Diversion to Stroke Center

[WAS967 97]

A recent hot topic of discussion has been that of Diversion to Stroke centers.

Attached please find both the BLS protocol from NYS and a recent advisory posted from the Westchester REMAC.

My question for all is this. If the patient meets the criteria, do you/will you divert to the nearest stroke center? In many cases (Northern Westchester, Putnam, Dutchess) this could mean a significantly longer transport than usual. Has anyone run into problems with a transporting agency refusing to take a patient to a stroke center because it was "too far away" or the like? Any cases of medical control or medical director saying to go to the closest facility even tho a stroke center might be more appropriate?

Many hospitals (Northern Westchester, Hudson Valley, Phelps and Westchester Medical for example) are working toward being Stroke Centers and approval could be imminent. But in the mean time the closest for most parts of the county is White Plains with Rockland (Good Sam and Nyack) and the Bronx (West. Square and Barnabas) being appropriate for others. Keep in mind CT hospitals do not yet factor into the stroke protocol because NONE have been approved by NYS as stroke centers. Yet.

I'm interested in hearing feedback.

NYS_strokeprotocol_update_feb05.pdf

REMAC_ADVISORY___stroke_centers_2sep05.pdf

[Guest alsfirefighter]

You can check on this also, but I believe that Hudson Valley is also a stroke center.

[WAS967 97]

Not according to NYS unless something was announced last night. When HVHC gets it's designation it will be announced. As of now, diversion to HVHC with a stroke as opposed to Nyack or WPHC would be inconsistent with protocol.

[Guest alsfirefighter]

WAS: I said the same exact thing but it came up that they actually have been for some time but I do not know why it wasn't announced. When I get more answers I'll share.

[RES20CUE 40]

I think it's ridiculous for an All Volunteer Corps, that already has about a 2-hour Ambulance call (ie: North Salem, Somers, Lewisboro, Pound Ridge), now has to take even more time away from work, family, dinner, etc.  to transport to White Plains Hospital! 

Hell, I don't even know where WP Hospital is or how to get to it from the North County!

I once read an article that the basic jist was- Are we doing any better as EMS is supposedly progressing? Years ago, but not that long ago in some parts of this county, all you needed was a driver and someone with a CPR card, and you did a "scoop and run" to the Hospital. Calls got covered easier, and the overall runtime was shorter. Everytime, something like this comes out- I think are we doing ourselves any good? Or are we just running the volunteer service out of business?

[roeems87 0]

I went to recent conference on this at White Plains hospital and I have heard opinions by many people on the idea. I am one who believes the protocol is a great idea. At the current time the protocol reads: "the hospital that will be most appropriate for treatment of the patient." That is what we are supposed to be doing anyway. "Stroke Centers" are a specialized form of treatment in the same way that "Trauma Centers" are. It means they have the staff, capabilities, and protocols to treat that specific medical problem (or symptoms of it) as quickly and most efficiently as possible for the patient...

As an aside for the moment, rememeber that these protocols are written for all of New York State. The county where I go to school (Tomkins County) has one hospital: Cayuga Medical Center. There aren't any other hospitals in this county. Transport to a trauma center or elsewhere means transporting 45 minutes to an hour (sometimes even longer, ROUTINE, transports). We are extraordinarily lucky (not un-duely so) to have 15 some-odd hospitals in Westchester county. Especially in lower Westchester, we have 7 or 8 hospitals within 15-20 minutes. This is a luxury, and besides that, one that should be used to best treat the patient.

If you have a patient presenting with obvious symptoms of a stroke, you are within the 2 hours (allowing a hour or so for transport and treatment initiation) of KNOWN ONSET OF SYMPTOMS, then I think it is certainly progress for field Emergency Medicine to transport to a stroke center. The person's chance of survival and full recovery is so much greater when taken to a designated center than it is just any community hospital. Remember the time frame necessary for the TPA stroke treatment. We don't just make these numbers up randomly, it has to be within 3 hours or it's not worth the risk. If we want to be considered an important link in the chain of Emergency Medicine, we have to do our part to make the most appropriate medical decisios for our patients--in the same way that any level of training would do that same.

You wouldn't take a patient with 50% third degree burns to Lawrence Hospital (unless they're already in full arrest)... they would go to the medical center, without a second thought (level 1 TRAUMA CENTER, or BURN CENTER)... Would you bring a patient in need of a hyperbaric (hypo?) chamber to Dobbs Ferry Hospital? A stroke is the same type of assumption and treatment protocol. Making STROKE CENTERS furthers our ability as EMS providers to get our patients the best treatment possible.

Part of the problem with Emergency medicine is that it is "treat 'em and street 'em" and we really have no lasting impression on continual care. Remember that the last stop for our patients isn't the ER many times. They have so many other doctors, nurses, and departments that they may be going to shortly thereafter. Getting them to the best hospital for the treatment they need is the first (and arguably the most important) step in ensuring adequate (and excellent) patient care...

Just one more note. We're not in this business just to get the job done and go home (especially if you look from a VAC standpoint). As much as getting through the shift and getting through a call efficiently is important, the reason we are there (as a whole) is to help people in a time of need. To make an argument that choosing a treatment that may take longer could keep you from other things (even if it is better for your patient) is not a fair one to make. Remember what this is all about... the patient...

[tbendick 27]

I think it's ridiculous for an All Volunteer Corps, that already has about a 2-hour Ambulance call (ie: North Salem, Somers, Lewisboro, Pound Ridge), now has to take even more time away from work, family, dinner, etc. to transport to White Plains Hospital!

Not sure if you know anyone on a family level who had a major stroke. If you did I think you would think different. Recently someone in our family had a stroke and was taking to a city hospital (Not a stroke center). For what ever reason they never picked up on the stroke. When I found out of the incident first thing came to mind was a CVA. Patient moved to another hospital by orders of the family and then began treatment. However the window was lost and now the road to recovery is much longer.

Also you can't be discouraged when you do have a CVA patient who doesn't have that miracle. Some CVA's will be a bleed and no clot buster will take care of that.

All in All the best treatment for anyone who might have a stroke is to get them to a Hospital that can deal with this. Currently we have these new Stroke Centers and they are the best chance. Not all hospitals are the same..

[STAT213 332]

I think it's ridiculous for an All Volunteer Corps, that already has about a 2-hour Ambulance call (ie: North Salem, Somers, Lewisboro, Pound Ridge), now has to take even more time away from work, family, dinner, etc.  to transport to White Plains Hospital! 

Then, Res20cue, it is time for you to hang up your uniform, your green light, and stay home.

This is where the EMS train is headed. Get on or get off, the choice is yours and it is ok either way.

[RES20CUE 40]

I don't have a green light!

Obviously you're not in tuned to what goes on in No Westchester, being from NH.

Anyway- I agree it's time for Westchester to have a paid/ career EMS service, but that's another whole story!

What I'm getting at it the burden that is continuously being placed on VOLUNTEERS, the "powers" are running volunteers out, with protocols like this.

Yes, Tom I've had family members suffer strokes, and I do realize the importance of this, but DOH could have had more hospitals ready to be onboard with this program, or better yet- why doesn't every hospital have this capability? Your right about the patient, thats really what we are here for, however the problem lies in all the other BLS or should I say BS calls, that are ever increasing. People are burning out faster and faster!

[Guest]

Any confirmation On Hudsen Valley Hospital being a stroke center ?

Edited September 21, 2005 by Nurse911EMT

[WAS967 97]

Hudson Valley is on the fast track to becoming a Stroke Center, but until the state approves the application, it is NOT one at present. I spoke with the ER nursing director at HVHC on Tuesday morning and right now all the work is done, it's just a waiting game. Until the approval comes through (they are hoping for early October) WPHC or Nyack are viable alternatives.

I expect Danbury and Greenwich hospitals will be working to get NYS-DOH to see them as valid stroke destinations (I am told they are both Stroke Centers). There was similar lag with Danbury getting approved as a Trauma center back when they came online as a level 2.

[Guest mediconpatrol]

Hudson Valley is on the fast track to becoming a Stroke Center, but until the state approves the application, it is NOT one at present. I spoke with the ER nursing director at HVHC on Tuesday morning and right now all the work is done, it's just a waiting game. Until the approval comes through (they are hoping for early October) WPHC or Nyack are viable alternatives.

I expect Danbury and Greenwich hospitals will be working to get NYS-DOH to see them as valid stroke destinations (I am told they are both Stroke Centers). There was similar lag with Danbury getting approved as a Trauma center back when they came online as a level 2.

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Hudson Valley is not a stroke center yet!!!...they are going for approval and the state and dept of health will be there next week for the final inspection. they do have protocals in place at this time..actually they have for some time now..but they have not had there official designation....

[Guest mediconpatrol]

Update on Hudson Valley Hospital Center...

Dept of Health cancelled their appt with HVHC and changed the inspection date to October 16 or 18th.

[Guest cheekmedic]

Just curious, has anyone out there been denied orders for transport to a stroke center by medical control, even when the patient has met the criteria? just wondering! Stay Safe

Edited October 19, 2005 by cheekmedic

[WAS967 97]

Update on Stroke Center progress. HVHC had thier site visit on Monday and word has it they have been granted approval. Just waiting on the final blessing in writing from DOH. NWHC was to have thier visit this week but it was rescheduled to next week. They hopefully won't be far behind.

Only CVA patient I've had in recent weeks did not meet criteria (symptoms started the night before) so I haven't had any problems or even heard of problems with Medical Control overriding the protocol and isisting on transport to local facility. If it does happen tho, just document it well and let your supervisor know.

[Guest]

I work in WP I dont have a long transport to WPH,as I was reading the posts about volunteer and paid EMS it isn't about that. As some of my fellow EMS providers state it is about what is best for the patient. I also think that if a volunteer can't do the response due to time then the volunteer needs to rethink what they are doing. I know plenty of volunteer EMS providers that call in sick to jobs miss family meals and everything else that paid people miss to go to the hot trauma job or the structure fire I have even done it when I was an active volunteer, the only difference is they do it for free which I think is comendable. As for the stroke center do I think it helps yes I was working the other day a patient was brought in with a volunteer agency with a code grey and they worked her up with cat scan and TPA and she was moving the extremity within an hour. The problem lies that the only type of CVA that can be reprofused is an occlusive stroke not the hemmoragic stroke which I think we all know is the worst of the two. Also I would say that dealing with a stroke vs a trauma is alot different in the pre hospital arena we all need to remember that all the protocols go out the window if there is not a stable airway, then the patient needs to go to the closest hospital even in a burn. I also dont think there are any places that would take four hours to do an als transport to WPH in the county but I am fairly new to the county and from the north county where I live is 684 is the best way to get to White Plains. I also want to say I am just putting my opinon down I in no way am trying to say anything bad about any EMS or fire agency in this county

[Guest]

I know this is an old topic, but I just have to mention one thing. For everyone who is advocating the WP stroke center, think about this. On average taking a bls patient to WP hospital turns into an hour long process. I bring patients there and the Er is never ready, and usually has us wait a while. Acouple of times in recent weeks I've brought cva patients to WP. I have waited just as long as before, and then had time to not only finish my pcr, but have three smokes and half a bottle of water, and the patient still wasn't at CT. So Until they tell me that I will be fired unless I go to wp with a stroke, I will be going to any of the better suited facilities in the area. WMC is weeks away from getting their certification as a stroke center, thank god.

[roeems87 0]

Just wanted to enter a disagreement... I find WPH to be one of the best hospitals to bring patients to. I am in and out of that hospital. If you're sitting and waiting for your patient to go to CT, I'm not sure what you're waiting for. They may not always be waiting for you to walk in the door (most hospitals aren't) and they're always ready to ask you what you have. Rarely, if ever, have i been ignored at White Plains. This is unlike some other southern Westchester hospitals...

It's not only a matter of getting to CT. The facilities are at WP and ready to be used, they may not always be there in other places. Your patient is better suited at a Stroke Center, that's their purpose. It's the same analogy of your trauma (legit) patient going to a trauma center...

[ny10570 745]

My vac has brought patients to WP and they were waiting for us to arrive at the door. Even had the ED head come in on it. As for the long transport times from north county...try the north country (clinton county). The nearest level one was Burlington Vt. Without a bird to get you over the lake from Plattsburgh its actually faster to go lights and sirens to Albany (never got a chance to try it though, damn). The long transports are a necessary evil. But liek others have said, if you're more concerned over missing dinner than you are over the best possible care for your patient your wasting your time.

[Guest NYTruckie]

. NWHC was to have thier visit this week but it was rescheduled to next week. They hopefully won't be far behind.

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As of last week NWH was still waiting for the visit

[Guest]

the attitude of 75% nurse'e at WPH is horrible i have been going there for a good 10 yrs, they are so rude to patients especially if they feel that they are not worthy of thier attention,God forbid if you are homeless or have the DISEASE of alcoholism,they get really angry if you start an iv on them,and they always think we are in thier pecking order they may be under the doc but we (EMS) are not under them I think they are mad cause they cant intubate,any way I miss united hospital they knew what patient care meant they were the best.................

[Guest S2758]

As of 11/30/05, you can add Hudson Valley Hospital Center to the list of approved Stroke Centers.

[WAS967 97]

Northern Westchester had thier site visit by DOH for Stroke Center certification. Should be soon that they can be added to the list.

[Guest]

the attitude of 75% nurse'e at WPH is horrible i have been going there for a good 10 yrs, they are so rude to patients especially if they feel that they are not worthy of thier attention,God forbid if you are homeless or have the DISEASE of alcoholism,they get really angry if you start an iv on them,and they always think we are in thier pecking order they may be under the doc but we (EMS) are not under them I think they are mad cause they cant intubate,any way  I miss united hospital they knew what patient care meant they were the best.................

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[Guest]

I think it's ridiculous for an All Volunteer Corps, that already has about a 2-hour Ambulance call (ie: North Salem, Somers, Lewisboro, Pound Ridge), now has to take even more time away from work, family, dinner, etc.  to transport to White Plains Hospital!

Then, dont volunteer. This is a problem that i find pervasive throughout many Volly organizations, even my own. Get over the the lights, sirens, badages, and buff belts and act like professionals. When things get to the five yard line, and you actually have to inciate extensive care, preofrm CPR for 45 minutes, or endure a long transport time, alot of volunteers dont want to do what has to be done. Dont get me wrong, im a volunteer, but the childish apathy and compalining is downright wrong and unprofessional. This is about patient care, simply put. Despite the fact that im unpaid, i always try to do my best by the patient, reguardless of how cold my food my get or how tired i may be because i know if it was my parent, brother or close friend i would want the highest level of care and professionalism.

[Guest]

the attitude of 75% nurse'e at WPH is horrible i have been going there for a good 10 yrs, they are so rude to patients especially if they feel that they are not worthy of thier attention,God forbid if you are homeless or have the DISEASE of alcoholism,they get really angry if you start an iv on them,and they always think we are in thier pecking order they may be under the doc but we (EMS) are not under them I think they are mad cause they cant intubate,any way  I miss united hospital they knew what patient care meant they were the best.................

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Well maybe it is in the way you treat them could that be an EMS provider with an attitude toward a nurse imagine. I know for a fact that I have had an attitude toward the nurse's there and it gets me no where. I think if certain EMS providers would treat the nurse's a little better and don't think that they are the end all beat all of emergency medicine and that certain nurse's would get over the fact that EMS is only a scoop and run get them to the hospital fast agency then maybe just maybe it would make the job a little easier for all parties concerned including the patients

As for a nurse being angry for putting an IV in a patient I have never seen that even in an intoxicated person, it just means that they don't have to do it and I have never seen them treat a patient badly or differently because they were homeless or an alcoholic maybe you should remember that you may only have a patient for maybe 1 hr tops depending on where you are comming from. When I bring a patient in as you described I have no probelms with the nurses at all.

Now United Im sure in its time it was a good facility but in the days that were near the end I don't think so from what I remember they would only take certain patients and on more than one occasion my partner and I had to pick up patients from the PMDs office and take them to White Plains and one went to WMC for second and third degree burns to her thighs back and abdomen she was released the night before by United. So in conclusion I think that maybe if nurses and paramedics put thier egos in check and came to grips with this is a team effort then maybe our jobs along with thiers would be a little easier. BTW nurse are allowed to intubate but they need a doctors orders kinda like paramedics do but it is standing orders but still an order from a doc but Im sure you already knew that

[roeems87 0]

Building a rapport with the people you work WITH is the best way to do this job. You are typically going to interact with the same people (at least some that you know) where ever you are working. If that means some people who don't know you see the way others that do treat you, it will all be beneficial for everyone. Working as a team will always work best...

[Guest paramedico987]

Reply to Rescue20...

I don't care where you are, you have a duty to act. Failure to follow your protocol [dumb as it may be] is abandonment of that duty and is therefore NEGLIGENCE. If the patient has injury or even THINKS they do some lawyer is gonna tear you apart in court. The extra hour you might spend sitting on the couch isn't worth that hastle.

I've been an active LVAC volunteer for 5 years, ya either love it or leave it! If you don't like it then leave. This situation is temprorary. The reality is that most if not all area hospitals are going to eventually recieve certification as stroke centers as they already meet darn near all of the requirements just because they're a 911 recieving facilty .

Edited January 2, 2006 by paramedico987

[WAS967 97]

First example that pops into my head is cold water drowning.

[Guest alsfirefighter]

Ok, this has gotten interesting.

First: Providing EMS has nothing to do with you, your family or whatever time you may lose. Its about your patient, and where they are going to get the best appropriate care for their injury or illness. Are we doing any better? You ask the patients I interact with, and treat. Are they all success stories, no. But many we do make a medical impact and also assist with door to door time in the ER.

This goes for all you diversion ignorers also. You don't have to like they are on diversion, but sometimes not bringing someone there is about your patient, whom may not get the difinitive care that they need and deserve. So grow up a little. I love when I get told by a certain individual, "I don't care, its not my problem, plus we have one rig out already." So ok genius if I had a trauma would I not take them to the medical center because you have a rig out. You have no problems with mutual aid when you get no crew, so whats the problem when someone is on diversion that everyone helps to cover calls as they come.

Second:

You get treated the way you act. I don't give a $hit if your having a bad day, or how busy you are. If your busy chances are I helped make it that way. I interact with everyone professionally. You piss me off and get nasty, I will be more then glad to give it back. You want to make a comment, I'll give you kudos if you say it directly. You make one out in the open and its still about me, you'll here my directly to you. And I bet whether they like it or not, it won't happen again.