks to be depleted in no time. In five minutes, communications let the supervisor know that Medic such and such is the only unit available in the city. So, it's not so much of how the county manages EMS, it's the freaking call volume and the frequency of those calls.

Since we are able to deny transport, that actually helps us to respond to more calls. For example, one time my partner and I had eleven calls within a 12-hour shift. You know that one call could take about an hour if you include responding to the scene, staying on the scene, transporting to the hospital, and waiting at the hospital, and getting your stretcher ready. There is NO WAY we could have ran eleven calls and transported all those folks to the hospital within a 12-hour shift. As you probably guessed, most of those calls did not end up in transportation. Another time, my partner and I ran about four calls within ONE HOUR. No, we didn't transport anybody, but that should give you an idea of how quickly calls come in. Literally, this county would be in BAD SHAPE if we took everybody to the hospital. And this county has less people than yours.

RUFF, I know you ain't trying to start something, buddy Like I said, not everybody would feel comfortable with how we run things. Personally, I LOVE it. I hate 911 abuse and I hate people treating us like a taxi ride. I'm actually glad that someone stepped up and said that we're going to use EMS the way it should be used. Not everybody agrees, but you can't always make everybody happy. And by the way, what I've learned is that not everybody who calls us necessarily want a hospital. They just want answers and think we're there to answer them. I agree that not everybody knows any better, so that is why we do educate them and explain to them why they don't need an ambulance and what would be the best thing for them. Sometimes, we would tell a person that making an appointment with their own doctor would be a much better choice than waiting 12 hours at an ER. And since we don't have to take everybody to the hospital, we don't have to lie or try to talk someone out of going to the hospital. We try to steer them in the right direction that is not only good for their medical needs, but also good for their financial needs as an ambulance ride ain't cheap.

CRAZYEMT, our protocol isn't perfect. No one's is. If we deny someone transport, we have to be certain that their condition does not merit emergent ALS transportation and carefully document our reason. We don't advocate cancelling everybody and we believe that it is always better to transport than to deny. Yes, you will get in trouble if you make the wrong choice, but it's always about making a thorough assessment, careful documentation, and standing by your decision. On top of that, our protocol allowed us to make that decision, so ultimately the person who would get in trouble would be the medical director and the EMS director. But if no one feels comfortable in denying someone, they would just transport. That's all.

By the way, you're right, our paperwork would be the same whether or not we transport a person. It's just the principal of thing

[VentMedic]

Personally, I LOVE it. I hate 911 abuse and I hate people treating us like a taxi ride. I'm actually glad that someone stepped up and said that we're going to use EMS the way it should be used.

I would not be comfortable with you denying transport to patients just based on your strong attitude. If you feel so strongly, you are not looking out for the best interest of the patient but what you think is best for EMS.

To express a dislike for something is one thing. But, when you use the word HATE, you have already planted an impression into your brain subconsciously and may be very quick to judge before medical assessment warrants.

You have already given numerous examples which are stereotyped. These examples demonstrate you can easily skew your assessment toward what you perceive to be guidelines.

[Christopher.Collins]

Would you please post your protocol for denying patients that do not need transport?

Oh boy, we're opening this can of worms again :twisted: :roll:

I spoke to my STATE OEMS Director on this whole matter as well as local hospital directors and many peers and instructors... and everyone came back with the same thing. Its not our job to decide what an emergency is, at least in a diagnostic sense. They all gave examples of true emergencies that may not present as such... tooth ache and jaw pain (without chest pain) could still be an MI.

Finally, for your reading pleasure:

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

Man Dies at Home After Paramedics Diagnose Acid Reflux

By Elissa Silverman

Washington Post Staff Writer

Thursday, December 4, 2008; Page B04

A 39-year-old Northeast Washington man died yesterday, a few hours after paramedics responding to his complaints of chest pains and trouble breathing told him he had acid reflux and did not take him to a hospital, family members said.

D.C. fire officials are investigating the circumstances surrounding the death of Edward L. Givens, who was found by family members just before 6 a.m. in his home in the 700 block of Division Avenue. Paramedics told Givens late Tuesday that he had acid reflux, instructed him to take Pepto-Bismol and left, family members said.

"I don't understand the paramedics, why, when he said he was in chest discomfort, he wasn't taken to the hospital," said Lolitha Givens, the man's mother, who lives in the home and was there when 911 was called Tuesday night. "I'm just baffled by that."

Paramedics are required by department protocol to transport by ambulance a patient who asks to go to a hospital, said Alan Etter, a spokesman for D.C. Fire and Emergency Medical Services.

Officials said the D.C. medical examiner will conduct an autopsy to determine a cause of death.

The department has launched an investigation into the call, Etter said. He said that the department will interview all personnel who responded and that top officials are involved in the review, including Fire Chief Dennis L. Rubin and Assistant Fire Chief Lawrence Schultz.

"As per protocol, we are conducting a thorough quality assurance case review, and we will determine whether proper care was provided and if the two medical events are related," Rubin said in a written statement.

Lolitha Givens said her son was in the living room Tuesday night when he yelled out to family members to call 911. He was on his back on the floor and said he had chest pains and was having trouble breathing.

A firetruck and ambulance from Engine 30 were dispatched to the house at 11:40 p.m., Etter said. The truck, staffed by three firefighters trained in emergency medicine and a firefighter-paramedic, arrived first.

Lolitha Givens said the firefighters asked her son what was wrong, and the emergency medical technicians who arrived by ambulance checked his vital signs and performed an electrocardiogram, the results of which they said were normal.

The EMTs asked Givens whether he had eaten or had anything to drink that evening, and he said he had eaten a burger, Givens said. They told him and his mother that he probably was suffering from acid reflux and suggested he take antacid.

"Six hours later, my son was on the floor, dead," Lolitha Givens said.

[spenac]

Oh boy, we're opening this can of worms again :twisted: :roll:

.

Bite me.

Oh yeah that artical was already posted somewhere. Besides somewhere because of all the idiots lately I changed my mind. I concede 99.9990865231% of EMS people are not educated enough, smart enough, have enough common sense and in fact many are just to lazy to trust with that responsibility. So there is no point in keeping an option available for the two us that have the ability to handle it. :shock:

[Christopher.Collins]

In regards to the OP:

Well Ill say in my humble opinion that buying more ambulances alone will not solve the problem. If staffing is a problem as well, then who will run the additional units? Its one thing if you have the man-power to effectivley do so but completley different if not. By effectivley doing so, I mean NOT putting alot of personel on overtime. Of course overtime can be an option but it should be regulated to prevent over work and burn out.

For instance my old agency did it like this:

We had 8 hour shifts mostly for the transport services and 12 hour shifts mostly for the 9-1-1 services. Regardless of what shift you worked your allowed to work a maximum of 16 straight hours, and generally have the right to deny any (non 911) calls twords the end of the 16 hours if they will run you beyond that alloted time. Say you worked 0700-2300 and you were asked to do a transport at 2230 that would take you about an hour to complete, you can deny it. Between shifts you must also have a minimum of 8 hours off. This is especially required if you worked a 16 hour shift. For thoes unable to work a shift a SWAP must be completed between an equal or higher certified member.

Anyways... even with all the overtime oppurtunities and in my opinion fairly lineant rules, staffing was still a problem. We had about 30 or so ambulances in the agency but no bodies to fill them all.

~~~~~~~~

So, if it were up to you and you had to solve the issue of lack of coverage, how would you solve it?

First and fore most I would start seeking funds and grants to become more compliant to safety and comfort of my crews. I know its not an easy thing to do always... but thats my start.

Second... Id also listen to my employees and find out what they need and maybe from time to time want. Using Acadian Ambulance who is based in Louisianna, Texas and Mississppi for example... Ive spoke to some of their employees and many of them seem very happy with the company. All of whom have encouraged me to apply to Acadian. Personally, nothing draws me more to a potential place of employment than happy employees. With respect to my friends and peers, most agencies I know of seem to have nice and good people working for them... who are happy about what they do, but miserable about the company.

Continuing with happy employees... I would want a proffesional but FREINDLY management staff. Returning from a call I ran into the CEO of my old agency, I introduced myself and he flat out ignored and walked around and past me. Great way to treat people who are putting money in your pocket! I like open door polocies myself... knowing that if you have a problem you can go to a supervisor or manager and they will do the best to address the matter. Of course, its important to make sure employees know to follow the chain of command when doing so, it creates less headaches for management.

(*NOTE* No matter what you do to maintain proffesionalism but try to keep everyone happy theres always going to be something wrong, there will always be some drama. We are human and not perfect. But keeping an eye out and reporting issues of course should be EVERYONES duty).

Happy patients is another important start. What good is happyness in the company when we have a bad reputation. Hopefully all that love and happyness within the ranks will rub off causing proffesionalism and good care... and happy patients

Once I get my happy employees and proffesional managers then solve my drama problems... Im ganna start recruiting. By recruiting I mean getting out in the publics eye and showing that we are hiring and a good company in addition to the usual "Now Hiring" on the company web site. I dont see a need to activley recruit if a company has a bad reputation. My old agency had a local news station run a couple of stories on how they need paramedics and EMTs... truth be told the company is a damn joke. They even cut the paramedic class curriculum hours in half... bear in mind that even the class instructors will say the course is a joke. Their reputation is known throughout by patients and fellow EMSers alike. If I have instructors in my ranks, Ill start hosting in house classes. Ride time of course to be done on our rigs with our staff. Maybe put some recruiting videos on local TV like LAPD and the military.

Now that I have my happy well funded staff and a bunch of wet behind the ears, fresh ink on the card rookies with some damn good FTOs training them. I am ready to prove to my community that we take care of our people and equipment... once they are caught off guard with pleasure and open wallets twords our great service... THEN ILL BUY NEW AMBULANCES!

Im sure I dont need to mention my tone is mostly sarcastic. Ideally I would try to work in that order though... start cleaning in-house before worrying about more bodies and more buses. Though in some areas, and no to mention with this economy... it may not always be a realistic approach.

[Christopher.Collins]

Bite me.

Are you up to date on your vaccinations? :twisted:

Oh yeah that artical was already posted somewhere. Besides somewhere because of all the idiots lately I changed my mind. I concede 99.9990865231% of EMS people are not educated enough, smart enough, have enough common sense and in fact many are just to lazy to trust with that responsibility. So there is no point in keeping an option available for the two us that have the ability to handle it. :shock:

Sorry, I must have missed that. Sorry for the re-post. Anyways... Im only being an ass, you dont need to justify yourself to me Sir. Im sure we can all agree that there are alot of times we'd rather be available doing nothing in the event of a serious call... than we would taking Mrs. Doubtfire to the hospital cuz her dentures fell out. Then again, that could be a choking suffocation hazzard :evil: lol