Just Plain Ruff

Addressing both your points I think that the OR issue is a small part of the issue. Patients needing surgery are a small part of the ED population. I know that at some of the facilities I've been involved in and also worked as a paramedic at may go 8-12 hours between a single patient needing surgery. To cease elective surgeries or require them to be cut down when the ED is overcrowded would result in a marked decrease in elective surgeries at a specific hospital thus causing the surgeons to go to a hospital which will accomodate them. Yes the OR Is a cash cow but so it physical therapy and also outpatient procedures departments. The OR truly does not have a big impact on throughput thru the ER. AS for addressing your 2nd point, I am in the industry that computerizes the ED's and I have not heard of this gaining much traction and I don't think it will. If you see patients as they appear would cause untold problems the least of which would be the non-emergent patients getting beds and then not having beds for the truly sick people. I am going to discuss this with some of my colleagues who also work in the automation of the ED's and ask them if they have heard of this. I think this is NOT a good idea to do away with Triage alltogether.

you are out in the wilderness with a long way to go to get help? is that the scenario? The person in arrest is dead. Simple as that. Sure go ahead and give the epi but be prepared to explain the two needle marks to the medical examiner. You will then after you realize that the epi didn't work, you will have to fashion a carry device to drag your friends body out of the woods. Or you could leave him and come back to him after you arrive to get assistance. My thought's are, make it out to get a body recovery team. The results of the scenario suck but sometimes it's what happens.

What if I refuse to have sex with say a good looking black gay atheist male with pschiatric issue? I guess that would make me a racist with anti-gay tendencies coupled with being a religious zealot and a discriminator of someone due to their mental handicap. For the record, I've not had sex with any of the above listed types of people.

Zilla I got to agree 100% for your response. The answer is not adding hundreds more beds. The answer partly lies in patient throughput, and fully on patient satisfaction. Hospitals do eat their ED costs above and beyond what medicare/medicaid/insurance/selfpay pay out to them. As to front door of the hospital For the past 7 hospitals I have been involved with in the transforming and automating their ED's the admission from the ER rates break down this way Hospital 1 - 57% of admissions come from the ER Hospital 2 - 79 Hospital 3 - 64% Hospital 4 - 93% Hospital 5 - 48% Hospital 6 - 76% Hospital 7 - 83% Don't ask for the hospital names as I won't give them but just to understand their size, several are level 1 trauma centers wiht all the fixins for cardiac, stroke, trauma, peds and pregnancy care. 2 or three were general hospitals that did not specialize in anything like the above ones. And one was a hospital that had 7 different ER's each ER on the campus catered to a different subset of patients. Hospitals are forced to work more with less resources and all the protocols, formulas and odds/ends out there cannot fully address the 60 people who walked in to the ER in the last hour and the 60-100 that will walk in the next hour and each subesequent hour. ER's do a great job getting patients in and out but it's a tough job. I'm looking at my computer screen right now and I see over 100 people waiting to be seen in my current clients ER and they have all been triaged to the waiting room. I see an additional 20 or so that have come in and are waiting to even be triaged. There are not enough beds in this ED to accomodate all the patients that walk in. This ER also gets about 20 ambulances an hour. they are the only hospital in the city. 120 people walking in and 20 more coming in by ambulance - this ER only has around 100 physical beds. Where are those people supposed to go? they go right to the waiting room and sit because there's just no room in the INN. If you build it they will come and that seems like a fine idea and a solution to the problem but seriously, this is NOT the answer.

It's a common theme in this society that it's ok for others to do without but when asked for you to do without then it's a problem. I use the word "you" to mean society as a generality. A big case in point is the Flight attendants union for American Airlines. According to thier website www.apfa.org they are claiming that they have given over 10 billion to date but the executive's have reaped bonuses. If it's across the board concessions then shouldn't it be everyone, from the lowest on the totem pole to the CEO? Plus the top 5 executives got 100 million in bonuses but the airline did not post a profit last year and will not this year. That's not equitable and we wonder why top executives of corporations like this have a bad image. But I digress, if the employee's are asked to take a pay cut then the executives should also. If one has to take a pay cut then all should. I've never been in that situation but I would think that as long as it's not a few who get cut but everyone then it should be a less bitter pill to swallow.

Can you tell me what the OR has to do with the ER and the doctors in the OR have to do with the ER? I've worked with physicians in over 30 Emergency departments across the USA and not many of those have doctors who pull double duty in the ER and in the OR. Doctors that are on the floor are forced to round at certain times because their offices are open at 9am. So they have between 6am and 9am to round and get all their work done and discharge the patients. The doctors on the floor are in no way involved in taking care of th ED patients until they are called for an admit. So I'm not sure why you are comparing apples to oranges in this. I may not be getting the drift of what you are trying to say. The OR docs do indeed have specific times for their OR's but how does that affect the ED flow? If you are saying that the bottleneck in the ER is partly caused by the OR I disagree with you. Like I said, I have worked with over 30 ED's over the past 10 years and the consistent themes of bottlenecks are the ones I listed. AS a matter of fact I have put into place bottleneck removers for lack of a better term and throughput has improved in a majority of those ED's. Not once did we address the OR or the nursing flow issues. Maybe that's something to look at for my next client which will be in Baltimore maryland.

I don't like any humor other than the kind where the F bomb is used every other word. NOW that is comedy with a capital F. Bomb. Rip red Sent from my SPH-D700 using Tapatalk

But seriously with a masters degree costing upwards of 40K depending on what school you go to, how will you recoup that cost when most ems agencies are run on the seniority promoting scale. What positions are there in small ambulance services that will use the masters level education? Even the big services would be hard pressed to pay the employee enough for them to recoup that out of pocket cost. I'm envisioning only the biggest ems agencies to take advantage of that education and those medics will definately not be working the streets. Maybe a governmental agency could use them. Certainly not the mom and pop systems. Maybe AMR corporate or Rural Metro and I am betting that the person with that education will be used differently than we might envision. Sent from my SPH-D700 using Tapatalk

The reason why patients wait so darn long is many fold but here are some of the major reasons 1. The ed is full and with the inability to add physical beds, patients have to wait. 2. Adding more staff is not the answer as long as you have a good staff to patient ratio. Adding more staff to an already good mix of staff to patients is just throwing money at a problem. 3. The ED's are chock full of non-emergent cases that should be at a doctors office but they are in the er. I'm looking at the census of my client and there are 32 patients with reason for visits that could be addressed in a doctors office. One is for a cough, the other a sore throat, one is for penis pain and the other is for suture removal among others. 4. The doctors offices can only accomodate a certain number of patients per hour without overwhelming the physicians in the office so when the available appointment slots of 15 mins per patient are taken up then those who want to see the doc have to wait till the next available appointment or they are referred to the ER. 5. Ambulances - patient who come in by ambulance almost always get a bed, even if the ER is packed. Triaging the non-emergent patients to the triage/waiting room should be done on a consistent basis. 6. The ED can only go so fast. The consistent bottlenecks in the ED that I have studied have been waiting for lab results, waiting for the physician to complete their documentation especially if they are using electronic charting and then patients waiting for a bed upstairs. These are the three big bottlenecks. 7. And finally, the murphy factor which means that as soon as the ED becomes less busy, a truck load of illegal immigrants crashes on the highway and all need to be seen in the ED. That is the monkey wrench that gets put in the mix. And yes I have been called to the waiting room of the ER but you know what the funny thing is? This particular ambulance service is run out of the hospital ER and calling 911 would only get the ambulance crew working in the ED to go to the waiting room and talk to the patient. This particular time the patient said they wanted to go to a different hospital and we refused to transport him. We told him that if he left the ED AMA and called 911 for an ambulance, that it would be me and my partner and the only place we transported to was to our ER that he was already at. He did AMA and called a BLS ambulance service to come get him. They did after they called us and we said that they could come in our district and transport him to the er of his choice. AS far as I know, he made it home that night and wasn't admitted to the hospital he ended up going to.

Here's the deal Do not lie on your application or your resume. That's one of the top 3 things that people get fired for. When they ask whether you were terminated, just say yes. When they ask you, be frank with them and explain that yes you were fired, you had attendance problems and you have learned. Tell them that if they were to call your clinical manager and the school that they would verify that your attendance was excellent. Tell them that you learned from the experience and you feel this makes you better suited to the job because you learned a hard life lesson right out of college. But seriously, most companies will just ask for resume's and go from there. Personally, when I hire someone to work for me at my LLC, I do ask about past jobs and if they say they were fired, then I ask why. Bad reason then they don't get the job but if they can show me they've learned from it then I'll give em a shot. Unfortunately, right now my LLC is struggling and I have no employees but myself and I get paid diddly. Just be honest and open with the interviewer. Do not offer any additional info if they don't ask. Sort of like court, answer the question but don't elaborate. It's the interviewers job to pull more info if they want it. But frankly, I was terminated from several jobs right out of college because I was young and immature and it never hurt me. If you get to the interview stage you have already made past the gate keepers and they are looking at you for the job. Companies cannot afford to grant interviews to everyone anymore. It just costs too much money to do that.

Yes there are other cartridges. I am at a hospital that uses the Istat. There are glucose cartridges, cbc's, chems, electrolytes, troponins and others. they cost a pretty penny also. The reason you are not seeing these in the ambulance is several fold. 1. Cost - 2. Will the ER take the results that you obtain or will they run their own tests. Sadly, they will run their own. It's the CYA thing all over again. 3. Who is doing the QI and daily checks? Sadly, it's hard enough to get medics to do QI and daily checks on their ambulances and the glucometers, add the daily checks to the Istat machines and you see where I'm going . 4. Resistance of insurance providers to pay for this type of testing when the tests will just be run again at the ER. That's double payment out when insurance companies are in the market to limit costs and benefits. Why put a machine on the ambulance that is a great thing(I truly believe that the IStat is a great thing) only for that machine to be discounted by the majority of the ED's because in order to cover their asses they have to do a CBC and Chems on these patients because well, that's the way it is. If you can get the ED to buy in on EMS use of this technology you have to engage them in a way that they feel that it was their idea. Just showing up with Chem and CBC and troponiin results will not get us taken seriously. The final limitation is this, if the ED consistently finds a difference in the results of the Istat results versus the hospitals own machine then you are DEAD in the water. No amount of persuasion will change their mind that the machines don't work. Perception often kills the greatest ideas.

What's wrong with a little A&P or Chemistry? For most of the EMT's and paramedics to be out there, they want it fast and easy. If they didn't we wouldn't be seeing these 12 week courses, or these fly by night get-ups that promise zero to hero in as short a time as possible. I propose that the first thing we do to increase our educational standards is to preclude these types of companies from letting their students sit for the national registry or the state exams. If you get rid of the zero to hero puppy mills, then you increase the standards 10 fold if you ask me. I then propose a national standard of an AS at least in paramedicine. If you want to work the streets as a paramedic then you get your AS or higher degree. Simple as that. If it's a national standard then there is no place to go bitch and moan about it. I would also require at least 2000 hours in hospital clinical work and then another 2000 hours of ambulance ride-time. Lofty numbers I know but the more exposure you get to the system and patient care the better you will be. Maybe 4000 hours total is too high a number but it should not be less than 1000 in each. Broken down that should be 500 ER hours, 250 hours in ICU/PICU/MICU etc etc. and then 250 hours divided by the other notable hospital departments. Break down for ambulance would be 750 hours in an urban system and 250 hours in a rural system. With a minimum of 250 ambulance calls and if you don't get the 250 then you have to keep in clinicals until you do get them. Continuing education is another sad sticking point. I relicensed in Missouri last time by taking all the credits from CE Solutions. I got over 150 hours of continuing education completed in less than 1 month. Did I learn anything, NOPE, it was all computer based and it was easy to skirt the system. Did I cheat, no, I just didn't put the most I could have put into it that I should have. Continuing education, 30 hours a year or 150 hours in 5 years. This includes 2 full refresher classes (total hours 80) and those can be done online. The rest should be done in a classroom setting or classes like PALS, ACLS, PHTLS/BTLS/ITLS, ABLS, NRP, Extrication - you get the picture. For a maximum of 80 hours online and 70 hours actually attending a class. Before anyone goes off to complain "whaaa it takes too much money to go to a class and I would have to drive a long way to get to the class" buck up and take responsibility for your job and licensure. ACLS/PALS often are taught inhouse or at the nearest hospital. I travelled 1200 miles to take ITLS. It's offered by PHI International for free if you know who to talk to. Once we take responsibility for our own education and stop expecting it to be given to us, we can begin to take ownership of our collective profeesions future and make changes that will really impact our profession. To continue to do nothing is tantamount to saying "I don't give a shit" I'm not ready to say that, are you? So Crotchity, how bout the 78 year old completely lucid male patient, in profound respiratory distress, purple to all get out, who knows who he is, where he is, what is going on and knows that today is the day he is going to die. I had that patient about 2 years ago. He adamantly refused to go to the hospital despite his daughters pleas, the phone call to his doctor that I made for him to try to convnice him to go- didn't work, the call from his son in california and the statement from me that said "if you do not go, you will be dead in less than an hour". Not one of those worked. I made him write out "I know I am going to die today if I don't go to the hospital but I refuse to go" and he signed it. I then told him that I was going to drive up the street, get a soda at the convenience store and wait for the call to go back to his residence. I told him that I would be back within 20 minutes to work his cardiac arrest and he said "get the hell out, I'm ready" 30 minutes later I was back and I coded him. Was I lazy or imcompetent in this call? I think not. I will also add that I did talk to medical control and they agreed no transport because the patient was completely lucid. You should have seen my run report. It was 3 pages long in the narrative. Some patients just want to be left and to die at home. WE cannot force them unless you have the protocols and medical control to back you up. It's still the patients right to refuse no matter how much like god some of our illustrious paragods think they are. Ruff

So why do you keep coming back. Keep playin the part of the jester. Sent from my SPH-D700 using Tapatalk

Wow, so original. I thought you were done with this thread, I guess you couldn't stay away. I was wondering when you were gonna show back up. No one on this thread is taking you seriously due to the name calling and cussing out everyone who disagreed with you. Sent from my SPH-D700 using Tapatalk

Would you just shut the hell up. Sent from my SPH-D700 using Tapatalk Not you mobey. I'm sure you know that wasn't directed at you Sent from my SPH-D700 using Tapatalk

Her boyfriend could be a child prodegy and in school at 16. Likely not but it could happen. Sent from my SPH-D700 using Tapatalk

I would think that the hospital board or their lawyers would want to know about a conflict of interest though. The administrator is supposed to be looking out for the hospitals best interest and if her being friends wiht the owner of the otehr service and that service provides worse service and more expensive than the other service then with the administrator being tasked with keeping costs low to both the hosptial and the patietns, she is not doing her job. But I'll bet an ethics complaint would go no-where especially if it's directed towards the CEO or ADministrator of the hospital. boy my spelling sucks today.

My understanding was that the cancer was treatable and the doctors said the child had a good chance. That I think is why they convicted the mother. Not that she's a bad mother, I'm sure she did this out of love but by her choice the child died. Maybe he would have died anyway but I believe the majority of the doctors reviewing the case or even being those who were taking care of the child all said that the child stood a good chance of remission. They convicted her because of that testimony, I can understand the juries thoughts where you had a bunch of medical experts who said the child more than likely would have survived with treatment yet the mother prevented that treatment and thus in the end her child died. Sad all around if you ask me.

I think of you as our quagmire!!! Plus you are a diamond in the rough in terms of dispatchers. It also seems that when my wife get's pregnant, yours is already pregnant or vice versa. My alter ego can be found at www.michaelruff.com he's much better looking than me though plus his singing voice is better than mine.

Ash, I think you've told this story before. If you went against my wishes on a call that would be the last time we worked together. It sounds like in your description that you both were out of control on this scene and both of you were yelling. So how did he get to be a medic if he had "never" been a basic??? I do not believe that the sugar was the cause of the arrest, I check sugars on all my arrests not to determine a first line treatment because in an arrest, sugar aint nowhere near first line but to have a baseline for treatment post arrest. I have have in the past 5 years about 40 codes and of those 40 about half showed LOW on the meter. Only had two or three that got a rhythm back and those 2 we gave an amp of D50 to but after the maintenance drips of amiodarone or lido were hung. Maybe you cured him? maybe you didn't.

i know. I just wanted to say that I didn't disagree with your thoughts on this issue.

I'm certainly not calling you an idiot, I have seen the change from alcohol to Chloraprep. It's what our service uses exclusively. In our IV start kits, there is no alcohol prep. It's not included based on the evidence that Chloraprep cleans skin better.

I just spent some time down in the ED of my client and talked to a ED Doc who also did some work in the OB department. He said that by presentation that this was more than likely the amniotic sac and your treatment was spot on. He said that it more than likely would signal the death of the fetus but there are a number of considerations to be taken in to account before that is the diagnosis. He didn't have time to go into all of them but he did say that if caught early enough that a skilled OB surgeon could maneuver the amniotic sac back up and possibly get it back in place. This all hinges on whether the placenta is damaged or has become detached. He said this was a very significant emergency for the fetus but not so much for the mother. He said that he would do his damndest to save the baby but he said he would never give any type of guarantee or even allude to success until the replacement was done. He said that this is one of those pucker factor moments that happen in OB. He also said in our conversation that he has had only a handful of these events and of those he's seen, none have had positive outcomes. But he said there's always HOPE! and if you pray, get on your knees and pray and if you don't pray maybe it's time to start in this situation.

Great video CH No wonder why I had such respect for a early resp therapist who was my EMT partner. Seeing all the stuff you had in the video makes me understand, somewhat minimally, how smart and accomplished this guy really was.

I read and heard this story this morning. At first I said to myself - Good riddens of a bad mother. Then I thought more about it, after my knee jerk reaction to a emotion evoking story. I said, 2nd bout of cancer, my loving child. If it was Liam or Gabby and the cancer had come back a second time. Seeing the suffering that they go thru what would I do? Would I at all costs try to keep them alive just to keep my son or daughter in my life? Could I continue to watch them waste away and get worse and see their pain and suffering or would I choose to let them go in as painless a manner as possible? What a thought process to go through. I had a family with a 5 year old daughter who brought her into the eR. She was in the end stages of cancer and treatment had not helped. The family asked for a DNR order and I was really upset that they would let their child go. The father told me this and I'll never forget it. I can't quote it completely but he said in essence we've had 5 years of love and laughter, hopes and dashed hopes, times of sorrow, times of death being near. I would never give those times up but I'm not signing this for myself or my wife, I'm signing this so my daughter can meet the end of her life with dignity and class. I do not want heroic measures to be done just so you guys can feel better about it nor do I want heroic measures so I can spend one more hour with her. I want her to see both her mother and father in the room with her instead of a bunch of people in white coats trying to keep her here. in the end, the child passed away very peacefully in a private hospital room with her mom and dad holding her. I felt privelidged to have gotten to know the family enough that they invited me to say goodbye to her. What a honor. So I am not sure what I would do in that particular situation. Would I fight for every minute left with my son or daughter or would I allow the disease to take it's natural course and cherish the time with my child? I have no idea because I have not had to face that and I hope I never do but if I do, I hope to have as much of an outlook as the father of that 5 year old girl. Rest in peace Rebekkah