Transfers vs. 911

[cosgrojo]

Shouldn't your education teach you all this before you go out and attempt to learn it all while already working?

In many current systems becoming a well-rounded provider may require you to work many different levels and certifications to get the whole picture. But it just seems it is best to educate providers to that level before sending them to do their job, especially in this career. This is where we should concentrate our efforts towards changing EMS, don't you agree?

Sorry if I sent this thread down a different road.

Are you implying that the only way to learn is through the classroom? Or are you saying that learning is done better in the classroom than in the field? Either way... yes I disagree.

VentMedic- Kudos on the explanation (incredibly well stated)... and thank you for the support.

[wrmedic82]

Ok I haven't put my foot in my mouth in a while so here it goes.

I'm kinda riding the fence on this topic. To a degree if a patient needs ongoing medical treatment during transport to point B. Then the ambulance is the way to go.

On the flip side.

Do I feel dialysis patients needing just a ride need a ambulance.. that can go 50/50 depending on PHx, and medical needs ( i.e. oxygen)

Do I feel that a patient that is cleared by a medical doctor to go home needs a ambulance..No

Do I feel psych transfers that require no, or expected by a physician to not require treatment en route need a ambulance..No

There are good arguments for both sides don't get me wrong. But where I draw the line is when no medical necessity is required, and using trained professionals as a taxi service paid for by tax payers. Luckily in our area we have a company that handles non-emergency transfers for patients that require no medical necessity. These people may only have CPR training. The state does set requirements for this service and what they can and cannot transport. Ultimately this helps to reduce the load on our already busy system.

That is my 2 cents

[Riblett]

I think that from a system status perspective, transport and 911 should be kept completely separate even if they are part of the same department. I am not an advocate of 911 trucks being taken out of service for non-emergency calls, especially when a medic level truck is taking a BLS run. That was a major problem in the last agency I worked at in NC. Allthough we had a private service with both BLS and ALS units, if their ETA was not convienent for the hospital they would call 911 and demand an ambulance. Some of these runs were BLS, take granny back to the nursing home from the ED. Never mind the fact that she has been in the ER for 17 hours, we decided ten minutes ago that she is being discharged and thirty minutes is too long for us to wait for the private service to get here! For whatever reason the county 911 service just could'nt say no. Many patients suffered negative outcomes, because another 911 unit had to come from as far as 15-20 minutes away. When there are no more transport ambulances available, hold the calls until they get in service. Now if it is something that is actually time sensitive transport, like a trauma patient or MI going to a trauma center or cath capable facility, that is different. But direct admits and nursing home returns do not fall into that category. Also, if there is a major disaster or a extreme system status overload, transport units can be pulled off non-urgent transfers to help ease the burden by doing lower level transports or providing more immediate assistance while waiting for a 911 unit from a long distance, especially in areas where there are few first responders.

I can definitely see a big advantage for having integration of personnel, particularly at the ALS level. Even so, I have to disagree with the idea that transport experience is not applicable to the BLS techs. I spent about 4 months on a BLS transfer truck before becoming a volunteer at my first squad and found the experience extremely valuable, particularly for someone with zero medical background. It was a great way to become familiar with equipment, learn to interact with other healthcare providers, gain a lot of practice taking vitals, reading H&Ps/charts, and transition into the completely new role of being a patient care provider. Many people will say, oh well you can teach a monkey that stuff. Sure you could. But you can't teach a monkey to do it well or comfortably, and certainly not in a 120 hour basic EMT course. I can only speak for my own EMT class, but we all lifted a strecher once, and briefly practiced vitals on our healthy, 20-something year old classmate, in a quiet classroom. I would go as far as to recommend 3-6 months on a transfer truck for EMT-Basics before entering the 911 sect, especially in high call volume area. It just makes for a more well rounded, fine tuning of skills before jumping on a 911 truck. Clumsy green EMTs have no business on a 911 truck, and certainly not as a primary crew member. (I am ready for the storm of EMT blasting now...)

As I went on to attend EMT-I class and college as medic, I found the interfacility even more valuable. As we learned about conditions like CHF, A-Fib, COPD, etc, I actually got to see and assess these patients in non-emergent environment. I learned what these patients looked like, saw their H&Ps, read their charts and their meds lists, learned what groups of medicines are used to treat these conditions. I carried a drug guide with me and and looked new meds up. I saw patients with diseases not covered in paramedic school and saw how diseases came in combinations. Combined with an elective pathophysiology class, it gave me a huge advantage over many of my coworkers when it comes to knowlege of pharmacology and the disease process. I suppose a lot of it is about what you put into it, but I truly believe that interfacility transport can be very valuable to all levels. EMT education certainly should be teaching these things better, paramedic school should include an in depth pharmacology class besides the drugs we carry, plus a 4-5 credit hour pathophysiology course, but the reality is that most of them don't. Realism vs idealism here, because if things in EMS were ideal we would all be paramedics, with bachelors degrees and salaries comparable to RNs. Our agencies would all be able to afford a complete and well paid paramedic staff (and hospital diversion would be illegal...while we are dreaming)

Some of the smartest paramedics I have met (most of them much smarter than me, with double or triple my experience level) have either worked in or still work in interfacility and critical care in addition to 911. Where I am from, 911 tech of all levels like to scoff at transport trucks, thinking they are somehow better than them. That sort of divisive attitude has no place in EMS. As I approach the 4 year mark in EMS and 1 year mark as a medic, I am actually considering taking a Critical Care class and getting back on a transport truck or spend some time as an ED or ICU medic. Hoping to get rid of my "special needs patients and pediatrics scare the hell outta me"-itis case.

Edited June 24, 2009 by Riblett

[WolfmanHarris]

Here there are three ways transfers are done (for the most part).

1) Private IFT companies. These companies provide stable IFT either without an escort (for patients who require no ongoing care, just a bed) or with a RN escort from the sending facility for any pt. requiring more then a NC. Even with an escort they can only take stable patients who are being sent to or from an appointment, from hospital to discharge, or similar transports. They are staffed with FR's or EMR's (or less at the truly sketchy services). Most use decommissioned Ambulances as their transfer vehicles, but the best ones have actually taken the trouble to have vehicles specifically designed and altered for this. These vehicles cannot use L&S and must call 911 if an emergency develops en route. (Legally they are not Ambulances under the "Ambulance Act"). This industry has been great for freeing up resources from the 911 system, but is currently unregulated and this needs to be addressed to stop some of the whacker services or those whose vehicles are not in good shape.

2) EMS transfers. When a patient needs a stat transfer to another facility, is in any way unstable EMS gets called and we transfer. Usually with an RN escort as legally the Pt. remains the responsibility of the sending facility.

3) ORNGE transfers. ORNGE runs the Air Ambulance system and ground CCT system in Ontario. Aside from scene responses, they take any patient requiring critical care en route or who is going long distance to a specialized facility. They do not take an escort on board with their teams of CCP's or RN's (for pediatric/neonate transfers only) as their transport physician is consulted by the sending facility and the Pt. is, for lack of a better term, admitted to ORNGE and legally becomes their pt.

I do tend to enjoy the transfers we get as with the IFT's taking most of the stable patients, the one's I'm seeing are facing some serious/complex conditions and I have learned alot from having their chart on one new and my patho pocket book on the other, and google on my phone in my pocket. Sometimes if the transfer isn't too far and ORNGE is unable to take the call, the facility will send a physician along which makes for a great opportunity to learn.

So I agree that IFT's and 911 should be separate to an extent. 911 should not be tied up transferring a discharge back to their LTC or to hospital for routine appointments. 911 should also not be taking critical transfers they're not equipped for, not when that's the entire purpose of ORNGE and they are educated and equipped for it. All the rest though is part of the job.