The future of medicine in Washington State

[Kiwiology]

There is a 16 page list of what is not covered. Check out the link for the full list.

http://www.wsha.org/...0Conditions.pdf

Some interesting ones include:

Streptococal septicemia

Hypoglycemic coma

Cardiac dysrhythmia

CHF

Pneumonia

COPD

Status Asthmaticus

Acute cholecystitis

Miscarriage

Pretty much any joint pain or sprain

Epistaxis

Abd pain

This shit is more fucked up than TAG fatty acid synthesis and you know that's just a whole bunch of screwed up right there, heck its so twisted it might even be a protein!

How in the bloody hell can they say septicaemia is not en emergency? coz maybe if your leukocyte count goes up and does a bit of left shift it'll be ok coz it'll magic away the s. aureus or whatever but what about that s. pneumonae hiding in your lung from thirty years of smoking and eating shit food so now it just turns up whenever the fuck it feels like coz your immune system is so screwed up y'alls helper T cells can't help no more? huh? what if that decides to go on a vacation to your bloodstream? man, freaking bacteria .... never happy, always wanting to travel to places they don't belong and become all virulent and shit ....hmm not unlike Kiwi

Same goes for status asthmaticus ... which if I remember correctly (you know each time I learn a new word like F0F1ATPase it pushes an old word out my brain like now I don't know what colour those red fire trucks are anymore...but when have they ever been important huh? huh? huh? hey IAFF go fuck yourself!) anyway so if I remember correctly status asthmaticus is severe, refractory asthma where oh I don't know the patient has a high chance of um, dying like right now like soon like where in the hell is the Consultant this bloke is nunngered up to buggery and my ass is puckering?

Adbo pain is the same thing ... abdo pain can be gastroenteritis or it could be something serious in his gizzard has gone kaput

I'm going to stop now because this shit makes me so angry ...

Edited January 17, 2012 by kiwimedic

[ERDoc]

EMTCitying drunk is as dangerous as texting and facebooking drunk.

[Kiwiology]

I don't drink

[ERDoc]

Then I think the Krebs Cycle has fried your brain, lol.

[systemet]

I think the problem of EMS-initiated refusals is a smaller part of the bigger issue of medical tort reform. I think if the healthcare system was better organised, some risk might be mitigated by having physician oversight on cancellations during an initial roll-out phase, and some point-of-care testing might mitigate some risks. if you could D-dimer that high risk patient in the field, then discuss with an MD, maybe they'll feel safer with the refusal with a negative D-dimer? Then again, maybe just the fact that the paramedic has done the D-dimer provides enough evidence for a lawyer to say "Well, you guys were thinking PE", and "What's the sensitivity of a D-dimer for acute PE?". [Also, can EMS be responsible enough not to D-dimer the low-risk cases, or would we just end up transporting a lot of false-negatives for expensive V-Q scanning?]

Malpractice law is a difficult area. It does protect patients, to some extent, but it also drives up the cost of the system, and results in a lot of unnecessary testing. In some countries you can chat with an RN on the phone, and they can book you an appointment with your family doctor, send you to a lower level ER, a higher-level ER, tell you not to present to healthcare, or simply book your appointment for 3 weeks time. These countries kill off a lot of atypical presenters, but do a much better job managing their resources, and provide expedient care for the sick patients with clear signs and symptoms.

-----

An example of such a system here:

http://www.electoral-math.com/archive/200504/20050430.html

[Haven't read this blog before, it was just one of the first links on google].

[ERDoc]

I think the problem of EMS-initiated refusals is a smaller part of the bigger issue of medical tort reform. I think if the healthcare system was better organised, some risk might be mitigated by having physician oversight on cancellations during an initial roll-out phase, and some point-of-care testing might mitigate some risks. if you could D-dimer that high risk patient in the field, then discuss with an MD, maybe they'll feel safer with the refusal with a negative D-dimer? Then again, maybe just the fact that the paramedic has done the D-dimer provides enough evidence for a lawyer to say "Well, you guys were thinking PE", and "What's the sensitivity of a D-dimer for acute PE?". [Also, can EMS be responsible enough not to D-dimer the low-risk cases, or would we just end up transporting a lot of false-negatives for expensive V-Q scanning?

I'm going a little off topic, but this is why the system is so difficult. If your pt has a moderate or high pretest probability of a PE, then the d-dimer is useless even if it is negative. There is still a high enough incidence in this population that you need to test (VQ vs CT). It is the low risk pts that the d-dimer works well for. As for the nurse lines, around here their answer is to send everyone to the ER.

[Just Plain Ruff]

As for the nurse lines, around here their answer is to send everyone to the ER.

Again, liability touts common sense.

Nurse lines are specifically trained to tell every single caller that if they think they need to go to the ER then they should go.

Anything above take 2 tylenol and call your doctor in the morning gets the standard "go to the ER" mantra.

Until tort reform in medicine is done, we are still going to have the majority of systems refusing to allow their medics to initiate refusals or no transports.

I've always offered the no transport suggestion to the patient if I don't think they need to go but I always, and I REPEAT ALWAYS temper that offer with a counter offer of transport to the ER for physician evaluation. Until my service backs me with specific "provider initiated no transport"protocols, I'm going to transport the patient. My licensure is too hard fought to lose by a service who won't back me.

[Kiwiology]

This is really a complex problem. I have been studying biochemistry for last five hours so excuse me if my thoughts run out my eyes ....

Paramedics should be able to leave people at home, they do here, in AU, in UK as well. Mind you we have a lot more education than US it still doesn't make us perfect, we leave people at home they die, ED sends people home they die ... our Clinical Director Tony Smith (FANZCA FJCICM) and Fiona Moore from the LAS (FCEM(UK)) have stated you cannot simply transport every patient, and you cannot, I do not understand how US hospital system does not collapse and simply implode with you blokes not being able to refuse to take people bloody hell!!

The balance of clinical risk will always be transporting some patients; e.g. OB/gynae I have a very low threshold for conveying to hospital; somebody who is in second trimester with diffuse abdo pain/cramp but pain free between cramps/watery diarrhoea/maybe a little fever/nausea and no vag bleeding I would let her stay at home but a multiparous black lady who has an IUD, multiple sexual partners, smokes like a train and has tummy pain is getting conveyed to hospital +/- red lights. Somebody who has BP >140 on 2 separate readings > 15 min apart technically has maternal hypertension and that's enough for me to tell them to go see the doctor.

In reality again, most people who go to ED probably need to go to the hospital for some sort of hospital level diagnostic testing or procedure the GP can't do or so the research here in and in AU says (I'll see what I can find) and most people with acute minor problem e.g. splinter / tummy pain can be dealt with by an NP (or Nurse Consultant) and/or House Surgeon/House Officer and sent on their way very quickly; some of our EDs have a GP during the day or extended hours for minor things. In the UK they have NHS Minor Injuries and Walk in Centre which is like what you in US call a "community ER"

However at the end of the day you should have access to the hospital if you need it; I will always choose to go to the hospital if I don't think my GP can handle the problem at their clinic; even if I'm seeing a dangerously overworked, underfed and horrendously fatigued House Surgeon they still have access to all the fancy machines (through their Registrar or Consultant) and it's just more reassuring honestly.

Primary care in the US seems to be very different than here or in Commonwealth/universal access countries e.g. in NZ GPs are private business with some subsidies from Government for low income/young children/free for under 6's etc while in UK they are private too but with NHS contract making free to patient ... we can get an appointment in one to two days wait or sometimes same day. Some big GP clinics do x-rays/sutures/fracture casting etc but this is more the realm of the accident and medical clinic but these are very expensive so why not go to hospital , wait a while and see the dangerously underfed, overworked and fatigued House Surgeon? Truth be told you do not even see a doctor here for a broken arm unless orthopaedically complex or a surgical opinion required the nurse can order and interpret the x-rays, cast it and give some simple analgesia.

The answer is not not sending people to emergency department; the answer is reforming how the system reimburses, to say "we will not pay" is stupid. Now, does that mean I am not going to rort the fuck out your totally screwed up privatised healthcare system for a few years to make a half million dollars a year as a Consultant Physician so I can retire at 45 and get me a boat? Hell no!

Edited January 17, 2012 by kiwimedic

[systemet]

I'm going a little off topic, but this is why the system is so difficult. If your pt has a moderate or high pretest probability of a PE, then the d-dimer is useless even if it is negative. There is still a high enough incidence in this population that you need to test (VQ vs CT). It is the low risk pts that the d-dimer works well for.

Perhaps I don't understand this area well enough -- but isn't the specificity for the D dimer also pretty crappy? If you were to routinely D dimer every chest pain, wouldn't you also end up getting a ton of false-positives? I thought this was part of the rationale behind the PERC rule / Wells score systems?

As for the nurse lines, around here their answer is to send everyone to the ER.

This was the problem when I was working in North America. And, really, you can't blame them. If they tell someone having a headache with symptoms similar to their prior migraine headaches to take an NSAID, rest, have someone responsible check on them periodically and call back if the nature of their symptoms changes, and it ends up being a CVA, then they're going to lose their house and their career.

It seems like sometimes we have very strange ideas about risk management and personal responsibility.

[Kiwiology]

This was the problem when I was working in North America. And, really, you can't blame them. If they tell someone having a headache with symptoms similar to their prior migraine headaches to take an NSAID, rest, have someone responsible check on them periodically and call back if the nature of their symptoms changes, and it ends up being a CVA, then they're going to lose their house and their career.

It seems like sometimes we have very strange ideas about risk management and personal responsibility.

Indeed, there is nothing in that statement that is clinically unreasonable given the information and history presented.

That is why I like it that you can't sue people here, cuts down on the frivolous lawsuits and defensive medicine