As EMS/PHC Providers; Are We That Lazy?

[Bieber]

We are not talking aboout Patient Refusals, we are talking about Lazy EMS people refusing patient transport. Big difference. No one is going to argue that patients refuse AMA, although I will contend there was rarely a patient I could not talk into going if I tried for more than 2 minutes.

So, in your mind, clinical competence is simply provider laziness? There's your problem right there, but I assume that trying to get you to understand clinical excellence as opposed to TRUE laziness ("just transport 'em 'cause I can't be bothered to use my head") will be harder than trying to cut a tree down with a dead fish.

[crotchitymedic1986]

Not at all, tell me what clinical competence you use to decide to let a 2 year old with fever stay at home and go see the doctor the next day ? How do you determine it is simple teething, versus ear infection, versus viral infection, versus menengitis ? Please tell me that you do not use the lack of petechia rash to determine the child is safe to go by car, I hope you are not that dumb ? Or do you subscribe to what we stupid people do and aire on the side of caution and transport all children with fever ? Show me a Doctor who wont look in an ear, do a CBC, or a strep test prior to discharging this child to stay at home !

So please educate me to your clinical expertise.

P.S. Not trying to insult you, but before you decide to lecture the rest of us, you might want to run at least 100 calls.

Edited April 18, 2011 by crotchitymedic1986

[usalsfyre]

Not at all, tell me what clinical competence you use to decide to let a 2 year old with fever stay at home and go see the doctor the next day ? How do you determine it is simple teething, versus ear infection, versus viral infection, versus menengitis ? Please tell me that you do not use the lack of petechia rash to determine the child is safe to go by car, I hope you are not that dumb ? Or do you subscribe to what we stupid people do and aire on the side of caution and transport all children with fever ? Show me a Doctor who wont look in an ear, do a CBC, or a strep test prior to discharging this child to stay at home !

So please educate me to your clinical expertise.

P.S. Not trying to insult you, but before you decide to lecture the rest of us, you might want to run at least 100 calls.

I've run far, far, far more than 100 calls. Not to mention I've made the decision to stay home vs go to the ED with my own kids. My kids have also gone to their primary care physician for fever, and never has a CBC been run. How oh how did the physician determine if my kid needed to be admitted without a million test? His 2 minute long assesment. Do we need ottoscopes in the truck? Probably, but figuring out otitis media isn't exactly rocket science.

So why does the ED do it? Because someone established this overkill as a "standard of care". Ask any EM physician how much of a catch-22 running a CBC actually is, I have a feeling you'd be supprised at the answer.

You know what's as bad as a lazy medic who actively seeks a refusal? A dumb medic who can't make clinical judgements based of his assesment and simply transports only starting an IV because he's too farking scared to actually DO anything (this guy sees lawyers on every scene). This guy is number two on my hit list when I take over the world, right after the guy that gets out with the clipboard in hand.

Edited April 18, 2011 by usalsfyre

[Bieber]

Not at all, tell me what clinical competence you use to decide to let a 2 year old with fever stay at home and go see the doctor the next day ? How do you determine it is simple teething, versus ear infection, versus viral infection, versus menengitis ? Please tell me that you do not use the lack of petechia rash to determine the child is safe to go by car, I hope you are not that dumb ? Or do you subscribe to what we stupid people do and aire on the side of caution and transport all children with fever ? Show me a Doctor who wont look in an ear, do a CBC, or a strep test prior to discharging this child to stay at home !

So please educate me to your clinical expertise.

P.S. Not trying to insult you, but before you decide to lecture the rest of us, you might want to run at least 100 calls.

First of all, I've run far more than one hundred calls. Am I inexperienced? You bet your ass I am. Does that make what I have to say any less true on that basis alone? Not one bit. Secondly, you make that decision the same way a physician would: by performing a thorough assessment and obtaining a complete and accurate history. Do you seriously think physicians do a CBC and strep test on every kid who has a fever? If so, you need to go back and spend some time in the hospital. It is for this exact reason that I advocate narrowing the gap between EMS medicine and hospital medicine and putting our practices more in line with theirs. Finally, with a patient whose only complaint is a fever with no signs or symptoms indicating an emergent condition is present, exactly what benefit is there in transporting that patient by EMS as opposed to the family taking the child in to see their pediatrician?

[crotchitymedic1986]

Because I worked in a pediatric ER, and 62% of menengitis patients were originally seen by EMS and sent to hospital or doctor by car. Close to 40% were seen in a regular ER and either discharged or transferred to us without a spinal tap being done. Petechia rash is a late sign of menengitis, and it is hard for a 2 year old to tell you his neck is stiff. Just read through the EMS news section and read the countless stories of medics leaving people at home to die. There is too much we can not diagnose in the field with the limited resources that we have, and there are many disease processes you simply do not have the experience to understand. For instance, WITHOUT GOOGLING, tell me the proper treatment for an adult sarchiodosis patient in respiratory distress ? Most new medics can not tell the difference between early CHF versus COPD ? Tell me all that you know about the prehospital treatment of pulmonary hypertension. Tell me about how you treat a child with hypoplastic left heart and an O2 sat of 68%.

I imagine you will have some of the answers by morning when you research the web for the next few hours, or you could be honest and say I do not have a clue. These are just a few examples of why we should not leave patients at home.

Then do me this one last favor; take the number of patients your service sees, and then multiply that number by 1-2%, what number did you come up with ? That is the number you kill every year from refusals. Sounds good when you say hey we are right 98-99% of the time, not so good when you say, damn we killed "x" number of patients. Even if the number is "2" that is "2" too many.

And for the record, an unexpected death due to EMS refusing to transport a patient to the hospital does not equal clinical excellance; it constitutes negligence.

Edited April 19, 2011 by crotchitymedic1986

[Bieber]

Because I worked in a pediatric ER, and 62% of menengitis patients were originally seen by EMS and sent to hospital or doctor by car. Close to 40% were seen in a regular ER and either discharged or transferred to us without a spinal tap being done. Petechia rash is a late sign of menengitis, and it is hard for a 2 year old to tell you his neck is stiff.

First of all, you DO know that the 2 year old doesn't have to TELL you in order for you to assess for nuchal rigidity, right? Secondly, assuming those patients who were transferred without a spinal tap being done were coming from a doctor's office, I'm not surprised. I wouldn't think that they would do spinal taps all that often in the doctor's office.

Just read through the EMS news section and read the countless stories of medics leaving people at home to die.

Indeed. And how many of them were left due to provider incompetence versus truly benign assessment findings? The question is not whether or not MIGHT die if we don't transport every last one of them, the question is, how many with truly benign assessment findings would die?

There is too much we can not diagnose in the field with the limited resources that we have, and there are many disease processes you simply do not have the experience to understand.

The old overkill them with tests adage again, I see. You do know that physicians don't regularly do invasive tests for patients with minor complaints and benign or low acuity assessment findings, right?

For instance, WITHOUT GOOGLING, tell me the proper treatment for an adult sarchiodosis patient in respiratory distress ? Most new medics can not tell the difference between early CHF versus COPD ? Tell me all that you know about the prehospital treatment of pulmonary hypertension. Tell me about how you treat a child with hypoplastic left heart and an O2 sat of 68%.

I can't tell you. But I bet you can't tell me why you won't acknowledge what I've already said multiple times now: that increased educational standards come first, then follows treat and release, and every other wonderful tool I feel we should implement.

I imagine you will have some of the answers by morning when you research the web for the next few hours, or you could be honest and say I do not have a clue. These are just a few examples of why we should not leave patients at home.

So, what you're saying is that if we COULD answer those questions (that is, if our educational standards were higher), you WOULD agree with treat and release?

Then do me this one last favor; take the number of patients your service sees, and then multiply that number by 1-2%, what number did you come up with ? That is the number you kill every year from refusals.

How about a little evidence to back up those numbers? Or are those numbers still brown from pulling them out of your ass?

Sounds good when you say hey we are right 98-99% of the time, not so good when you say, damn we killed "x" number of patients. Even if the number is "2" that is "2" too many.

By that insane logic, nobody should ever be let out of the hospital after they've walked through the doorways. Because if even two die following discharge, that's too many.

And for the record, an unexpected death due to EMS refusing to transport a patient to the hospital does not equal clinical excellance; it constitutes negligence.

For the record, simply transporting everyone to the hospital "just cause" does not equal good patient care, it constitutes clinical incompetence.

[usalsfyre]

Crochity, none of the patients you mention are candidates for treat and release.

No matter your personal feelings on the matter, there is an acceptable rate of death. No one is perfect. Some of the "minor" problems you transport because your scared of your own shadow will be released from the ED and go home and die. All you've done is shifted the blame so you can sleep at night. Unexpected death is not negligence, it's inevitable.

I'm not sure what rainbow and unicorn reality you live in, but the truth is medicine is practiced by imperfect humans. Mistakes will be made and people will die from them. At some point cost absoloutely has to play a factor, otherwise no one will get any quality of care.

[usmc_chris]

I just thought I'd add... the technology to perform field lab tests DOES exist. Coupled with increased educational standards, more field testing could certainly equal more patients directed to appropriate care. In fact, with appropriate labs, and on-line consultation, provided the hospital isn't too busy, I could foresee a day when not only do we refer (or even transport) patients to non-hospital health care facilities, but where we could admit the patient directly to inpatient floors completely bypassing the ED.

Once again, this is predicated on INCREASED educational standards.

The Pediatric ICU team that my service works with has an iSTAT to perform field labs without relying on the outlying hospital lab (which takes so long so much of the time), it works great. So far they only do ABG's, but I'm fairly certain other cartridges exist for the machine to perform other labs.

I see no reason (other than cost) why this technology shouldn't be in the hands of Paramedics, as well. Do we need to do routine labs on EVERY patient. NO, but neither does the hospital. With increased educational standards, however, and therefore providers knowing WHEN to assess lab values and WHAT they mean, we can provide much better care for our patients.

Does this mean longer on-scene and patient contact times? Yes, so we will probably need more units in order to deal with the load. That being said, you wouldn't need as many hospital beds, especially in the ED, so from a Health Care SYSTEM perspective, it is MUCH better patient care.

And I completely agree, payment SHOULD be for services provided, not being a meatwagon. It's ridiculous that we only get paid, most of the time, if we transport to the hospital. What about field terms? It's ridiculous that we transport DEAD people, but if we don't, we can't get paid, despite all the medications we dumped into the person before, with on-line consultation, declaring them to be deceased.

[Just Plain Ruff]

The Pediatric ICU team that my service works with has an iSTAT to perform field labs without relying on the outlying hospital lab (which takes so long so much of the time), it works great. So far they only do ABG's, but I'm fairly certain other cartridges exist for the machine to perform other labs.

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.

Edited April 19, 2011 by Ruffems

[usmc_chris]

Yes, cost would certainly be a factor. Maybe they'll come down in price someday. Here's hoping.