Inter-facility transports

[Don1977]

If patient needs no medical interventions enroute to any location, they should not be in an ambulance. IMHO most ambulance services that do that type of work do so because it is so easy to defraud the government. These patients could be safely transported by a taxi, but based on some comments, taxi drivers are all some people on here are anyway.

Just like an interfacility psyche transport, call a damn taxi or for the violent person have a county sheriff do it in a paddy wagon. What am I going to do for a person wanting to kill someone??? sounds like he needs to go to jail.

Heres a patient of mine the other night... get a guy who has been in jail a year, gets released 1 friggin day, goes to work, fights with a guy, literally pushes him off ladder and beats his ass...and the guy "needs psych help"!!!!! BULLSHIT!!! He needs to go back to friggin jail!!! the man has Homicidal Ideations! WHAT THE HELL YOU WANT ME TO DO?!?!?!!?!?! Transport him in a police van!! Allegheny county Sheriffs don't do anything, let them transport them!!!!

Most interfacility transports here are for upgrade of care or insurance reasons, most are legit.

[Just Plain Ruff]

it's all anectdotal evidence Cb. I'll concede your point on the fact that all we have are anecdotal evidence but let me ask you a personal question.

You are 30 minutes outside of the the dialysis clinic. You are the patient. You are being transported for dialysis and you code. Your transport is 30 minutes to the hospital.

You now have two emt's, one driving and one in the back. But the ambulance service transporting you has two trucks available, one with 2 medics, and one with a medic and an EMT.

Remember you are 30 minutes away from the hospital.

Here is the question, who do you want treating you? 2 emts who can't do much more than cpr, aed, and an airway and drive fast, or would you want a medic who could administer drugs, defibrillate and put in an advanced airway.

I'd like to see some justification why you say that the EMT's would be just as beneficial to the patient because in your own words (paraphrased somewhat) you say that 2 emts rushing to the hospital would be as good as a medic.

I'd like to hear your justification as to why you choose what answer you give.

I for one want the highest trained person in the back with me if this happens to me but then again, that's just me.

I know that we are not going to agree with each other and my example of a fbao arrest should not have been put in there but it was not a red herring meant to confuse or anger you.

I'm not sure why this topic has gotten you so upset.

[WestSideBorderPatrol]

Just playing Devil's advocate here:

But if you code...aren't you most likely going to die or have a shi**y outcome regardless of the level of training the provider has? Just thinking out loud...

[Just Plain Ruff]

hmmmm maybe you should ask that to a couple of the witnessed arrest patients I've taken care of. If you code unwitnessed then yes but we are talking about witnessed arrest here at least that is how the course of this thread has gone.

Had one lady walk down the stairs from her house, perfect 12 lead no issues noted. Had some chest pain. She refused to be carried.

I put her in the back of the ambulance, began transport for about 10 minutes and were still about 25 minutes outside of the hosptial, I was talking to her and she went into v-fib. 3 stacked shocks, no response, one round of epi and another shock. Converted into A-fib with RVR. Hung a lidocaine drip. I had a high index of suspicion that she was truly having an MI but the EKG didn't show it so my suspicions were much more heightened.

We get her to the hospital. She arrests again, is brought out of it. Call her house one week later and amazingly she answered the phone. Said the only problem she has is pain in her sternum due to a fracture caused by guess what? CPR..

The cardiologist attributed her survival to the early defib, the epi and the lido. Can't say that an EMT could have done the drugs and such.

So yes, I think that a medic in the back is much more beneficial to an arrest than 2 emt's anyday.

Again, that's my opinion and nothing more but I've seen it proven many times over that having a medic is more effective to the patient then 2 emt's anyday. You will not be able to convince me otherwise. And with that said, I'm getting out of this discussion unless i'm forced back into it.

[WestSideBorderPatrol]

I have no doubt that a having a medic aboard is better than an two EMT's, I mean, you did go to school for a lot longer than me. lol. I hope something good came out of that education to make you better than an EMT since we EMT's are nothing more than advanced first aid

But it's just economics, its a heck of a lot cheaper for someone to afford 2 of me then it is for them to afford one medic.

[Just Plain Ruff]

I have never once said that all emt's are good for is advanced first aid. NEVER once. you can search through every one of my posts. And I do not prescribe to the viewpoint that a service operating with less than two medics is a poor system. I do not prescribe to that viewpoint.

As a matter of fact I have said on many occasions that if I have a competent emt partner then I'm happy with that. Would two medics be best, sure if you have a service that can afford dual medics but I've only worked in 3 systems that had the luxury of 2 medics and two were hospital based EMS and the other was Johnson County Kansas which is a very affluent county in Kansas.

So please don't attribute what you read here as holding to my views.

I've had medics who couldn't hold a candle to one memorable emt partnerr of mine and I've also had emts who couldn't hold a candle to a memorable first responder I've worked with.

I just don't agree that in a code going down the road that two emt's can be as effective as a medic and a competent partner, be that partner an EMT or another medic.

[WestSideBorderPatrol]

Sorry Ruff, I never meant for what I said to come off as me stating your views. My apologizes.

In other news...the other day at my private EMS gig, I got to stabilize a hip fracture which was cool since it was the only real "work" that I've done in awhile

[CBEMT]

You are 30 minutes outside of the the dialysis clinic. You are the patient. You are being transported for dialysis and you code. Your transport is 30 minutes to the hospital.

You now have two emt's, one driving and one in the back. But the ambulance service transporting you has two trucks available, one with 2 medics, and one with a medic and an EMT.

Remember you are 30 minutes away from the hospital.

See, now you're inserting things into the scenario that weren't there. We're talking about a paramedic making a dialysis transport versus two EMTs. I'll even allow the 30-minute hospital trip (not applicable to my area) addition.

It's my contention that I'm dead regardless of who's there. How long are your medics going to work the code on the side of the road? Are you going to call it right there and THEN take me in?

I put her in the back of the ambulance, began transport for about 10 minutes and were still about 25 minutes outside of the hosptial, I was talking to her and she went into v-fib.

The cardiologist attributed her survival to the early defib, the epi and the lido. Can't say that an EMT could have done the drugs and such.

Here's where you prove that we're really comparing apples and oranges here. I'm not contesting that the chest pain call should be getting ALS, and any assertion to the contrary is an out and out lie. (In terms of risk to benefit, the most effective intervention you can do for an MI is ASA and transport to a cath lab, but I still won't use that to justify BLSing chest pain. I've seen in person how much time can be saved by transmitting 12-leads from the field. That said, if the first response is a BLS transport and ALS response is going to take longer than a trip to the hospital, I would hope that BLS would pack it up and run.)

But notice- you were, more or less, PREPARED for your patient to code- you knew you were on a serious medical call with the potential to go downhill quickly, you had your IV already established, she was already on the monitor, you had your drug box open and ready.... etc etc.

I'm sorry. Comparing that to a stable patient dialysis patient who mysteriously craps out enroute to treatment, and then using it to justify ALS dialysis transfers, is simply ridiculous.

[VentMedic]

Stable dialysis patient? If you ever looked at any dialysis patient's labs even those that can walk around shouldn't be by the "norms". They totally change the scales on lab values. There's no mystery why they code. The only thing left to figure out is what finally got them. And yes, there are dialysis patients that should go by ALS definitely and they do. Even ALS intervention might be just enough only for a short time. Of course, we get the occasional paramedic that will openly complain and don't understand why they have to transport "just a dialysis patient'. They really do the profession a disservice.

CBEMT, you are correct that on a long dialysis patient transport, there may be little anyone can do if a patient codes. However, even for the dialysis patient, the rhythm, if witnessed, may respond to an immediate shock and a round of epi long enough to get to a hospital. I am not a fan of running fast with L/S either. For the EMT, this may be the only choice but effective chest compressions will sacrificed. I would hope a paramedic has enough confidence in his/her abilities without panicking and running. A call from the ambulance to inform the hospital what they've got in the back will get the party at the ED started. Usually just stating dialysis patient unstable or coding will sum up the report. Many dialysis patients are considered end-stage (but are still full codes) and a few minutes gained by speeding may not make a difference in the outcome.

I have worked many dialysis codes both in the clinic attached to the hospital which are witnessed and had a good survival rate and those brought in by ambulance. Those that have been witnessed by EMTs during transport with at least compressions started may have a chance, though less, of surviving also if they are close to the hospital. I've also spent countless hours as an RT in the hospital trying to buy the patient, who thought they could skip a day or who got careless with their diet or just having a bad dialysis day, a little more time until they can be transported to dialysis. But, there are limited options for keeping a dialysis patient stable even in the hospital. 15 mg of Albuterol will only shift the K+ for a very short time if their cardiac status is still stable. More fluids may not be much of an alternative either. These patients do require careful monitoring during transport to the clinic which hopefully will be beside or inside the hospital.

However, post code or near code, the patient now has to be stabilized and on minimal vasopressors for regular dialysis. If not, they will need CVVH (Continuous Venovenous Hemofiltration). Many hospitals do not offer regular dialysis, hence, the reason for hospital patients transported regularly to dialysis clinics. And, definitely not many hospitals offer CVVH. So, diverting to the nearest facility also may be futile but necessary in a code situation. Hopefully if a patient needs CVVH, some hospital CCT will transport the patient to the appropriate facility.

So essentially the dialysis patient can be in the same dilemma without a dialysis machine as the cardiac patient is without a cath lab and they, too are now on a clock for difinitive care.

Many EMTs and Paramedics who have transported at least a hundred dialysis transports, don't actually know much of anything about the process or the fluid mixture or why and the cause of the patient's renal failure. For them, it's considered a B.S. taxi ride. For the dialysis patient, it's considered life and death. If they want to live, that may be their life 3 times per week.

Again, even though EMTs and Paramedics think they are running all the dialysis and routine taxi rides, they probably are transporting just a small percentage of patients. Even in rural America, many do go POV. In the cities there are transport vans. Some of these patients get diverted to the ED for stabilization immediately upon arrival. If an ambulance is requested, either ALS or BLS, there is a reason. EMTs and Paramedics also don't always get to see the most unstable dialysis patients either. The hospital, either sending or receiving, will see they get transported by one of their CCTs because these patients require more than the perceived taxi ride.

[Niftymedi911]

Hyperkalemic? Absolutely, run that 12-lead with no pulse, let me know how it turns out. Or are we not just drawing labs now, but running the tests too?

Yes, CB we are doing tests, keep up with the times,..... Read this article on point of care testing for EMS:

http://www.jems.com/news_and_articles/colu...re_Testing.html

My agency is doing a six sigma project on wether we should invest in starting the point of care blood testing for our patients. With our hospital system (6 hospitals) within the next 3 years are cutting the duplication of servcies out and creating specialty hospitals, this would make sense.

BTW, you don't need to do a 12 lead on someone on diaylsis, they often have tall actue T waves in any lead if you hook em up.