As EMS/PHC Providers; Are We That Lazy?

[Richard B the EMT]

Once again, I posit that the 9-1-1 system has become a victim of it's own success. Everyone calls, from an EMS viewpoint, from stubbed toes, to multiple gunshot wounds, to jet airliner crashes.

Reeducating the public will take somewhat longer, as to when to call 9-1-1. Once again, I mention the Public Service commercial, showing a large 1930s party, which, while needing the police to calm them down, is not a true emergency, followed by the classic King Kong, carrying Fay Wray up the side of the Empire State Building, obviously a true emergency.

[crotchitymedic1986]

i would just remind you that if the only people who called an ambulance were only those who truly needed an ambulance, 75% of you would be unemployed.

[Bieber]

I actually agree with Crotchity on this one; to a point. Now matter how good of a practitioner one is, we can't rule out every possible outcome for our pts.

Why? Two reasons: time and diagnostic tools. Our time of contact with pts is limited, over time the clinical picture can change. Sometimes, this may become obvious over the course of an ambulance transport, or while the pt sits in an ER waiting room.

The diagnostic tools we have are good, but limited. Labs can be important in determining pt Dx. For instance, a may be borderline septic, to the point its not overwhelmingly obvious, but a lactate measurement may help direct timely Tx in the ER.

You're right, but our job isn't to rule out every possible outcome for our patients, and trying to do that is an impossible goal that makes it too easy to default to the "transport everyone 'cause y'never know" mentality. Yeah, patients will probably die as a result of being treated and released. That's just one of those unfortunate realities about medicine; sometimes people who get released from the hospital die as well.

Not every patient should be treated and released, but not every patient needs to go to the hospital either. It's about finding a balance and keeping patient care in mind. Hopefully, with increased education and as more tools start to trickle down towards EMS, we'll be able to make more informed decisions about our patients and actually be able to treat and release competently in the future.

i would just remind you that if the only people who called an ambulance were only those who truly needed an ambulance, 75% of you would be unemployed.

Makes you wonder, what in the world would EMS do if medicare changed their billing schedule so that if it was later determined by the hospital that the patient hadn't needed EMS at all to begin with, they wouldn't pay the cost of transport.

Edited April 17, 2011 by Bieber

[HERBIE1]

i would just remind you that if the only people who called an ambulance were only those who truly needed an ambulance, 75% of you would be unemployed.

No, if the only people who called for an ambulance actually needed one, the system would no longer be overwhelmed, and things like prehospital primary care would probably flourish. The only way to change the system and the problems within is making everyone shoulder some responsibility for their choices and their care. Everyone- even those with top of the line insurance- needs to follow procedures to receive that care. Don't contact your insurance provider prior to seeking care? You get stuck with the ambulance and/or ER bill. Same should be for someone on public assistance. Pay a nominal fee for your care and ride(deducted from your monthly subsidy) and suddenly folks would need to be judicious about obtaining that care.

[Richard B the EMT]

There has also been discussion, not on this particular string, of legal penalties for calling 9-1-1 when there is no emergency, both pro and con.

[crotchitymedic1986]

You are sadly mistaken if you think a drop in call volume would be good for us. Just look at your brothers/sisters in the Fire Departmet, if it were not for EMS calls, most departments could not justifiy half thier equipment and people based solely on the number of fires they respond to. Thank God people call you for BS every day, cause once they go away, your job goes with them.

And beiber, anytime you start a conversation with "this will undoubtedly cause patient deaths, but that is ok", you just gave lawyers everywhere a hard-on. Any policy or procedure that results in predictable patient death should result in the license being pulled from that service or individuals who spout it. If it were your grandmother, you would have a different opinion.

I knew of a service who refused to transport hospice patients per policy (makes sense in theory, if you are in hospice you do not need an emergency ambulance), it was the worst political nightmare that service ever came out with when they implemented that policy. Again, you rarely have a chance to save a life, but you have the chance to touch a life everyday, if you choose. But for some providers, having nap/tv/feeding/masturbating time interrupted by patients who dare call them is a sin.

Edited April 17, 2011 by crotchitymedic1986

[Bieber]

You are sadly mistaken if you think a drop in call volume would be good for us. Just look at your brothers/sisters in the Fire Departmet, if it were not for EMS calls, most departments could not justifiy half thier equipment and people based solely on the number of fires they respond to. Thank God people call you for BS every day, cause once they go away, your job goes with them.

Ah, so the solution is to ignore what's best for the patient and the healthcare system as a whole, and to simply hope nobody else notices that transportation of patients who don't NEED an ER is completely unnecessary. How much longer do you think that's going to last in our current "pay for performance" healthcare environment? It's time for EMS to evolve, because we're fast approaching an era when we're going to have to justify ourselves, and just like the fire department, we're going to be in for a rude awakening when the only thing we have to show for ourselves is groundless propaganda.

And beiber, anytime you start a conversation with "this will undoubtedly cause patient deaths, but that is ok", you just gave lawyers everywhere a hard-on. Any policy or procedure that results in predictable patient death should result in the license being pulled from that service or individuals who spout it. If it were your grandmother, you would have a different opinion.

Wake up and try using your head a little bit. We can't save anyone. At the end of the day, nobody, and I mean NOBODY in medicine is doing anything more than delaying the inevitable. Everyone is going to die. You, me, and every patient you or I ever save is destined for the grave. We can't make universal policies to try and prevent every single patient from dying, it's statistically unrealistic. We have to be implementing the BEST practices for the WHOLE, not to try and keep every single breadcrumb from falling to the ground. We're never going to have a system that prevents every possible bad scenario. What we CAN do, however, is provide reasonable, sensible, scientifically proven standards of care. And that does NOT include transporting everyone to the hospital. And you know what? If you do that, if you follow the standard of care as supported by scientific fact, you're not going to get sued. Do you think the hospital gets sued every time a patient who is released dies? No. You know why? Because the standard of care was followed and sometimes, believe it or not, people just die despite our best efforts. Nobody expects medicine to be perfect or to be able to save everyone from the inevitable. What IS expected is that competent treatment backed by research is followed and that every reasonable chance for life is given. That does NOT mean wantonly transporting everyone to the hospital, nor should it. How many times do I and the rest of the educated (see, non-US) EMS world have to tell you that not everyone needs to go to the ER before you'll start to consider that, hey, maybe, just MAYBE, these people might just be right?

A predictable patient death is one that is, as stated by its title, PREDICTABLE. If you have a patient with a minor complaint, no significant signs noted on assessment, and stable vital signs, and there is no reason to suspect that the complaint is emergent or serious, and you release and refer that patient to a more appropriate level of care based on those findings, and they die, you do not have a predictable patient death. The only thing predictable about it is that we know that there are those exceptions which prove the rule, and that every now and then patients will simply die despite having only minor complaints, no significant assessment findings, and stable vital signs.

Surely you don't think every patient who goes to the ER should or actually does receive labs, an ultrasound, an echo, a CT and an MRI, and a full workup by every specialty present? Because, you know, if you leave any stone unturned, that's a predictable death, right?

[crotchitymedic1986]

It is only predictable because you refused to transport to definitive care. The EMS standard of care does not contain the ability for lazy medics to not transport those they deem non-emergent. Please correct me by citing where you find that in the DOT curriculum, CAAS standards, or any other national standard. You do not have the proper tools in the field to be even 60% accurate in determining who needs to see a doctor and who does not, if you could get close to 99%, I might agree with you as there is always a 1% outlier in everything that is done in the world (including ems). But just scroll through the EMS News section of this one forum, and you will see countless examples of what happens when EMS does not transport. Start doing labs and xrays in the field, and we will talk.

[zippyRN]

You are sadly mistaken if you think a drop in call volume would be good for us. Just look at your brothers/sisters in the Fire Departmet, if it were not for EMS calls, most departments could not justifiy half thier equipment and people based solely on the number of fires they respond to. Thank God people call you for BS every day, cause once they go away, your job goes with them.

resourcing patterns would change, look at 'front loaded' systems, there iss a different skill mix and fleet mix , primarily because in the FLM - the practitioner in the response vehicle is not automatically backed up apart from certain types of job, s/he is empowered on the basis of clinical findings to prioritise any further resources not only by skill level but also by time -frame , there is also no presumption of transport as the default outcome of ALL calls.

A similar picture is being played out with the Fire Service in the UK where the traditional one response ( of 2 multi crewed rescue pumps in urban areas and one going and one standing to in the sticks)to everything ) is being challenged by the fact that a significant number of the fires reported during the early evening or all day in the school holidays are nuisance fires, often on waste ground and not involving premises, vehicles or technical rescue / extrication - meaning that the valuable resource of the multi crewed rescue pump is tied up using an extinguisher or at most a hundred litres of water from the HP reel on a bin fire or a unattended bonfire ...

And beiber, anytime you start a conversation with "this will undoubtedly cause patient deaths, but that is ok", you just gave lawyers everywhere a hard-on. Any policy or procedure that results in predictable patient death should result in the license being pulled from that service or individuals who spout it. If it were your grandmother, you would have a different opinion.

is there any evidence to suggest that avoidable patient deaths are a regular occurence in systems which don't transport everything ?

[Bieber]

It is only predictable because you refused to transport to definitive care. The EMS standard of care does not contain the ability for lazy medics to not transport those they deem non-emergent. Please correct me by citing where you find that in the DOT curriculum, CAAS standards, or any other national standard. You do not have the proper tools in the field to be even 60% accurate in determining who needs to see a doctor and who does not, if you could get close to 99%, I might agree with you as there is always a 1% outlier in everything that is done in the world (including ems). But just scroll through the EMS News section of this one forum, and you will see countless examples of what happens when EMS does not transport. Start doing labs and xrays in the field, and we will talk.

Definitive care does not equal the ER in every scenario. The CURRENT EMS standard of care in the U.S. How about you show me where you got those numbers? And since when did every patient need (or actually get) labs and X-rays at the ER?