"Nearest Appropriate Facility"

[firemoose827 324]

Is it me, or do certain EMS providers read as far as the "Nearest" and than stop? The protocols all tell the EMS provider to transport the patient to the "Nearest Appropriate Facility", in other words a facility that can provide the level of care the patient needs...NOT the one that will get you back to bed faster.

I have been noticing lately that there is a GROSS need for re-education of our EMT's and Paramedics (in my county any way) to express the Need to transport the patient to the Appropriate facility and replace "Nearest" with "In a timely fashion that meets or exceeds the Golden Hour criteria" for trauma patients.

My county has a small, poorly equipped and understaffed community hospital called "Cobleskill Regional Hospital". It can do very little for Stroke patients, OB patients, or broken bones, can do nothing at all for burn victims or psych patients. To make a long story short, its a "First Aid Station" or "Clinic" for the locals to go to after hours to get attention for their sniffles and aches and pains when their doctors offices are closed. BUT, most of the squads in our area, mine included, always seem to transport the patients they treat in the field to this facility...Why? Because its local. We have a Level II trauma center 35 minutes away in Cooperstown NY, a level I trauma center in Albany Medical Center where the Life Net Helicopter is stationed, we have a stroke center located in Schenectady called Ellis Hospital all of which are about a 40 minute ride without L&S. But do you think the squad will transport to these facilities? Very Rare. I listen to the scanner when Im at my PT job for the ambulance I work for and hear all the squads taking patients that need a high level of care to our hospital, and can usually predict when we will get the call to transport that patient to a better facility to the nearest 5 minutes!! Its realy pathetic I know, but they do it, and the only thing it does for the patient is prolong the needed treatment and gives them another ambulance ride and a bigger insurance bill...All because the EMT needed to get back to dinner, or a family party, or the football game...Have we as EMS providers lost our sense of duty for the patient? Have we forgotten what our jobs are, to provide the best level of care for the patient including transportation to the "Appropriate" medical facility that can treat and care for the patient properly? It is something that has been bugging me now for a long time. What does everyone else have to say about this issue? Advice?

[Guest alsfirefighter]

Good post Moose and I have seen it all to often as well, particularly with certain VACS that disregard hospitals diversion requests. And why for their own convenience instead of getting the patient to the hospital that can take care of their needs in a timely and better fashion. Also in that arena is the thread I'm sure you read about the difference between calling a medevac and waiting several minutes or just getting up the road to the hospital. It comes down to several things...understanding your job, training, knowing your role (I love when non-ems cert'd firefighters tell me how to treat my patient or where they should go and how) and doing what is best for your patient that you feel...even if its not the most popular amongst the peanut gallery.

As far as the golden hour criteria...while that is still a good benchmark there are those arguing that it isn't as solid as originally thought. I don't mean this as a slight...but Paramedics shouldn't be having this issue. Most significantly ill persons are going to have a Medic on board and they should be making good transport decisions for several reasons. The first and the priority is getting the patient to appropriate treatment and care and the other is being a solid leader and mentor for BLS to learn from. As far as the EMT's it sounds like it comes down to no or inadequate QA/QI and no leadership and/or management stepping up to solve the issue. As well as training issues. I've never been a fan of the current curriculum after it went into place 8 or so years ago. Too simplified in my honest opinion. After good training and they still do it then its a personal issue...that's the importance of QA/QI and management with a backbone to discipline those whom seem to have an issue complying.

[NWFDMedic 58]

Along with this, we as an EMS system need to do a better job of educating the public. Ten years ago here in the Hudson Valley a hospital was a hospital and you went there regardless, with the possible exception of a serious trauma or burn. Sometimes a patient's preferred hospital is not the best choice and you have to educate them and their families. Sometimes, even other medical professionals (ie. doctors) need to be educated. I've even had cases where I've gotten the ER doctor on the phone and had him tell the patient that their facility was not the most appropriate and could not provide them definitive care. The patient will not always agree with our definition of closest appropriate.

The other issue I've had recently is with some of the facilities. Just because hospital A is a trauma center and hospital B is a cardiac center, it doesn't release their responsibility to be an emergency department. There is no reason why the cardiac center cannot handle a simple trauma that does not meet trauma criteria. Likewise, there is no reason why the trauma center cannot handle a non-acute cardiac patient. Even hospitals that do not handle certain types of patients (ie. pediatrics) still can treat basic ED cases.

I try to make an appropriate decision and I will advocate my patient going to the closest appropriate facility. Sometimes, however, that may not be possible.

[50-65 205]

Exactly!

Ex 1. I know of a case about 2 years ago where a VAC took a GSW to Phelps instead of a few miles down the road to WMC, where we ended up transfering him to.

Ex 2. A pt in cardiac arrest is taken to Northern Westchester, bypassing Hudson Valley Hospital, because they were on diversion. The pt was later transferred to WMC in critical condition.

Ex 3. A pt with left arm fracture and chest trauma taken to Putnam Hospital. Transferred by ground to Jacobi.

I'm sure everyone out there could give many examples. NWFD, you are correct. It comes down to training, along with experiance.

But sometimes some people don't care. They just want the pt out of their ambulance so they can get on with their life.

[firemoose827 324]

Along with this, we as an EMS system need to do a better job of educating the public. Ten years ago here in the Hudson Valley a hospital was a hospital and you went there regardless, with the possible exception of a serious trauma or burn. Sometimes a patient's preferred hospital is not the best choice and you have to educate them and their families. Sometimes, even other medical professionals (ie. doctors) need to be educated. I've even had cases where I've gotten the ER doctor on the phone and had him tell the patient that their facility was not the most appropriate and could not provide them definitive care. The patient will not always agree with our definition of closest appropriate.

That is another frustration of mine, you hit it on the head NWFD. One of our EMS COORDINATORS took a cardiac patient, pale, extremely diaphoretic, substernal CP 8/10, multifocal PVC's, the whole nine to our LOCAL HOSPITAL instead of Albany or Schenectady where he needed to be. The doctor got on the radio when he called in the report to the ED and told him "Negative, you WILL divert to Albany Med, we can not care for this patient here!!" He ended up getting in trouble. So its not just training, this coordinator is a Paramedic, CIC, been doing this for 25-30 years now and he still messed up.

My other favorite is the radio reports I hear some times! My last favorite one was for a stroke patient. KNOWN History, paralysis to the right side with facial droop, not fully alert, and this squad is located about halfway between Coby Regional and Albany Med and they took him to Coby!! Their report stated that "They advised patient of the need to go to Ellis or Albany Med and they REFUSED and demanded to go to Coby." The patient refused??? A minute ago they were not fully alert!!! LOL So now they are covering themselves on the radio reports to the ED!!

The other issue I've had recently is with some of the facilities. Just because hospital A is a trauma center and hospital B is a cardiac center, it doesn't release their responsibility to be an emergency department. There is no reason why the cardiac center cannot handle a simple trauma that does not meet trauma criteria. Likewise, there is no reason why the trauma center cannot handle a non-acute cardiac patient. Even hospitals that do not handle certain types of patients (ie. pediatrics) still can treat basic ED cases.

I agree totally. I was merely stating that the hospital is a certain level of care, meaning they should have the capability to render the appropriate care to the patient. I just try to keep a mental note of the best facilities for certain patients based on experience with them both personal and professional. Like Ellis hospital in Schenectady has the best Stroke center and can specialize in stroke care. St Peters in Albany has a great Cardiac Center and good cardiac doctors so I take cardiac there. Albany Med is a Level I trauma with a great staff and specialties in many different fields as well as a HUGE ED with plenty of equipment and staff to handle anything. The Life Net Chopper is based on the roof of Albany Med as well. Good posts, thank you all so far.

[MerlinMedic 5]

Moose, you are preaching to the choir here. There isn't a whole lot you or I can do about it. The ReMac wont do anything about it, SCARSA wont either. Nor will the Docs. Until someone brings a lawsuit, we are SoL.

The answer is for YOU to get your ALS back & take your patients where they need to be. I do that. Bassett Mothership (Cooperstown for all you non-AAREMS folk) has been very surprised to me several times over ths last few months, but extreemly happy with presentation & care. Of course, I want narcs & 12 lead, but we are a poor rural volly squad who can't get our driveway paved 'casue we be too poor.

[firemoose827 324]

Moose, you are preaching to the choir here. There isn't a whole lot you or I can do about it. The ReMac wont do anything about it, SCARSA wont either. Nor will the Docs. Until someone brings a lawsuit, we are SoL.

The answer is for YOU to get your ALS back & take your patients where they need to be. I do that. Bassett Mothership (Cooperstown for all you non-AAREMS folk) has been very surprised to me several times over ths last few months, but extreemly happy with presentation & care. Of course, I want narcs & 12 lead, but we are a poor rural volly squad who can't get our driveway paved 'casue we be too poor.

LOL, you dont need a paved driveway, your in the country...Suck it up!!! LOL

If you want Narcs and 12 lead call me at work, 24 hour shift every saturday in Station 3, Cobleskill. LOL

And one more thing, about me getting my ALS back...NO!!!

Did I say that clear enough for ya?!!! LOL Stay Safe and talk to you soon hopefully.

[mfkap 0]

But sometimes some people don't care. They just want the pt out of their ambulance so they can get on with their life.

I volly in a system that has 5 receiving hospitals within 10 minutes using L&S. And while approximately 90% of our calls are S or P on the CUPS scale (do we still use that?), over 90% of the calls transport to the hospital from the scene with Lights and Sirens. Ankle sprains, minor lacs, stable patients with general malaise, all go hats n horns to the hospital. And the reason I mention it in this thread is because it is the same "I have better things to do" attitude. SEVERAL times I have had EMT's (and officers) instruct the ambulance to transport lights and sirens because they have dinner waiting at home, or they have to go to work, or they have plans that night. Combine that with the "I do this volunteer only so I can drive a big truck with lights and make a lot of noise, and I don't want to do it if I have to just drive normal" and it is only a matter of time before there is a serious MVA involving an ambulance, and the patient in the back was a 24 y.o. female with shoulder pain after tripping on the sidewalk. It makes me sick that we need good people to get hurt, and the services to look bad, before any changes are made.

[WAS967 97]

Combine that with the "I do this volunteer only so I can drive a big truck with lights and make a lot of noise, and I don't want to do it if I have to just drive normal" and it is only a matter of time before there is a serious MVA involving an ambulance, and the patient in the back was a 24 y.o. female with shoulder pain after tripping on the sidewalk.

We just discussed this at an inservice tonight. If you are driving lights and sirens, and the case in the back is NOT an "emergency" then you place youself in a huge amount of liability. There was a case of a 22 Year Old female EMT who was driving L&S to a hospital with a DNR Cancer patient in the back with trouble breathing. She crashed into a car and killed 2 people. The jury is not anticipated to see that as justifiable use of L&S and she is facing 2 counts of Vehicular Homicide. Use your head when you use your lights and sirens. If you have dinner at home waiting for you, you can nuke it when you get back. If there are other things more more important to you then the patient, then you need to rethink your being involved in EMS.

Edited October 3, 2008 by WAS967

[MerlinMedic 5]

If there are other things more more important to you then the patient, then you need to rethink your being involved in EMS.

EERRRRRRRRGGGGGG! You are so right. I once got into a pretty good pissing match with a volly who said her Fire Chief ordered them to go L & S anytime the medic was on board. I ended that argument in my typical, kind, professional manor: "What a great Nazi you would have been, that argument got a lot of folks hung in Nuremburg 1945!"

Now, with hind sight, I can safely say that I have told people who use that logic to get an opinion, in writing, form their insurance carrier; to bring the matter to the floor at a regular meeting & make it a formal request WITH A VOTE. That has made a few tone down their L & S response.

And Moose, GET YOUR BLOODY ALS BACK!!!!!!!! Did I say it clearly enough for you?