Shouldn't all EMS systems be the same?

Dixielee, BSN, RN · Jul 31, 2004

I have worked in a variety of hospitals, mostly Level 2 trauma. Some hospitals shipped everything critical out and some we were the receiving hospital of some really bad transfers. The last hospital was Level 2 only because they could not get a neurosurgeon to take call on a regular basis. It was a teaching hospital, transplant center and had the regional burn center. We have received patients who were way to unstable to be transfered, but they showed up at our door anyway. It was much worse before the COBRA laws in terms of patient dumping. We received a patient by helicoptor who just landed and showed up at our door because they had been diverted from the hospital that originally accepted the patient. I have worked in situations where some of the EMS were EMT/first responders and their only plan was to get the patient to the hospital, any hosptial as fast as they could because their resources were so limited. In the situation you mention, you definately should have gotten an update from EMS. Sometimes if they are not on our system, they will call dispatch with update and dispatch will call us, so that is no excuse. Yes, it would be nice if all EMS systems were the same, but like hospitals, doctors and nurses, we are all different, and it is up to us as ER staff to roll with the punches. That is one of the things that makes ER nursing so much fun, you never know what is gonna roll thru that door!

EMTtoRN · Jul 31, 2004

Hi, Not a nurse yet but am currently in EMS. It is amazing how much EMS varies from state to state. Each hospital has thier own protocols even if they are 5 minutes from each other. It is odd to me that they were not able to contact you in some way. I know we have certain hospitals who only want a patch if it is an ALS call, which yours was. Again we only call paramedics in certain situations because we have I techs on our rigs. If we need meds or heart monitoring we call medics who come on board with us.

I think it was right that you questioned their actions. Maybe it will open your EMS office's eyes to a problem. I am glad to hear that he was able to be helped in your facility. I can only imagine if he had to be moved yet again.

In defense to us, it is correct that 99% of the time we HAVE to go to the nearest facility. Especially if the patient is unstable. If they are stable then we have a couple of choices for hospitals. The idea is that they can at least be stabalized and then flown out as when we call the "bird" it usually takes then 25 minutes to come on scene vs 10 minutes for us to transport them to the nearest facility.

RNin92 · Aug 1, 2004

Hi, Not a nurse yet but am currently in EMS. It is amazing how much EMS varies from state to state. Each hospital has thier own protocols even if they are 5 minutes from each other. It is odd to me that they were not able to contact you in some way. I know we have certain hospitals who only want a patch if it is an ALS call, which yours was. Again we only call paramedics in certain situations because we have I techs on our rigs. If we need meds or heart monitoring we call medics who come on board with us.
I think it was right that you questioned their actions. Maybe it will open your EMS office's eyes to a problem. I am glad to hear that he was able to be helped in your facility. I can only imagine if he had to be moved yet again.
In defense to us, it is correct that 99% of the time we HAVE to go to the nearest facility. Especially if the patient is unstable. If they are stable then we have a couple of choices for hospitals. The idea is that they can at least be stabalized and then flown out as when we call the "bird" it usually takes then 25 minutes to come on scene vs 10 minutes for us to transport them to the nearest facility.

It was VERY odd that didn't at least contact there own Medical Control...

And the reason that they didn't divert to a closer facility with their unstable patient...

They never recognized that he was unstable.

Scary...very scary.

Medic2RN, BSN, RN, EMT-P · Aug 4, 2004

Sounds like you had a BLS ambulance although it was an ALS call. As far as not getting a radio report and only receiving information of BP & HR for a transfer report - this is why I think they might have been Basics. If they were paramedics, then shame on them!!

4 hours is a long time until the patient finally gets to the hospital - someone might have dropped the ball there or did not paint a serious enough picture regarding the status of the patient. When the tone goes out for an ambulance, the ambulance is en route. There was a time I had snide remarks directed at me and a fellow paramedic because "we took so long to get there". Turned out my response time was 3 minutes.....A box can't roll out is we don't get a tone!!

I'm sorry that kid had to go through such a terrible experience!!

:balloons:

qanik · Aug 5, 2004

There are several factors that need to be pointed out. Having been a paramedic for 16 years and a nurse for 14, I have worked and been part of numerous EMS systems throughout the East Coast and Mid West.As others have stated EMS systems are different everywhere. The one thing that seems to be the same is there are a lot of politics involved wherever you go. I current practice in an area where I can cross three different EMS systems all on the way to the level one about ten miles away and all three systems have different SOP's and destination protocols. It is crazy. Unfortunately the systems want to keep their patients within the system hospitals and God forbid the poor EMS people that end up outside the system, even if it is in the appropriate hospital. I lecture frequently on transport medicine and the case in the original post highlights the all to frequent mistakes made during transfer. The original MD knew or should have known that he did not have the resources to care for the patient.- Time to transfer. The EMTALA rules and regs are now in play. The MD must find an appropriate facility that can handle the patient, (in this case a facility with a surgeon, why would an ER MD ever accept a trauma patient, he is not going to be caring for them?) and the facility must have the room and expertise to handle the patient. After a receiving physician and facility has been found, he must find and provide appropriate transportation for this patient. In the case mentioned a minimum of an ALS rig more likely a Critical Care rig or aeromedical team. The refering physician is responsible for that patient legally untill they arrive at the receiving facility. The EMS workers in the above mentioned scenario may have not known any better. They may have been EMT basics and been in over there head. They would only be following their SOP's and wouldn't know better. If they where paramedics they should have known better and should be written up regardless of their system so they could benefit from the education. In any case they would be still following their SOP's with the ability to call their Medical Control Doc. The refering MD could easily be found in EMTALA violation for the transfer. Is it likely? No, not unless the patient suffered a poor outcome- (a miracle he didn't) Last with regard to The quote

"In defense to us, it is correct that 99% of the time we HAVE to go to the nearest facility. Especially if the patient is unstable. If they are stable then we have a couple of choices for hospitals. The idea is that they can at least be stabalized and then flown out as when we call the "bird" it usually takes then 25 minutes to come on scene vs 10 minutes for us to transport them to the nearest facility."

I understand that the EMS providers don't have a choice but it has been proven time and time again in trauma studies that the patient will have a better outcome if they are brought to the appropriate facility regardless of the extra time spent getting them there. The argument that the patient can be stabilized untill the "bird" gets there is complete BS

If we use the original post example, what would that patient have gained from arriving at the closest facility if they did not have the resources to bring the patient to the OR immediately? Did the ED physician know that there was a surgeon ready to take this patient to the OR? The ONLY reason to divert to the closest facility with a trauma is for an airway emergency. If you pick up an ATLS manual it clearly states as soon as the trauma arrives and the determination is made that the facility does not have the resources to handle them then transfer arrangements should be made immediately to move the patient to a facility that can. No need for C-spine chest pelvis, labs, CT's etc. A B C transfer and if you have time for the other things then great. Sorry so long.

Qanik

jackleg27 · Aug 5, 2004

A) Sounds like they were Basic EMT's and not Medics possibly not realizing that the kid was unstable.

B)There was some sort of communication breakdown somewhere in choosing which crew, ALS or BLS to send

C) They could have called you on a cell phone to give you report.

magicman · Aug 5, 2004

First and foremost, all good answers to this question!! I'm MUCHO happy to see many EMSers and previous EMSers around!!

I am currently in a similar situation where I work almost daily. It is a smaller county and we are the only hospital. Long story short, the politics invloved on BOTH sides is enough to put the Bush/Kerry thing to shame!

Now to speak to the question at hand...........

While I can agree the kid SHOULD have gone to a level I, you ARE a level II and (at least by Florida standards), should be able to handle this type of patient. Therefore, it IS an appropriate transfer unless there is a level I closer than you to this UC facility. That not withstanding, the physician SENDING the patient IS responsible for care up to the receiving facility accepting the patient physically in their building. That means he/she is responsible for the level of care provided to them enroute. The sending facility should make appropriate arrangements with the transferring agency to make sure the level of care is appropriate for the patient. It sounds, from what you wrote, that he totally missed this kids problem to begin with. He, or more appropriately, the UC center should be written up.

As for the private company who transported, it sounds like they were EMT's and probably didn't know much better than what they did. Although even THEY should have known they were in too deep and called for an ALS truck. So even THEY should be written up since (even at their level of education) they shold have known better.

As to the question about all EMS agencies beign the same.....no, actually they shouldn't. EMS is set up on the needs of the community they serve. Unfortunately, there also comes politics with this. While the training involved to become an EMT or Paramedic is standardised at a minimum by the federal government, the teaching can go above this if so desired. And regardless, the protocols of each service can vary so greatly that even going from one city to the next things can be DRASTICALLY different.

I'm glad to hear the outcome was better than the fustercluck that got this kid there though!

RNin92 · Aug 5, 2004

Hey thanks all for the great responses!

I understand that different areas have different needs...but I still think that there need to be some universal rules.

So far I have learned that MANY errors happened that day...

UC doc NOT board certified for ER/Trauma

CT read as bowel inflammation at the UC

UC doc thought the kid was stable... (??)

My ER doc...did not listen to his Nurse's "almost always right on the money gut instinct"

BLS transport crew...

even with an IV

even with unstable VS

even with mechanism

Ambulance crew NEVER contacted their medical control

They also never contacted their base with an unstable patient report

This one is STILL ongoing...

And we are a Level II...and had the kid been brought in from the scene...we may have kept him anyway...but this kid came from someplace where the ambulance had to pass by several other Level IIs and a Level I...to get to us.

Because that's where mom said his doc was...

Wonder if they talked about what happens when the son dies en route to the hospital with mom.

Medic2RN, BSN, RN, EMT-P · Aug 7, 2004

Since you named the thread "Shouldn't all EMS systems be the same?", what type of universal rules are you referring to? Just curious.... :)

RNin92 · Aug 7, 2004

Since you named the thread "Shouldn't all EMS systems be the same?", what type of universal rules are you referring to? Just curious.... :)

ALS crew for trauma pt transport to higher level of care

ALS crew for pt with IVs/Meds

Ambulance crew report to medical control and receiving ER

Training to recognize S/S of unstable pts

Diversion of unstable pt to nearest facility

Don't even start me on the UC doc and staff!!!!

Don't get me wrong...

Our EMS crews are awesome!

By and large they are well trained and recognize an unstable pt...

and more importantly...know when to treat and when to divert...

But THIS crew...who were NOT part of our system...

Well. they had the cute jumpsuits...

Medic2RN, BSN, RN, EMT-P · Aug 8, 2004

I see where you're coming from....cute jumpsuits, huh? :chuckle