Shouldn't all EMS systems be the same?

RNin92 · Aug 8, 2004

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

well..ya know...

ya gotta look for the bright spots!!!

:chuckle

magicman · Aug 8, 2004

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...

Lemme just take these one at a time. I'll preface it by saying that in a PERFECT world, ALL ambulances would be ALS and have TWO paramdeics on them. The reality is that only 30% (approximately) of EMS calls are truly ALS in nature, and that, by and large, EMT's treat trauma patients BETTER than paramedics (more on this in a bit), and that financial constraints (i.e. reimbursement has hit pre hospital HARDER than hospitals) prohibit staffing that way.

ALS crew for trauma pt transport to higher level of care

This type of request should be made by the SENDING facility (i.e. the doc in the box). This does NOT however, relieve the BLS crew from the responsibility of knowing they're in over their heads. :)

ALS crew for pt with IVs/Meds

EMT's are now allowed in most states to start IV's and monitor them as long as they are not a drip of medicine or have a piggyback. This again, is a financial thing. But realistically, you don't NEED a paramedic to monitor a KVO line of normal saline on a stable patient.

Ambulance crew report to medical control and receiving ER
Training to recognize S/S of unstable pts

The first definitely needs to be done on ALL transported patients. The second can be directed at both the sending facility AND the ambulance.

Diversion of unstable pt to nearest facility

This one again, should be more toward the sending facility. The ambulance crew has to follow physician orders -- to a point. If they see a patient crashing, they have the duty to divert to a closer facility that is APPROPRIATE for the patient. In other words, if a relatively stable patient is being transported to a specific hospital based on request and they pass two other hospitals enroute, they can bypass those two (if their protocol states they can) as long as the patient remains stable. If his condition changes, then the nearest appropriate facility becomes their choice.......even if it is further away than another hospital.......if the closer hospital does not have the capability to care for that patient. Kind of confusing, I appologize. :)

In other words, there are a lot of things that go into putting an EMS system together. None the least of which is competent training and con ed. There are obviously some things the EMS crew did wrong and also some things the UC center did wrong. The EMS crew's biggest problem was/is their lack of knowledge of assessment of the patient. That's not to say that entire SYSTEM is bad, but that CREW needs retraining (at the least). The UC center needs to be looked at and dealt with also. THEY initiated the transport and sent an unstable patient to an appropriate facility, but not the CLOSEST apporpriate one. THAT is a BIG problem.

Now, about EMT's v. paramedics for trauma patients. Interfacility transports asside, EMT's are better at trauma than paramedics by and large. Now, before I get flamed for this, let me explain. EMT's can't do anything definitive for trauma patients except immobilize them and control bleeding. Therefore, they spend less time on secne because there is nothing else TO do. Paramedics, on the other hand, have the ability to start IV's, intubate, give drugs, etc. These skills, while VERY IMPORTANT, are better done ENROUTE to the trauma center. Doing them on scene only delays the patient getting to definitive care and takes away from the golden hour. It has been found that trauma patients do not NEED fluids for the most part, and that actually the indescriminate use of fluids actually does more harm than good, depending on the type of trauma. And unless you need an airway, transport to a trauma center is the BEST thing an EMS crew can do for a trauma patient after immobilizing them.

AFA the amount of EMS calls that are TRULY ALS, many studies have been done on this. The average is 30%. Why use a sledge hammer to kill a fly if a fly swatter will do the same more efficiently? In other words, it's a matter of effective utilization of resources. Just as in the hospital, not all nurses are RN's ONLY, not all ambulances are ALS. This is a reality of doing business. And let's face it........health care IS a business. I don't LIKE that, but it IS the reality.

Please, I'm not looking to start an arguement, or get flamed because of any of this. I'm only stating some points to consider instead of pointing the finger at only one source. There are many things to take into consideration in this (as in many) cases.

RNin92 · Aug 8, 2004

Magicman...

You have many great points.

You're rationale about EMTs vs Paramedics in the case of trauma in relation to tramsport times IS interesting. And I think I might even agree with you...in the case of a crew responding to a scene.

That was not the case in my situation...it was a private ambulance service.

I also totally agree with the bulk of the responsibility with the UC doc...he, in my humble opinion, is the most culpable... (and a complete yahoo!)

My concerns were that the rules that are rigorous in some states do not exist in others. And that sometimes, as in my situation living in a border community, that circumstance creates problems. Mostly, problems for the patients.

I just wondered how much disparity really exists.

In my situation, the sending hospital was required to send the patient by ambulance...the laws in that state apparently DID NOT require a paramedic to be a part of that crew. THAT is my issue.

edogs334 · Aug 9, 2004

Good points made by all so far. I am an EMT-Basic who works part-time for a private ambulance service (I am a full-time college student wanting to go to RN school). I would like to offer my perspective on the situation that RNin92 was involved in.

Yes, there is a lot of variation in terms of what EMT's and paramedics can do from state to state and even from locality to locality. As said before, most of it is because of politics- i.e.- people don't want to lose their egos and they think that their way is the "best way" and that anything else can just go onto the proverbial highway. Thus, it's sometimes confusing for EMT's and paramedics from a different system to come into another system and be confronted with different expectations about treatments and protocols.

That being said, the statement that "oh, they didn't recognize that the patient was circleing the drain because they were basics" is pretty inaccurate. Good EMT's (and paramedics) should be well-versed and trained in recognizing patients whose overall conditions are in the toilet (or could potentially be in the toilet); the latter vs. patients who are all in all most likely stable. In other words, differentiating between stable and unstable patients is a BLS skill. No offense to medics, but if you're an EMT-P and you need all those ALS gadgets and gizmos to tell that your patient is unstable, then may God help you and especially your patient. Bottom line, it doesn't take all sorts of ALS training and equipment to recognize that a patient is going down the tube.

Here's what might have happened. The Doc, since he obviously mistriaged the patient, may not have requested ALS when he called the private ambulance service dispatcher. If he really thought the patient was unstable, he would have called 911 and had the local municipal provider transport the patient to the closest APPROPRIATE facility. Anyways, a lot of the dispatchers in private services, instead of triaging the call themselves, are told to rely on the medical professional calling to provide a triage decision, even if the patient's condition sounds like they may need prompt ALS care. The private ambulance service, instead of calling the local municipal provider, probably opted to send one of their BLS units, which was probably not very close by anyways, to the "Doc in the Box" health center. The EMT's were either both new (it isn't uncommon for privates to place 2 new EMT's in a truck together) or just plain incompetent- so they failed to take the mechanism of injury and signs of impending shock into account. The patient (and/or the doc) probably requested that they go to your hospital, even though that facility was far away. The EMT's either thought that was a good decision, or thought that they absolutely had to abide by the doc's transport decision (which, in my company, you don't have to if you feel that the decision is not an appropriate one). They also probably did not call for an ALS intercept, which is the least that they could have done for their unstable patient.

Now, I'm not saying that the above IS what happened- I was never there. However, this is my speculative explaination of what MIGHT have happened prehospitally, based upon the data you gave in your post and based upon my own experience. I hope this helps.

Ian D.L. EMT-B

Massachusetts

magicman · Aug 9, 2004

Magicman...
You have many great points.
You're rationale about EMTs vs Paramedics in the case of trauma in relation to tramsport times IS interesting. And I think I might even agree with you...in the case of a crew responding to a scene.
That was not the case in my situation...it was a private ambulance service.

Just an FYI, even privates respond to 911 calls. In a lot of systems, they are the ONLY ambulance responding. But that was why I quantified my statement to scene response only, as your situation was an interfacility transfer. :)

I also totally agree with the bulk of the responsibility with the UC doc...he, in my humble opinion, is the most culpable... (and a complete yahoo!)

I'm betting we ALL agree here!! :chuckle

My concerns were that the rules that are rigorous in some states do not exist in others. And that sometimes, as in my situation living in a border community, that circumstance creates problems. Mostly, problems for the patients.
I just wondered how much disparity really exists.
In my situation, the sending hospital was required to send the patient by ambulance...the laws in that state apparently DID NOT require a paramedic to be a part of that crew. THAT is my issue.

If you take a look at your states EMS regulations, I'll bet 10:1 that it does NOT specify that a paramedic HAS to be on EVERY ambulance. Only on every ALS unit. Also, it more than likely won't specify that an ALS unit is mandated for interfacility transfers. If the boy had fallen and only broken his leg (compound fracture), he would not require ALS care for the transport..........EMT's can monitor IV's and the leg would already be splinted. Even if it weren't, the EMT's are supposed to be qualified to splint for transport. Crew makeup is left to local EMS directors/administrations. The type of unit sent on a specific call should be decided upon by dispatch when taking the call (which, in this case sounds like it didn't happen).

I agree that the private company that made the transport had poor judgement (the crew at the very least), but please don't label ALL privates as being money grubbing bottom dwellers who only want the calls to make more money. Don't even label THAT private that way until you look at the whole system and what their protocols are. Obviously THAT CREW has a BIG problem, but that doesn't necessarily mean the entire service is bad (although it can make one wonder!!). I've seen more municipal and government (county) run EMS system Paramedics who were burned out and just down right pissy about doing interfacility runs that THEY were sloppy in their care too. It all really DOES start at the top......the medical director for the service/system and the administration. If they are comitted to quality, then the people in the streets will be too (most of them....there are always the few standouts).

RNin92, PLEASE, keep us informed of the outcome of this from the other side (i.e. the administrative side). I'm very curious to know what, if anything, gets done or changed because of this incident........both at your facility and in the other EMS system. This is truly an opportunity to make a GREAT change for the positive if someone can or is willing to step up (it could be a great position to create for some nurse who wants to become an EMS liason/QA coordinator/educator too!!!!! Hint, hint). :wink2: :idea:

RNin92 · Aug 9, 2004

Hmmmm...one more job!!!!

:chuckle

I will let you all know the outcome...but the wheels turn slowly!

Certainly there is enough...um..."opporunity" here to go around...my own doc included...freakin' cowboy! (no offense to any southwesterners!)

And the botom line is the kid did fine...in spite of all our "help" :rolleyes:

paraloco · Dec 16, 2004

Had a strange situation happen a couple of weeks ago that has been bothering me. So I put it out there to the ER nurses in cyberspace. Here's my tale and my question...
My ER doc accepts a pt from a local "doc-in-the-box" but it is on the other side of the state line. (we are 10 minutes from the border). I was the Charge Nurse that day so he's now telling me what's coming. Here goes...
19 y/o male kicked in the abdomen by a horse.
VS=180/90-58-24-Afebrile
No Meds/Hx/NKA
Diaphoretic-Pale
Abdomen tender...VERY tender
Here's the clincher (like he needs one!)...NO BS
Now understand...I work at a Level II Trauma Center...Level II.
So i say to my doc...who I should have killed already...what are ya thinking????
He says...they scanned his abdomen (no contrast)...just some bowel "inflammation"
ARE YOU KIDDING???!!???
So I get the report from the nurse...45 minutes later
Same as above...except his abdomen is now rigid...
great.
I am now begging my doc...this kid needs to fly off...say to a Level I somewhere...with his perforated bowel...
No No...he's coming here.
Turns out that this particular urgent care is about 40 minutes away...and they are waiting for a private ambulance to come get him.
So 4 hours after the original call in rolls the ambulance...no radio report...nothing...just here we are!
The crew says...hey..good news...
His BP is dropping down to "normal" nicely...and...
His heart rate is back up to normal.

Can I just say one thing here ...OH MY GOD!!!!
The kid was whiter than my sheets...diaphoretic...in excruciating pain...pressure in the toilet...tachying along at 130...rigid abdomen with NO BS...bruising...DYING...
Now someone was bright enough to have the Trauma surgeon notified and in the ED mucho pronto...thank God he hung around...
This kid was in surgery in about 30 minutes...for his perfed bowel...
And in the ICU for a week for his peritonitis.
So on to my question...although there are SOOOOOO many...
When I talked to the crew of the ambulance I asked why they didn't call me
They said...we are not in your system
I asked...why didn't you call whoever your medical control was?
They said...why?
How about recognizing that this kid was crashing on you...not "good news"
They said...huh?
So I write up the incident and talk to our EMS coordinator...
She says...not all states have the same rules. They might not have even been Paramedics!!!!!
So back to my question...
Shouldn't the EMS systems be uniform state to state?
Shouldn't there be stringent requirements that are all the same?
What do you think?

Go join the TExas EMS listserv. It's almost all they talk about now. Its a proposal for a National Scope of Practice. Alot of big city fire department EMS systems would welcome it, because it would take the pressure off of them to increase their capabilities. Privates would like it, because they may be able to reduce the amount of meds and equipment they have to buy. For the more advanced systems, it would be a taking some large steps backward. The medical director we have takes an active role in our QA/QI. We also do frequent CE , 'merit badge' courses ACLS BTLS PALS PEPP He lets us do alot because its not as hard for him to keep tabs on us as it would be a for the medical director of, say, Houston Fire Dept., to keep up with all the guys he is responsible for. The National Scope of Practice as it is envisioned by The National Registry of EMT's would take away an individual medical director's discretion to pick and choose what he/she/it want the medics to do. If enacted, those who choose to ignore it would leave themselves exposed for some serious liablity

stbernardclub · Dec 16, 2004

YES....DITTO DITTO...TRYING TO UNDERSTAND THE TITLE..THE DR WAS ALSO GOING BY A SCAN THAT SHOWED INFLAMMATION...I DON'T KNOW, GUESS YOU JUST HAD TO BE THERE TO GET THE FULL STORY.

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