The future of medicine in Washington State

[ERDoc]

Agreed Bieber. It's not just about letting EMS providers turn down transport though. It is also about protecting them, legally, when they do. Let's face it, even with a good exam some things are going to be missed and there is going to be a bad outcome and some poor medic or EMT is going to be sued. If we are going to be required to turn people down, we need to be protected to do so.

[Bieber]

Exactly. The goal has to be to provide a system where EMS providers can make reasonable decisions on the behalf of their patients given the information they have available to them, and protection from them when patients slip through the cracks. Like it or not, there WILL be that patient who has a history of anxiety and panic attacks, presents like a panic attack, and ends up having a PE and dies an hour after the EMS crew leaves. EMT's, paramedics and the lawyers all have to understand that the goal is not and cannot be to prevent everyone from dying or having a bad outcome; that's an unrealistic goal that expects and demands punishment for any and all failure. The goal is to provide adequate and reasonable care based on the facts available. The "you never know" philosophy is a slippery slope that leads to both financial ruin and unacceptably high levels of unnecessary transport for unnecessary ER evaluation for too many low-risk patients. And the 25 year old male who is otherwise healthy except for a history of acid reflux complaining of chest pain is simply not the same as the 58 year old female diabetic who is feeling nauseous and short of breath and nor should they be looked at equally when they have bad outcomes due to a provider initiated refusal. One of those refusals would be grossly negligent, the other would be reasonable--even if they had similar outcomes.

Edited January 15, 2012 by Bieber

[ERDoc]

All good points again. The problem is that none of that makes good reelection soundbites. There is nothing like a kid in a wheelchair due to bad, evil, greedy doctors and ambulance drivers to really win over the public and turn them against the medical system.

Your mention of PE did give me pause though. If we expect EMS to turn away pts, will we be bringing up the level of education to that level? I don't want to turn this into an ALS/BLS, etc discussion again but I had never heard of a PE when I was an EMT. How can I say someone is safe not to transport if I don't know about the things that can be fatal?

[BAYAMedic]

ERDOC, are you Practicing in Washington state now? If so I'd love to meet up sometime.

Yes, the brilliance of my home state... What its doesn't mention is that the Community Health Clinics have taken a HUGE hit in their budgets as well, over the last 18 months. The Clinic my Wife used to work for had to show a reduction in services, to include dental, Suboxone, and Pain management and face staffing reductions and reorganization in leadership structure. Receptionists were required to change to all 15 minute appointments and had to go to the supervisor for authorization for extended appointments (with some exceptions). So if the ease of access to primary health care management is reduced, the Emergency room usage is going to spike. With every discharge from the ED a referral is given to the patient to follow up in the next 72 hours with GP. The Clinic still doesn’t have any appointments for the next month..... Vicious cycle continues.

So how is this currently being dealt with? From a semi reliable source, Deliberate miscoding on the physicians part. If you use a DX code that is correlated with "Emergent acceptance" and increase the number of tests you run to make it look like a difficult case, from a billing standpoint, the likelihood of rejection is lower. So this case of esophageal reflux is esophageal spasm, and had to be ruled out it wasn’t a cardiac event, so 4 set of enzymes are performed, on a nitro drip for a couple hours then after all cardiac markers come back negative, chest x-ray negative and echo negative, give a GI Cocktail and release with an RX for omezaprole. Am I being a touch excessive and cynical for the case of making a point, Yes.

So how do we deal with this in EMS? I LOVE the idea of paramedics having a Medicare- debit card, and a different mode of transfer form. Right elbow pain times three months and has been taken by EMS twice. The pt. requested hospital happens to be next to the Mall. So rather than driving by 2 hospitals to get to said hospital, get a modified refusal form and release of liability form, and a cab to requested hospital ABC, with a Remote check-in patch called to ABC by Paramedic to get them in line for triage. Or better yet, have contracts with the doc-in-the-box urgent cares and tell the patient that they will be able to handle the complaint just as effectively. Cost to tax payers $30 bucks for a cab vs $600 minimum ambulance transfer fee. $200 dollar Urgent care vs $1200 ER.

Fireman1037

[ERDoc]

ERDOC, are you Practicing in Washington state now? If so I'd love to meet up sometime.

No, I am in Michigan. Meeting up with me can be problematic, just ask Ruff.

Am I being a touch excessive and cynical for the case of making a point, Yes.

No, I don't think you are. With half-assed ideas like this, your example will become the unofficial standard of care.

[Kiwiology]

All good points again. The problem is that none of that makes good reelection soundbites. There is nothing like a kid in a wheelchair due to bad, evil, greedy doctors and ambulance drivers to really win over the public and turn them against the medical system.

Let's not forget those Consultant Kiwiologists .... they are about the most evil bastards out there

Your mention of PE did give me pause though. If we expect EMS to turn away pts, will we be bringing up the level of education to that level? I don't want to turn this into an ALS/BLS, etc discussion again but I had never heard of a PE when I was an EMT. How can I say someone is safe not to transport if I don't know about the things that can be fatal?

None of this makes sense period; it's just crazy; but this is what happens when you have a privatised health system ....

Now, get me into that health system man I want to make a half million dollars a year for a lil' bit as a Consultant, the $120,000 I'd get here is just pale in comparison, heck I'll even learn what the bloody hell a bisphosphate is and how to look intelligent with that stethoscope thingo by putting it round my neck not up my ass!

[Bieber]

All good points again. The problem is that none of that makes good reelection soundbites. There is nothing like a kid in a wheelchair due to bad, evil, greedy doctors and ambulance drivers to really win over the public and turn them against the medical system.

Your mention of PE did give me pause though. If we expect EMS to turn away pts, will we be bringing up the level of education to that level? I don't want to turn this into an ALS/BLS, etc discussion again but I had never heard of a PE when I was an EMT. How can I say someone is safe not to transport if I don't know about the things that can be fatal?

Honestly, man, my opinion is that an associates degree paramedic should be the minimum--and I mean the absolute minimum--level required to work in EMS. Eliminate EMT all together, basic and intermediate alike, and go to a system more akin to that in Australia and New Zealand where you have a "basic" paramedic with an associates degree and an "advanced" paramedic with a bachelors degree. Kansas and Oregon both require associates degrees to become a paramedic, and I can tell you that even with my bright and shiny AAS that our educational standards need to be elevated.

Ironically, Kansas, which has higher educational standards for paramedics than the majority of the country, has absolutely no bachelors degree programs in paramedicine...

Also, with regards to knowing when it's safe to transport and not safe to, educational standards are just one half of the equation. We need to talk about the elephant in the room, and that is provider-initiated refusals. Nowhere in my education, nor in my orientation at my job, were provider-guided/initiated refusals ever discussed. Not once. Nobody, and I mean nobody, in EMS wants to talk about them. And then we wonder why EMS providers end up getting sued when a patient they "refused" has a bad outcome. If we're not willing to talk about it, and we're not willing to educate ourselves on when it is and is not appropriate to "refuse" a patient, we are going to have bad outcomes. The system is working exactly like it was designed, the problem is that it was designed for failure when it comes to refusals.

Until we're willing to accept that it is OKAY to discuss patient-guided refusals, we aren't going to educate ourselves on them, and there will be no standards for when it is appropriate and when it is not. And that means a lot of education on the difference between a diagnosis and a prognosis, how to make educated prognoses based on the information we obtain, and how to take that knowledge and turn it into sound clinical decision making.

[HERBIE1]

OK doc, so is it time to switch professions yet? Isn't one of the money saving ideas of Obamacare to cut Medicare reimbursement to physicians? Couple that with this idea in Washington, and I would expect to see tons of ER MD's there packing their bags and heading out of town.

I love this- under the FAQ's of the plan:

Who will decide what is medically necessary?

Answer: The Health Care Authority will use sound evidence and a collaborative process in

determining what constitutes medically necessary care in an Emergency Room setting.

Sound evidence? As defined by whom?

Collaborative process? Would that be a bunch of politicians and bureaucrats, sitting around a table?

Just WOW.

[ERDoc]

There is a 16 page list of what is not covered. Check out the link for the full list.

http://www.wsha.org/files/65/Non-Emergency%20Conditions.pdf

Some interesting ones include:

Streptococal septicemia

Hypoglycemic coma

Cardiac dysrhythmia

CHF

Pneumonia

COPD

Status Asthmaticus

Acute cholecystitis

Miscarriage

Pretty much any joint pain or sprain

Epistaxis

Abd pain

And those are just the ones I noticed skimming through the list.

Some are not emergencies once you know the diagnosis but the differential includes some really bad things which require a workup (Bells Palsy or CVA?). Some are just conditions that are very painful and it would be inhumane to make someone wait (acute thrombosed hemorrhoids). Again, I hope WA will be issuing retrospectroscopes to all ERs. I feel sorry for the people on medicaid. It is nearly impossible to get an appointment in a reasonable time, much less 24-48 hours when you need it. We have a county clinic near one of our hospitals that constantly tells their pts, "We can't get you in for a few weeks, you should go to the ER."

[Bieber]

I see quite a few diagnoses on this list that I would consider emergent conditions, and even more that can only be determined to be non-emergent after a thorough workup to rule out serious diseases and etiologies. Some other interesting ones I found:

Mittelschmerz

Cervicalgia

Tietze's syndrome

Headache

Shortness of breath

Now I'm just a lowly ambulance driver, but it seems to me like most of those diseases are diagnoses of exclusion after life threats have been ruled out (i.e. ectopic pregnancy, cervical spine injury, MI, CVA, asthma/COPD/CHF/PE).

But again, I'm just a lowly ambulance driver, and I'm just paid for taking folks to the hospital and a preset "level of care" provided. =)

Edited January 17, 2012 by Bieber