Every call to the ER?

[HERBIE1]

Here's the deal. Like everything, local protocols and regulations differ. Our state statutes say that the caller defines what an emergency is, thus, nobody is turned away. It's not our job to determine whether or not WE think the issue is a true emergency. Now obviously someone who calls and complains of abdominal pain x's 3 months and they cannot take it any more- is that an "emergency"? Of course not, but then we(or more accurately, a lawyer) can "what if" the situation to death. What if they have a dissecting AAA and it's finally ready to rupture? Likely- no, but without further tests to confirm that DX, we have no foolproof way of ruling it out either in the field, either.

If your system has options other than transport via ambulance, then it's a good thing. Most places do not. So, in the interest of risk management, despite overburdening an already taxed EMS and hospital system, we bring them in, they wait for hours in an ER, and are sent home with a DX of constipation. For most of us, this will not change any time soon because it's all about potential liability, and rather than address the root problem, we get a reflexive CYA policy.

\Edit-

Just as an aside, with a private provider, unless it's a 911 response, the only limiting factor is whether or not the patient's complaint will warrant reimbursement by an insurance carrier. If it's cash up front, then it really does not matter.

Edited June 4, 2010 by HERBIE1

[paramedicmike]

You mean all 120 hours of the first aid course that constitutes EMTB in this country? If we want discretion to make transport decisions in the field then we need to commit to a proper education. And I don't mean a 7 month medic mill or even a 2 year associate degree.

I'm not sure why someone felt to mark this comment negatively. This is absolutely correct. EMT-Bs do not have adequate education to be making the decision whether or not someone really needs to be transported to the ER. Hell, a lot of paramedics don't have it, either.

EMT-B is glorified first aid. I hate to break it to all of you who may think otherwise. But that's what it is. (And at this point I think it would be good to remind people, too, that making such comments is NOT a personal slam. So don't take it as such.)

If you want to be able to make the determination as to who needs transport and who doesn't several things need to happen. First, we need to create an adequate educational process that will put providers on the street who have the educational foundation to function at a level higher than what we are now. Then, we'll need to demonstrate we can competently provide care at that higher level. Once that is done we'll be able to argue that we have the ability to refuse transports or direct people to alternative sites of care (e.g. urgent care clinics, primary care docs etc...).

In the meantime, expand your education. Move up to paramedic by taking a full on degree awarding program. Take as many classes as you can in addition to this educational foundation. It will not be wasted effort.

At times it may seem like it's simple to determine who needs transport and who doesn't. But it's not always that easy. And at this point it is simply an issue of not knowing what we don't know.

edited to fix a couple pretty blatant spelling errors.

Edited June 4, 2010 by paramedicmike

[Timmy]

I agree, EMT level providers should not be making clinical decisions in regards to patient transport.

In Australia (my state) our requests for emergency ambulance care are put through a triage type system and put into either one of the four categories. Code One Emergency = life threatening, Code Two = semi emergent, Code Three non life threatening and Code Four = psych patients. We also have a nurse on call system were you can receive information over the phone.

Maybe Josh or Phil could enlighten the situation because I don’t work for the ambulance but as far as I know paramedics here can refuse to transport. Were also seeing a growing number of paramedic practitioners who attend non life threatening jobs and can treat a patient accordingly, these guys have higher education in the primary health care area. We also have a paramedic clinician in all the operations centres who can decide what happens with a patient.

[Just Plain Ruff]

Looking for advice/suggestions/all the above: I work for a private ambulance service in Florida where the 911 service is fire-rescue. Often times my service is called to a residence where fire-rescue has already responded and deemed the patient non-urgent and in no need of ER care. So the patient calls us and even though we are under the same impression as fire-rescue we take the patient to the ER because that is what we are told to do. Upon arrival to the ER the staff usually shakes their heads and asks us why we thought the transport was necessary.

And of course I am not trying to dodge work....but I feel that through my training I can tell that a scratch and bump on the elbow does not require adding to the deluge of patients to the ER's in my city. I agree that most patients should go to the ER just to be sure there are no additional problems, i'm not a doctor just an EMT-B but shouldn't there be room for discretion?

Ok, you are the non-contracted ambulance service that if the contracted 911 service no-services these people then they call you to get taken to the ER? Do I have that right?

So the contracted service said that the person did not need to go to the ER via ambulance and then they call you and you take them?

If you aren't contracted then you certainly should be able to say, "Hey buttkis, the 911 guys said you didn't need to go so that's what we are saying" and leave. I would suspect that if you transported them and turned it in to insurance that the insurtards are gonna refuse to pay your servicde based on the original no service. Plus I do know that most insurance companies won't pay a hospital claim if you AMA and then come back to be seen again.

Your service is under no obligation to transport these people but to say that you have the medical training to know when a patient needs to go to the ER or not with just 120 hours of classwork and 2 days of ride time is making a huge assumption and it's going to get you in trouble.

I have had many emt's working with me who bitch and moan about transporting patients who they think do not need to be transported. It's like it's inconvenient to them. I usually tell these know it all's, to go back, get their paramedic and then they can make those decisions.

I had a paramedic partner tell me once when I was an EMT. Until I get my paramedic license, have 1-3 years in the field, and know a crapload more than I knew then, I needed to learn my place in the EMS hierarchy and stop trying to be a medic.

I am not digging at you but maybe you need that talk too.

It's like my son. He says Dad, I want to do so and so. I say no to him, he goes and does it anyway, he gets hurt or fails at it and I tell him, I told you so Liam, Daddy knows more about this than you and that's why I didn't want you to do it. I compare that to the EMT who tries to no service a patient or whatever and things go wrong.

Do I think you can tell the difference between a stubbed toe and a broken ankle YEP but can you tell the difference between a cold and pneumonia or chest pain versus PE?

I'll end with this. I know a medic who went on a chest pain call. Diagnosed it as costochondritis. Told the guy it wasn't cardiac related, guy refused. Time of refusal was 2330 or so. Next shift, other EMS crew goes out on a Dead body call. Same patient. Coroner ruled time of death around 2300 last night. The cause of death, Myocardial Infarction. Medic being sued for negligence and she says to me that "They are gonna kill me in court"

One other thing, if everytime that your service brings a patient in to the ER maybe you should step back and think of why this is happening?

Is it just that the nurses are overworked or is there another reason?

What are the attitudes of your EMS Staff? Do you treat the nurses at the ER with respect?

Or do your crews act like this patient is a burden to you and the nurses see that attitude and relay it back to you?

Does your service have a good reputation? You would be surprised at how often this is the underlying proximal cause of this type of ER reception. If your reputation is that you do not do a good job with the patients you bring then that might be the reason.

I've worked in areas where one service was despised by the nurses at the local ER based on the fact that the service was full of poor providers, had been caught stealing supplies (the ems service had financial issues and supplies were in short "supply") and had been accused of inapprorpriately treating patients with very outdated protocols.

That service no longer exists though.

When you get a feeling that people are not giving you a good reception, look inward at yourself and your service and see what might be the underlying issue.

If indeed they are bitchy because of their workload and taking it out on your crews, then definately a discussion with not only the hospital administration but with the ED administration as well. Don't go in half cocked to air your grievances about how you are treated by the nurses, your service needs to have a formulated outline of what is happening with CONCRETE examples. The generic "this happened one day" or "the other day one of your nurses" NO that does not cut it.

Your management has to have valid concrete examples with dates and times, patient names, nurses names and anyone else who may have witnessed the behavior.

You should be prepared for criticism of your companies actions if they perceive your service to be poor.

Once you have had a discussion with management on both sides, then you can formulate a plan between the hospital and the service to begin to improve relationships between the two entities.

A solid game plan will help you out with a lot of things.

ok ok ok I just have one more thing to say.

The nurses cannot control who brings who in to the ER. But since they can't bitch and moan to the patients who walk in or drive themselves they can do the next best thing.

Bitch about and to the people who also have no control over who or what they bring to the ER but you are a very easy target because their bitching and complaining does not get back to the patient. It stays with you.

What you can say is when they bitch about you bringing a certain patient in to the ER, tell em this "I'll go tell the patient what you just told me. I'll go tell that patient that you are mad at me for bringing them to the ER"

That will for sure, shut that nurse up for a long time.

I'd then follow it up with this "I'd like to talk to your nurse manager please" and discuss that nurses attitude in front of her.

That will also shut the nurse up but she would of course be your enemy for life but for every time she complains to you, you just go to her supervisor. Eventually the nurse will either be fired or you will have found a better job with a bunch of other nurses to bitch about you.

I tell you this because talking to the nurse manager in front of the offending nurse works, or at least it did for me.

Edited June 4, 2010 by Ruffems