# holding the wall



## Joe (Jan 14, 2012)

Don't know how common of a term it is but as I sit here with a pt I think...how does everyone else get in and out of the hospital in a timely manner? Maybe its just the abuse of the system or maybe this hospital is really slow. We've been waiting for a bed for the last 2 hours and 12 mins. What's the longest wait for you guys?


----------



## DesertMedic66 (Jan 14, 2012)

We have 3 hospitals in my response area. The longest I have been on "bed delay" or "holding the wall" is 30 mins. And that was only one time. Normally we walk in tell the charge nurse which patient this is so they can match up the call in we did with the patient and then give us a bed. Then we hand over patient identifiers to registration.

Normally we walk in and say "chest pain" and the charge nurse will say "bed N" as we are still entering the ER.


----------



## Joe (Jan 14, 2012)

That must ne nice. Were still holding and our pt is chest pain. Nsr on the monitor so I don't think they care that much :/


----------



## Handsome Robb (Jan 14, 2012)

Well chest pain can mean a lot of different things 

It happens to us pretty regularly but never for that long, 30 minutes is the longest I ever waited, and I ended up giving 2 mg of narcan. My partner finally put his foot down and told the charge nurse to give us a room or we were transporting to another facility. Needless to say we got a room and a very grumpy ER doc. Not grumpy with us, grumpy with the nurse for making us wait with a PT we had to continually give meds to. 

If more than 2 units are status 99 (holding the wall) our dispatch center puts that hospital on bypass and that's bad news for the hospital so they do everything in their power to keep it from happening. 

I've heard stories of units in the past being stuck for an hour or more.


----------



## Joe (Jan 14, 2012)

Yea were in one of 2 hospitals in the area. This is the most appropriate facility. Were still holding with no end in sight


----------



## DesertMedic66 (Jan 14, 2012)

Well you are in LA county...


----------



## Bruiser (Jan 14, 2012)

6 hours but im sure some poor soul on this forum has done more hahaha


----------



## Joe (Jan 14, 2012)

Wow 6 hrs is crazy! We finally cleared at 0150. 10 mins prior to eos. Funny thing...people that came in after us cleared first and returned with pt and cleared again...


----------



## JPINFV (Jan 14, 2012)

It really depends on the hospital. There's one hospital in the OC/Long Beach area where a "long wait" is 10 minutes. There's another hospital where a short wait is over an hour. There are some hospitals where it depends on how busy they are and sometimes it's fast, and sometimes it's slow. I guess you could buff your chart, but that doesn't help anyone in the end.


----------



## AlphaButch (Jan 14, 2012)

We call that "parking" a patient around here.

CMS statement regarding "parking" and in consideration of EMTALA - "hospitals have an obligation to assess the patient's condition once they "present" at a hospital's dedicated emergency department."

CMS states that it "recognize(s) the enormous strain and crowding many hospital emergency departments face...however, this practice ["parking"] is not a solution. 'Parking' patients in hospitals and refusing to release EMS equipment or personnel jeopardizes patient health and impacts the ability of the EMS personnel to provide emergency services to the rest of the community."

Of course, we (EMS providers) should act reasonably and/or wait a reasonable amount of time given circumstances - "remember we're on the same team ultimately". I've only had to wait over 10  minutes once and that was due to the arrival of two codes simultaneously.


----------



## Sasha (Jan 14, 2012)

4 and a half hours. But this was at our trauma center with an abnormal labs while they had multiple trauma alerts, one medical code and a few medical reds and yellows come in prior to us getting a bed.

Record for my service is 5 hours.


----------



## fast65 (Jan 14, 2012)

The longest I've had to wait is like 10 minutes.



Joe said:


> That must ne nice. Were still holding and our pt is chest pain. Nsr on the monitor so I don't think they care that much :/



If you guys were still holding your patient, why are you on the internet posting?


----------



## DV_EMT (Jan 14, 2012)

For anyone who knows Hollywood Community Hospital... Longest time there was 1hr 45 mins..... Along with 5 other crews


----------



## STXmedic (Jan 14, 2012)

Never more than 5 minutes. 99 times out of 100 it's straight to the room. We also have something like 18 hospitals to choose from in our city.

Now waiting to give report after the patient is in bed... Sometimes that can approach 10min...


----------



## JPINFV (Jan 14, 2012)

DV_EMT said:


> For anyone who knows Hollywood Community Hospital... Longest time there was 1hr 45 mins..... Along with 5 other crews




Ever been to Presbyterian Intercommunity Hospital (PIH) in Whittier? 3 hours.


----------



## Joe (Jan 14, 2012)

fast65 said:


> The longest I've had to wait is like 10 minutes.
> 
> 
> 
> If you guys were still holding your patient, why are you on the internet posting?



We take water breaks and figured I would start something to keep me entertained on future water trips. Some crews will sit behind the gurney and play games out if sight but that's there thing.


----------



## Sasha (Jan 14, 2012)

fast65 said:


> The longest I've had to wait is like 10 minutes.
> 
> 
> 
> If you guys were still holding your patient, why are you on the internet posting?



If the patients stable they don't need to be staring at them non stop.

I've emtlifed while with a patient holding or on long distance calls. Gets boring after awhile. Nothing wrong with it.


----------



## abckidsmom (Jan 14, 2012)

Sasha said:


> If the patients stable they don't need to be staring at them non stop.
> 
> I've emtlifed while with a patient holding or on long distance calls. Gets boring after awhile. Nothing wrong with it.



Yep, me too.  If I am all done with my work and we aren't to the hospital  yet, whatever.  I have no idea how I survived so many long out of towns back before cell phones were so ubiquitous.


----------



## Handsome Robb (Jan 14, 2012)

As long as you aren't doing it in front of your patient who cares?


----------



## Tigger (Jan 14, 2012)

NVRob said:


> As long as you aren't doing it in front of your patient who cares?



Exactly, nothing wrong with sitting behind the patient or switching off the babysitting duties with your partner.

At the major hospitals in Boston the only wait is for the triage nurse, and that's rarely longer than 10-15 minutes if it's busy. Other hospitals require a call in which usually means the bed is assigned before I get there.


----------



## Trose34 (Jan 14, 2012)

Well your in Cali.....lol...thats why. Im from Cali and I would have them fly me to Texas to fix a broken finger....lol..just kidding but you will never get a bed there. 
I do know one rule in health care and that means life threts first so grab a wheel chair sit in it and tell your buddy to go up to the desk and say" My buddys chest hurts and they are having trouble breathing.....This now becomes first priority .....lol.  You did tell them you had insurance RIGHT...lol...just kidding Have fun holding the wall up.


----------



## Trose34 (Jan 14, 2012)

Sad that most of the time the ones that call for EMS....have waited to the point that it is urgent and willing to pay the extra cost but do not get the extra care once its left up to the ER.


----------



## Joe (Jan 14, 2012)

Trose34 said:


> Well your in Cali.....lol...thats why. Im from Cali and I would have them fly me to Texas to fix a broken finger....lol..just kidding but you will never get a bed there.
> I do know one rule in health care and that means life threts first so grab a wheel chair sit in it and tell your buddy to go up to the desk and say" My buddys chest hurts and they are having trouble breathing.....This now becomes first priority .....lol.  You did tell them you had insurance RIGHT...lol...just kidding Have fun holding the wall up.



Ha! The er has gotten smart. They do ecg as soon as we hit the doors. If they deem it normal then we sit for hours. That night we called in to update our status. Dispatch asked if we atleast were buying the wall dinner after fondling it all night


----------



## Traumjunk (Jan 14, 2012)

In Orlando the average is 30 min for the non critical, even though I have seen codes worked in the hallway due to no beds available.


----------



## DrParasite (Jan 16, 2012)

on a stable not sick patient, when i'm in no rush, the most i have waited is 20 minutes.  

on an unstable sick patient, if I have to wait 10 minutes it's a lot.  usually it's just finding a bed and getting the patient registered that takes a few minutes, but none of this BS holding a wall for hours on an ALS patient.

If I were to ever wait more than an hour, I would be on the phone with the DOH, the on call hospital administrator, the nursing director, and every news agency I could think of.  If you shout loud enough, soon someone will give you a bed just to shut you up.  

Then again, if it's the accepted practice on the west coast, well, I hope I never need to go to the hospital when i visit the west coast.


----------



## Hockey (Jan 16, 2012)

48 minutes with a patient with chest pains.  12 lead went from good, to eh, to full blown STEMI to...well...we got a room quickly.  Patient refused to go to the other hospitals and I knew they had multiple shootings, and other traumas.  Poor guy didn't make it.


----------



## Sasha (Jan 16, 2012)

DrParasite said:


> on a stable not sick patient, when i'm in no rush, the most i have waited is 20 minutes.
> 
> on an unstable sick patient, if I have to wait 10 minutes it's a lot.  usually it's just finding a bed and getting the patient registered that takes a few minutes, but none of this BS holding a wall for hours on an ALS patient.
> 
> ...



It's an accepted practice in hospitals that are too busy with no beds. Sure they might find you a bed but not have anyone to attend to that patient.

If your patient isn't critical or potentially unstable sit down and take it as a break. 

No need to get the media. It's not unlike waiting a few hours out in triage to be seen.


----------



## Veneficus (Jan 16, 2012)

*2 sides of the same coin*

In EMS there seems to be this idea that a hospital has unlimited resources or at least enough where they can take whatever EMS brings in.

But in the end, everyone is trying to do what they think is best for the patient. 

Having an ALS EMS squad wait with a patient can be much more attentive care than if the patient was put on a hospital bed and shunted to some dark corner of the hospital.

Additionally, it is easy to complain things are not moving fast enough when you are basically babysitting one patient.

Most EMS providers consider it a bad day when they have to manage 2 or 3 at once. In a hospital a Dozen or so is not uncommon. With more complex interactions. 

Most EMS providers simply have to deal with the ED. Try calling an ICU and claim you have a sick patient, to be told it is full, (as in no beds no staff) and the intensivist tells you she will have to downgrade somebody to make room, but has nobody they feel can be downgraded. Now this ICU patient is sucking up ED resources, while the ICU is trying to get a serial measurement or a nursing floor to accept a patient that doesn't meet their normal criteria. On a good day, it can take an hour. On a bad day, many more.

That also assumes people want to work with you. If any one person decides they want to punt or turf, it can cause even more delay and headache.

Even in the busiest hospitals I have been in, EMS accounts for only 10-20% of the total patient load.

But the hospital is not without fault. They often do not see the EMS side.

Like a responsibility to respond. Often to more calls then they can handle. Making unstable or potentially unstable patients wait extended periods of time for help. 

They do not understand a handful of crews may really be getting their butts handed to them, which is dangerous for all.

They don't really know the feeling of listening to a radio with a dispatcher nagging at them that calls are waiting. (or a supervisor)

When the EMS and hospital systems cannot function together in a timely manner, it is a sign of misunderstanding on both parts at best, and an ineffective dysfunctional system at worst.

Calling in all kinds of authorities will not only cost some friendly cooperation, it usually doesn't actually solve any of the fundamental problems. It just causes somebody to get pissed on, as the powers that be are not going to take responsibility for failures of a system they created.

Any idiot can build a wall. It takes a much greater person to build a bridge.


----------



## FourLoko (Jan 16, 2012)

Veneficus said:


> In EMS there seems to be this idea that a hospital has unlimited resources or at least enough where they can take whatever EMS brings in.
> 
> But in the end, everyone is trying to do what they think is best for the patient.
> 
> ...



Great points, how dare you be so reasonable? Our longest wait recently was about 1.5 hours. PT from a SNF who requested a trip to the ER, not urgent at all. In fact, he was still on antibiotics from the last ER visit he requested.

As we waited we took vitals countless times, got him water to drink, watched him call family members on his cell phone to tell them he was sitting there waiting, etc. 

At least a couple LA City fire calls rolled in while we sat and even they had to wait a bit each time. One was a big dude that evidently "bug bombed" himself. Hook up the pulse ox, 99% on that guy despite his heavy "labored" breathing.

As soon as you leave the ER it's off to another call anyway so just relax and forget about the dispatchers feelings for a while. 

At a different hospital this weekend, the "dark corner" scenario. Two patients in one ER room, ours is chillin' but the guy next to her is practically jumping out of bed. He's hooked up to telly, some IV and is about to yank it all out. Asking for food, water and his clothes.

Long story short, thanks to a noob nurse and an unobservant partner we ended up taking this guys belongings/clothes with our patient and had to make a U-Turn to bring them back. I was happy to see him calm down when I returned his property and felt bad that he was being ignored. 

So much good stuff all for fast food money. I can't decide if I love it or hate it.


----------



## mycrofft (Jan 16, 2012)

If Safeway saw backups at a checkout they's open more. If a hospital does they say "That'll slow down those nonpaying suckers" and then they put in more landscaping, buy three lots down the a street, and give the executive board a raise.


----------



## Veneficus (Jan 16, 2012)

FourLoko said:


> Great points, how dare you be so reasonable?



It is something of a curse it seems.

(especially to people who don't want to hear it)


----------



## Joe (Jan 16, 2012)

i know its going to be the nature of the beast when you have a population of 300k people and only two hospitals seperated by over 15 miles in a busy metro area. if people didnt call for bs reasons then the people that actually need to go to the hospital would get a bed a lot faster. example, abd pain for last 1 day. htn under control by meds.(+)n/v about 3 hrs ago. vital on scene= 152/90something, 94hr, 18rr, 99%ra. bgl 132. we felt the family could transport to the er and pt family was completely willing to do this. fire decided to keep talking and had us transport bls and hold the wall. once fire says take em, we take em...who can guess what time this call came in?


----------



## Fish (Jan 16, 2012)

Joe said:


> Don't know how common of a term it is but as I sit here with a pt I think...how does everyone else get in and out of the hospital in a timely manner? Maybe its just the abuse of the system or maybe this hospital is really slow. We've been waiting for a bed for the last 2 hours and 12 mins. What's the longest wait for you guys?



1 hour


----------



## DrParasite (Jan 16, 2012)

Sasha said:


> It's an accepted practice in hospitals that are too busy with no beds. Sure they might find you a bed but not have anyone to attend to that patient.
> 
> If your patient isn't critical or potentially unstable sit down and take it as a break.
> 
> No need to get the media. It's not unlike waiting a few hours out in triage to be seen.


I think I need to clarify my position.  I was only referring to 911 services, not IFTs.  There is a huge difference, one that I think the IFT crowd isn't seeing.

if a 911 ambulance is holding a wall for an extended period of time, than their primary area doesn't have an ambulance covering it.  if another emergency call comes in, than a mutual aid ambulance needs to respond, with a longer eta that should.  a 911 ambulance's job is to be in the street, not tied up in the ER waiting for a bed.  For those who say ignore the dispatcher, remember, the dispatcher is only passing along the request for emergency service from the caller.  

for IFT, it's a little different.  the patients are usually less acutely sick, and there isn't a time crunch for anything.  it's a scheduling issues, and holding the wall time needs to be built into the schedule.  does the delay screw up the schedule?  sure, but it's not as big of a problem as a delayed response to an emergency call (chest pain/unconc/diff breathing or major trauma).

btw, an ambulance should never wait a few hours in triage.  never ever.  the patient might end up waiting, but the ambulance needs to get back in service to answer the next assignment.





Veneficus said:


> In EMS there seems to be this idea that a hospital has unlimited resources or at least enough where they can take whatever EMS brings in.


No one thinks that.  however, the hospitals want EMS to bring them patients, and typically say they can handle the load (or they can go on divert, bypass, whatever).  Well, admin says they can handle the load, the working staff might disagree.  No one is saying you should demand immediate service (well, maybe if you have a sick patient who is circling the drain), but holding a wall because the ER is mismanaged or lacks the resources to do their job properly isn't right.


Veneficus said:


> But in the end, everyone is trying to do what they think is best for the patient.


that patient, yes, but what about the patients that no longer have an ambulance in the area since they are stuck holding a wall?





Veneficus said:


> Having an ALS EMS squad wait with a patient can be much more attentive care than if the patient was put on a hospital bed and shunted to some dark corner of the hospital.


hmmm, having an ALS squad with the patient on an ambulance cot, vs on a hospital  bed, with a hospital tele monitor, being assessed and treated by doctor, nurses and techs, who can start the ball rolling on getting the definitive care that the patient needs.  Plus it gets the medic out of the ER to answer the next job, and the ER can use it's resources to document any changes in the patient condition.  And even patients in the dark corners have hospital staffed assigned to check up on them.





Veneficus said:


> Additionally, it is easy to complain things are not moving fast enough when you are basically babysitting one patient.


repeating what I said, you are babysitting on patient, but then you are unavailable for any other patients who need you.  if the patient is sick, they probably need a hospital nurse and doctor, if they are not sick, they need a hospital bed, and the ER staff can look at them when they get around to it.  either way, no need to tie up the ambulance.





Veneficus said:


> Most EMS providers consider it a bad day when they have to manage 2 or 3 at once. In a hospital a Dozen or so is not uncommon. With more complex interactions.


ER staffing and resource management is not the problem of EMS.  not only that, but if they are are in deed that overwhelmed, than the ER needs to hire more staff, not refuse to accept the patient and leave them on the EM cot.





Veneficus said:


> Most EMS providers simply have to deal with the ED. Try calling an ICU and claim you have a sick patient, to be told it is full, (as in no beds no staff) and the intensivist tells you she will have to downgrade somebody to make room, but has nobody they feel can be downgraded. Now this ICU patient is sucking up ED resources, while the ICU is trying to get a serial measurement or a nursing floor to accept a patient that doesn't meet their normal criteria. On a good day, it can take an hour. On a bad day, many more.


yep, it sucks, and it's a headache for the ER.  still doesn't justify refusing an EMS patient.  





Veneficus said:


> That also assumes people want to work with you. If any one person decides they want to punt or turf, it can cause even more delay and headache.


yep.  doesn't make it right.





Veneficus said:


> Calling in all kinds of authorities will not only cost some friendly cooperation, it usually doesn't actually solve any of the fundamental problems. It just causes somebody to get pissed on, as the powers that be are not going to take responsibility for failures of a system they created.


actually, it does.  if EMS is getting pushed around by the hospital, because the hospital knows EMS is small and can be pushed around, then EMS needs to get someone to push back even harder.  If the fundamental problems aren't being solved, than maybe having the authorities involved will get the hospital to realize there is a problem, and a solution needs to be found.

If I'm the ambulance person, there is a good change i don't want to get any of the staff nurses in trouble.  there is a good chance these people are my friends, drinking buddies, and people that can make my job much easier.  But if the nurse is ignoring me, and refusing to acknowledge my presence, than yes, that is a problem, and the proper notification should be made.

I am paid to cover a town/area.  if I am stuck in the ER holding a wall, than I am not doing my job.  if my area is uncovered, than I am not doing the job my taxpayers pay me for.  a private company is contracted to cover a town or an area, so if they are holding a wall, than they are failing to provide the service from.  

An ambulance doesn't belong in the ER; it belongs in its primary answering 911 calls.  drop the patient off in the ER, and then return to your area of service.


----------



## JPINFV (Jan 16, 2012)

DrParasite said:


> I think I need to clarify my position.  I was only referring to 911 services, not IFTs.  There is a huge difference, one that I think the IFT crowd isn't seeing.
> 
> if a 911 ambulance is holding a wall for an extended period of time, than their primary area doesn't have an ambulance covering it.  if another emergency call comes in, than a mutual aid ambulance needs to respond, with a longer eta that should.  a 911 ambulance's job is to be in the street, not tied up in the ER waiting for a bed.  For those who say ignore the dispatcher, remember, the dispatcher is only passing along the request for emergency service from the caller.
> 
> for IFT, it's a little different.  the patients are usually less acutely sick, and there isn't a time crunch for anything.  it's a scheduling issues, and holding the wall time needs to be built into the schedule.  does the delay screw up the schedule?  sure, but it's not as big of a problem as a delayed response to an emergency call (chest pain/unconc/diff breathing or major trauma).



...and here's what you're missing. 

A lot of places IFT and 911 isn't strictly separated. You take an IFT unit off the road, you take a unit that could also be responding to 911 units if the 911 units are overloaded (if the 911 units aren't overloaded, then wait time for 911 units is of no concern). 

If the IFT company is having response time issues, then the facilities that normally would utilize their IFT service could convert those calls into 911 calls. Thus further burdening the 911 system.

If the IFT ambulance is holding the wall, then that's one less IFT unit that could be used for interhospital transfers or discharges. These calls can either directly reduce the patient load in the ED by transferring out or discharging ED patients, or indirectly reduce the patient load by opening up beds in the hospital which ED patients can be transferred to.

In response to everyone else, what is the 911 service doing to reduce call volume and ensure that only patients who appropriately need ambulance service are being transported? 

Finally, why is it that EMS providers are the first to complain if the hospital isn't diverting due to overcrowding, but also the first to complain if the closest open hospital is 30 minutes away, all while often doing nothing to attempt to ensure that their patients are accessing the appropriate level of care, which may often be an urgent care center.


----------



## Handsome Robb (Jan 16, 2012)

DrParasite I see where you are coming from but from working in a high volume, urban 911 system it doesn't always work the perfect way you want it to work. 

We have 4 hospitals in our area and every now and again we end up with the hospitals being overloaded. you can end up with 2 of them on critical care divert so that cuts our options in half if we have a patient who truly is sick. 

It's easy to say they need to build a bigger ER but where is that money going to come from to build it and staff it?

Once we are on hospital property the patient is their "problem" if the 911 system gets so busy that we need to be pulled from the ER then so be it but then again it's not fair to the patient to be stuck in a hall bed and I doubt JACHO would be happy with patients being stuck in hall beds without the necessary resources to care for them.

edit: you also seem to be talking about an EMS system that utilizes stations. Where I work we don't, we run system status management, so units posted in outlying areas can be moved inward to cover the central areas.


----------



## Sasha (Jan 16, 2012)

DrParasite said:


> I think I need to clarify my position.  I was only referring to 911 services, not IFTs.  There is a huge difference, one that I think the IFT crowd isn't seeing.
> 
> if a 911 ambulance is holding a wall for an extended period of time, than their primary area doesn't have an ambulance covering it.  if another emergency call comes in, than a mutual aid ambulance needs to respond, with a longer eta that should.  a 911 ambulance's job is to be in the street, not tied up in the ER waiting for a bed.  For those who say ignore the dispatcher, remember, the dispatcher is only passing along the request for emergency service from the caller.
> 
> ...



The patients are less acutely sick? Maybe. But that still doesn't put your acute stuffy nose above my exacerbated chf. 

We are important too. If we are holding a wall we are out of service for any stat transfers. (cath labs, strokes, sick pedis, trauma etc. We aren't all dialysis transfers and pulled out PEGs)  My company's response area is huge, it can take more than an hour to get from one end to the other.  It happens. The hospitals don't enjoy having you sit there staring at them but when there are no beds, there are no beds. If there is no staff to care for the patient then there isn't the staff and they're staying on the stretcher. 
Maybe your company needs more ambulances if one being out of service is so devastating.


----------



## Epi-do (Jan 16, 2012)

I've never waited more than 10-15 minutes for a triage nurse, and that is very rare.  Typically, we show up, talk to the triage nurse, and immediately get sent either to a room, or get told to have the pt wait in the waiting room (if that is appropriate).

Now, waiting for a nurse for a bedside report.... I have waited up to 40 minutes before, but, again, that is very rare.  Typically, that nurse is there within 5 minutes or so.

I can't imagine waiting over an hour with someone on my cot, just to get a bed.  It seems to me, if they are able to wait that long, they can go to the waiting room, and I can get back in service.  (Keep in mind, I haven't worked outside of the system I currently work within, so I only have that one example to compare things to.  I realize there very well may be systems where patients will wait an hour for a bed, but have something going on that precludes them from being a candidate for going out to the waiting room.)


----------



## Joe (Jan 17, 2012)

yea we have droped off pts in the waiting room. they look at you like your the antichrist and it makes my day. the other hospital in our area is about 20 mins outside our response area but you can get a bed in 20mins or so. they ift all their pts out once they get seen so there are always open beds. the only downside is we cant transport there if were in our normal area unless the wait at the first hospital is over 2 hrs. (not that uncommon)


----------



## rmabrey (Jan 17, 2012)

I've never been in an ER for more than 12 minutes, including getting a bed, transferring pt to bed and giving a report. 

Sent from my Desire HD using Tapatalk


----------



## truetiger (Jan 17, 2012)

Local ER, never. Big city hospitals, 10 mins max or we'll start asking for the charge nurse or DON.


----------



## DrParasite (Jan 17, 2012)

NVRob said:


> DrParasite I see where you are coming from but from working in a high volume, urban 911 system it doesn't always work the perfect way you want it to work.


in my current system, our busiest units can do 20 jobs in 12 hours in the summer.  power trucks (12 to 12) do between 12 and 18 year round.  whats your definition of high volume urban 911? 

My former system typically had one unit assigned to a municipality for duration of the shift, and rapid turnarounds were often done out of the ER for pending calls, and we averaged between 4 and 10 jobs in 12 hrs, with busy being 12+.

Our units have 10 minutes from the time of drop off until they can get assigned the next call, 20 if the ER is busy.


NVRob said:


> We have 4 hospitals in our area and every now and again we end up with the hospitals being overloaded. you can end up with 2 of them on critical care divert so that cuts our options in half if we have a patient who truly is sick.


so you go on the two that aren't on CC divert.  but if they request an on divert hospital, notify the hospital in advance so they can make proper arrangements.





NVRob said:


> It's easy to say they need to build a bigger ER but where is that money going to come from to build it and staff it?


i didn't say build a bigger ER.  I said the ER management needs to manage their beds, or put on more staff.  whether it means discharging the patients who won't be admitted quicker, or admitting those who need beds, or cramming them in like sardines (which isn't preferable, but I did see an ER in NYC that did just that), the hospital needs to manage the flow.





NVRob said:


> Once we are on hospital property the patient is their "problem" if the 911 system gets so busy that we need to be pulled from the ER then so be it but then again it's not fair to the patient to be stuck in a hall bed and I doubt JACHO would be happy with patients being stuck in hall beds without the necessary resources to care for them.


100% right





NVRob said:


> edit: you also seem to be talking about an EMS system that utilizes stations. Where I work we don't, we run system status management, so units posted in outlying areas can be moved inward to cover the central areas.


which shortens the response time, but still stretches your EMS resources thin.  instead of 1 ambulance per town, you end up with 1 ambulance covering 4 towns, and once that ambulance goes on a job, it gets even worse.





Sasha said:


> The patients are less acutely sick? Maybe. But that still doesn't put your acute stuffy nose above my exacerbated chf.


not for nothing, but if you have an exacerbated chf call, the facility should have probably called 911.  had there been a shorter response the patient's chf might not have been exasperated.  You really should get some 911 experience, especially in a system where you primarily treat only ALS patients, I think it will change you opinion.





Sasha said:


> We are important too. If we are holding a wall we are out of service for any stat transfers. (cath labs, strokes, sick pedis, trauma etc. We aren't all dialysis transfers and pulled out PEGs)


ehhh. while valid statement, the ER should be able to stable the as best they can until you get there.  Plus you run schedules dialysis runs and pulled out pegtubes (which do get picked up by 911 when located at home).





Sasha said:


> My company's response area is huge, it can take more than an hour to get from one end to the other.


if you are responding L&S for an emergency and it's taking you 60 minutes, you either need more units better deployed or the caller should call 911 to get a quicker response.


Sasha said:


> If there is no staff to care for the patient then there isn't the staff and they're staying on the stretcher.


that's a hospital problem not mine.  and as you said, what happens 30 minutes into you waiting for a bed, a call comes in for a stat transfer for a STEMI, trauma, etc?  now you have to wait another 30-90 minutes, and the patient ends up suffering.  golden hour is shot and with the STEMI, well time is muscle.





Sasha said:


> Maybe your company needs more ambulances if one being out of service is so devastating.


I could not agree with you more.  However to paraphrase NVRob,  where is that money going to come from for for the staffing and equipping of all those ambulances?


----------



## Sasha (Jan 17, 2012)

DrParasite said:


> in my current system, our busiest units can do 20 jobs in 12 hours in the summer.  power trucks (12 to 12) do between 12 and 18 year round.  whats your definition of high volume urban 911?
> 
> My former system typically had one unit assigned to a municipality for duration of the shift, and rapid turnarounds were often done out of the ER for pending calls, and we averaged between 4 and 10 jobs in 12 hrs, with busy being 12+.
> 
> ...



Nursing homes don't call 911. Neither do home health care or hospice services. They call IFT. For everything. We had a call Saturday from a skilled nursing facility for possible internal bleed an a hgb of 4. All we can do is respond. We actually do not respond lights and sirens but I legitimately transport lights and sirens at least once every three shifts. 

They may be at a hospital but if they have a heart attack they need a cath lab and only a cath lab will fix them. If they have a stroke only a stroke center will fix them. They can have their symptoms managed but they will continue to decline. 

I did a short stent in 911 plus all my ride times. 90% of those calls were bs stuff that could have been driven themselves to an urgent care and managed just as well. 

With IFT there's no one to throw the patient into a car and drive them. They are going to be waiting for us however long we take.

So don't downplay it like we can wait and you can't. I hate that. The only time I pitch fits in the ER is when some stupid stable fire medic gets a bed first when we were waiting with our patient first because "well they are 911." When they're going back to their station to eat lunch and watch the fights and we are holding an immediate response for ams or something like that.


----------



## Bullets (Jan 17, 2012)

Ummm, 15 minute wait at University-Newark, a busy urban system, and one of 2 Level I trauma centers in NJ

I Couldn't imagine waiting hours, do ER not separate triage and main?


----------



## Veneficus (Jan 17, 2012)

Sasha said:


> Nursing homes don't call 911. Neither do home health care or hospice services. They call IFT. For everything. We had a call Saturday from a skilled nursing facility for possible internal bleed an a hgb of 4. All we can do is respond. We actually do not respond lights and sirens but I legitimately transport lights and sirens at least once every three shifts.
> 
> They may be at a hospital but if they have a heart attack they need a cath lab and only a cath lab will fix them. If they have a stroke only a stroke center will fix them. They can have their symptoms managed but they will continue to decline.
> 
> ...



Sasha,

Do not dispair.

I have done high volume, "high performance,"urban EMS. It's called doing a full work up on everyone, needed or not. It does not increase the amount of high acuity patients. 

Anyone who takes care of sick people can tell you it takes more resources and longer. 

The only thing 20 jobs in 12 hours means to me from doing it myself is most of those people don't actually need an ambulance and you waste a lot of money performing the medical error of overtreating.

I remember running the entire early ACLS algorythms on arrest patients. (epi to mag sulfate, skipping no antiarrythmic or alternating epi in about 10 minutes. 15 including response time and first contact.) 

Knowing what I know now, I am not fool enough to think I actually did those people any good though.

Nothing an enhanced public health sector couldn't do cheaper and more efficent, and could include SNFs.


----------



## DrParasite (Jan 17, 2012)

Sasha said:


> Nursing homes don't call 911. Neither do home health care or hospice services. They call IFT. For everything. We had a call Saturday from a skilled nursing facility for possible internal bleed an a hgb of 4. All we can do is respond. We actually do not respond lights and sirens but I legitimately transport lights and sirens at least once every three shifts.


wow, one emergency transport every 3 shifts?  I know people who transport 3 emergent patients every shift.

and I know nursing homes don't call 911.  maybe you should educate those nursing homes to call 911 for emergent medical emergencies, and use IFT for stable patients?  Remember, we are all supposed to be doing what's best for the patient, and more often than not, that means getting the most qualified person to the patient's side in the shortest amount of time.


Sasha said:


> They may be at a hospital but if they have a heart attack they need a cath lab and only a cath lab will fix them. If they have a stroke only a stroke center will fix them. They can have their symptoms managed but they will continue to decline.


yep, your right.  maybe your IFT company should put on more units, so you always have one available in case those STAT cath or stroke patients come in?





Sasha said:


> I did a short stent in 911 plus all my ride times. 90% of those calls were bs stuff that could have been driven themselves to an urgent care and managed just as well.


ok, first off, the word is stint, not stent.  secondly, did you work on a dual ALS unit, where you only saw ALS patients, and had BLS units handling BLS calls, or did you respond to everything?  

911 abuse happens all too often.  yes, ambulances are used as a taxi service.  In theory, BLS handles BS while ALS will only deal with acutely sick patient.  at least that's the theory anyway





Sasha said:


> With IFT there's no one to throw the patient into a car and drive them. They are going to be waiting for us however long we take.


but in IFT, if you are taking too long, they can always just call another IFT company.


Sasha said:


> So don't downplay it like we can wait and you can't. I hate that. The only time I pitch fits in the ER is when some stupid stable fire medic gets a bed first when we were waiting with our patient first because "well they are 911." When they're going back to their station to eat lunch and watch the fights and we are holding an immediate response for ams or something like that.


haha, that's pretty funny.  you can wait, for the exact reason you just stated.  maybe they are going back to their station, maybe they have another call pending.  you really don't know.

you have a request for IFT for AMS, that's fine, but if there is a problem and you are unavailable or delayed, they can always call 911.  


Bullets said:


> Ummm, 15 minute wait at University-Newark, a busy urban system, and one of 2 Level I trauma centers in NJ


10 minute is standard, and there are 3 Level 1s (RWJ, UMD, and Cooper).


Veneficus said:


> I have done high volume, "high performance,"urban EMS. It's called doing a full work up on everyone, needed or not. It does not increase the amount of high acuity patients.


I disagree.  the percentage of high acuity patients is about the same (between 10% and 20%), but because you are dealing with more patient contacts, you average more sick patients (same percentage, higher number).


Veneficus said:


> Anyone who takes care of sick people can tell you it takes more resources and longer.
> 
> The only thing 20 jobs in 12 hours means to me from doing it myself is most of those people don't actually need an ambulance and you waste a lot of money performing the medical error of overtreating.


you are absolutely 100% correct.  most people are either curbside pickups or walk in/walk out and drive the stable patient to the hospital, and leave them in triage.


Veneficus said:


> Knowing what I know now, I am not fool enough to think I actually did those people any good though.


don't sell yourself short.  they needed a  ride to the hospital, and you provided it to them.  that's that they wanted, and you did it for them.


----------



## JPINFV (Jan 17, 2012)

DrParasite said:


> at least that's the theory anywaybut in IFT, if you are taking too long, they can always just call another IFT company.


...because 911 systems can't call another company too? You know... like mutual aid or something. Heck, I'm willing to bet that the IFT companies in the area would be willing to sign a mutual aid contract for when there isn't enough 911 units on the road for their call volume.


----------



## Fish (Jan 17, 2012)

In San Diego we were always given beds over IFT patients, even if our patient was stable, why? because we had calls responding and needed to go.

The service I work for now tries to maintain an Ambulance for every 20k people so there is always a unit available and a minor bed delay would not be a big deal, the service I used to work for had 2 Ambulances covering a district of 150k.


----------



## DrParasite (Jan 17, 2012)

JPINFV said:


> ...because 911 systems can't call another company too? You know... like mutual aid or something.


sure.... call a company from further away who doesn't know the area.  not only that, but 911 companies typically have a monopoly on a geographic area, and no other services operate in that area.  IFT companies, on the other hand, go anywhere, and you can often find multiple ambulance companies in the same geographic areas.  plus just because a company is stationed in an area, doesn't mean their ambulance isn't 50 miles away.  very different than a 911 ambulance that covers a particular geographic area.  QUOTE=JPINFV;369292]Heck, I'm willing to bet that the IFT companies in the area would be willing to sign a mutual aid contract for when there isn't enough 911 units on the road for their call volume.[/QUOTE]you'd lose that bet.  many IFT companies don't want to do 911 because it isn't guaranteed money.  there is little to no profit in 911 (most private 911 companies take a loss on 911 and make up the difference in IFT).  plus an IFT can refuse a run if the patient doesn't have a way to pay, a 911 service can't do that.


----------



## frdude1000 (Jan 17, 2012)

I do street EMS in suburban MD near D.C.  We usually wait around 15 min for a bed.  We have a hospital alert tracker that tells us which hospitals are full/not accepting Priority II/III pts, when EKG beds are all full, etc.  If we wait 30 min and a bed is not available after asking again, we are to contact our EMS supervisor.  Most of the time we can get in and out quick....friday nights usually have a line of BLS pt's at the charge nurse desk.


----------



## JPINFV (Jan 17, 2012)

DrParasite said:


> you'd lose that bet.  many IFT companies don't want to do 911 because it isn't guaranteed money.  there is little to no profit in 911 (most private 911 companies take a loss on 911 and make up the difference in IFT).  plus an IFT can refuse a run if the patient doesn't have a way to pay, a 911 service can't do that.



Yet where I worked just about every IFT company either had a 911 contract or a backup contract. Also, just because the 911 unit is supposed to cover area "x" doesn't mean it's available either. However, with an appropriate mutual aid contract with IFT companies, the 911 service can always request that an IFT service stations a unit in the mutual aid area until additional 911 units become available. Does your system not engage in planning and system development with other resources in the area?


----------



## JPINFV (Jan 17, 2012)

DrParasite said:


> plus an IFT can refuse a run if the patient doesn't have a way to pay, a 911 service can't do that.



911 services can refuse if the patient doesn't have an emergency ("paramedic initiated refusal"). The question is, does the service trust their paramedics enough to do it, and if not why not? Not being up to the game is different than not being able to play the game.


----------



## Joe (Jan 17, 2012)

some interesting points brought up that i never thought of hahaha. if we go to level 0 then units are called up from another area about 30 miles south. we do have an ift company on backup for 911 but they are very seldom used in my experiance. lets be real for a second.. if the ift company is doing a transfer to er all that means to me is that pt needs the er just as bad as the next bls call that comes in. is it frustrating waiting behind an ift company because both our pts need er but they got there first? yea but we both need to be here. me being on a 911 rig doesnt give me some higher authority. we all have the same la county emt patch on our right arm... if an als call comes in then i dont mind them line jumping.


----------



## the_negro_puppy (Jan 17, 2012)

We call it ramping and it is an everyday occurence here.
Longest wait is only 4 hours, but we have to wait 30min to 1 hour on an almost daily basis








Heres a pic from a bad day at our 2nd largest hospital, 20 ambulance crews, pretty much no-one left to respond


----------



## Cup of Joe (Jan 18, 2012)

the_negro_puppy said:


>



Now which one was mine again? :rofl:


----------



## Sasha (Jan 18, 2012)

DrParasite said:


> wow, one emergency transport every 3 shifts?  I know people who transport 3 emergent patients every shift.
> 
> and I know nursing homes don't call 911.  maybe you should educate those nursing homes to call 911 for emergent medical emergencies, and use IFT for stable patients?  Remember, we are all supposed to be doing what's best for the patient, and more often than not, that means getting the most qualified person to the patient's side in the shortest amount of time.
> yep, your right.  maybe your IFT company should put on more units, so you always have one available in case those STAT cath or stroke patients come in?ok, first off, the word is stint, not stent.  secondly, did you work on a dual ALS unit, where you only saw ALS patients, and had BLS units handling BLS calls, or did you respond to everything?
> ...



Doesn't matter what you tell a nursing home they likely aren't going to call 911. Even if our call taker is strongly urging them (due to contracts we can't refuse an immediate response transport and tell them to call 911) to reconsider considering our eta is xx minutes based on the complaint

They can call another IFT company, violate their contract and still wait for txp. 

You know people who do 3 emergent transports every shift? Nice. I know 911 medics who do nothing but neck pain, stuffy noses, tummy aches and broken toes with the occasional legitimately emergent call. I know 911 medics who will go three shifts without turning a wheel. 

And I would argue IFT medics and emts are more qualified to deal with nursing home patients emergencies anyway as they are more familiar and comfortable with the chronic disease processes and equipment you will run into at the nursing homes. Just like 911 medics are more qualified for trauma (i will freely and unabashadly admit I suck at trauma beyond stuff like hip fractures because we don't get those calls)

I am not trying to turn this into a one is better than the other, honestly just trying to prove a point that IFT is just as important. 

My favorite off load problem:

"Oh you're here! We were just going to call you guys to take bed 17 here's the paperwork let's get him moved over."
"uhm... First we have to get rid of the patient currently on the stretcher...." 
"Oh... You can put him in bed 17 as soon as you take that guy."


----------



## Niccigsu (Jan 18, 2012)

1 of our local EMS providers has a designated "holding the wall" guy (he's an older EMT) that is stationed @ the Emergency Department to specifically wait with patients for a room. That way it frees up the transporting EMT's without abandoning the patient when there isn't anyone available to transfer care to at the moment.


----------



## Jon (Jan 18, 2012)

In Philadelphia itself, I think I've babysat a patient in the ED for 30-40 minutes on RARE occasions. Usually it's brutally obvious that our patient isn't nearly as sick as the ones getting priority. It's frustrating, but I also understand.

In the suburbs, on a rare bad day, it's 10-15 minutes before I get a bad Usually I'll have the patient in a bed an a report given in ~5 minutes from hitting the door.


----------



## Tigger (Jan 18, 2012)

I swear most of the nursing homes we service would rather just have the patient die then call 911. It apparently generates too much paperwork and the very vast majority of the time we can get a truck to a contracted facility just as fast as the city can. And before anyone asks our operations people do have a sit down meeting with the facility's staff to explain to them what the contract entails and when they should be calling 911.

Also I would imagine that most major cities have mutual aid contracts with the private companies in the city. Almost every private will take roll over 911 calls if they have a unit available since they stand a better chance of making money by taking the call then just having the truck parked. Our contract is no obligation, if we don't have a unit available we don't get penalized, if we do we make money (sometimes).

Even cities that contract 911 ambulance service frequently mandate that that the contracted provider nominate a "mutual aid partner" that is another private.


----------



## MedicBender (Jan 18, 2012)

I've been diverted from a hospital once due to a full ER. The rest of the time we go straight to a room. When I was in Maryland it wasn't uncommon to wait 20-30 min at the bigger hospitals. 

I usually call a head to try and give the ER enough time to get a bed together. When I arrive at some of the hospitals around here they already have a room assignment when we pull up.


----------



## Fish (Jan 18, 2012)

Sasha said:


> And I would argue IFT medics and emts are more qualified to deal with nursing home patients emergencies anyway as they are more familiar and comfortable with the chronic disease processes and equipment you will run into at the nursing homes. Just like 911 medics are more qualified for trauma (i will freely and unabashadly admit I suck at trauma beyond stuff like hip fractures because we don't get those calls)



I disagree, the inner workings of a nursing home are not complex enough for us to not be as familiar because we do not go there10 times a day like an IFT. We do however run 911 calls to nursing homes all the time, 911 units get more Medical than they do Trauma. Trauma is a boring easy call, how can you be bad at a Trauma call? Medical is complex, but Medical is what we mostly get and there is no way an IFT service is more qaulified for patients with multiple Chronic issues than a 911 service is. Hearing that makes me think you may not have much experience in 911, not saying that to be rude.


----------



## Fish (Jan 18, 2012)

MedicBender said:


> I've been diverted from a hospital once due to a full ER. The rest of the time we go straight to a room. When I was in Maryland it wasn't uncommon to wait 20-30 min at the bigger hospitals.
> 
> I usually call a head to try and give the ER enough time to get a bed together. When I arrive at some of the hospitals around here they already have a room assignment when we pull up.



I have been diverted with a CPR in progress. The ER had two patients on Cath tables already and one in the ER waiting.


----------



## Sasha (Jan 18, 2012)

Fish said:


> I disagree, the inner workings of a nursing home are not complex enough for us to not be as familiar because we do not go there10 times a day like an IFT. We do however run 911 calls to nursing homes all the time, 911 units get more Medical than they do Trauma. Trauma is a boring easy call, how can you be bad at a Trauma call? Medical is complex, but Medical is what we mostly get and there is no way an IFT service is more qaulified for patients with multiple Chronic issues than a 911 service is. Hearing that makes me think you may not have much experience in 911, not saying that to be rude.



I am not talking about inner workings I am talking about equipment and precautions the patients will be on. I would say I am more comfortable around vents, trachs, medication pumps, pleurX drains, fistulas etc then the average 911 medic. I am also more familiar with stuff like the effects of dialysis and what to expect from patients with certain chronic illnesses. I am also probably more familiar with lab values than the average 911 medic.

I am also probably more familiar with the patient because there is a good chance I've transported them before. 

So yes, I would say that I am better suited to deal with nursing home patient emergencies than a 911 medic.

I have freely admitted most of my experience is in IFT.


----------



## DrParasite (Jan 18, 2012)

Sasha said:


> Doesn't matter what you tell a nursing home they likely aren't going to call 911. Even if our call taker is strongly urging them (due to contracts we can't refuse an immediate response transport and tell them to call 911) to reconsider considering our eta is xx minutes based on the complaint
> 
> They can call another IFT company, violate their contract and still wait for txp.


that might be how it is, but it's stupid, and not being done in the best interests of the patient.  I know some of the reasons they do it, and doing what's best for the patient isn't on the list.





Sasha said:


> You know people who do 3 emergent transports every shift? Nice. I know 911 medics who do nothing but neck pain, stuffy noses, tummy aches and broken toes with the occasional legitimately emergent call. I know 911 medics who will go three shifts without turning a wheel.


damn 3 shifts without turning a wheel?  that gets boring, really boring.  

and if you, as a paramedic, are dealing with "neck pain, stuffy noses, tummy aches and broken toes with the occasional legitimately emergent call" that I questions how good of a paramedic you can be, if you mostly deal with BS, so you don't see sick patients.  and if you don't see sick patients, you don't get to use any of your advance skills, and your assessment skills degrade.  

I know some paramedics that will intubate 4 people a month.  how many intubations did you do last year?  how many needle decompression?  2 is a lot of a 911 provider, have you ever done one?  how many children have you assisted in the delivery of?  how many times last year did you do CPR?  any CPR saves?  

Are there 911 medics that intubate 1 person a year (hello California!!!), never done a decompression, have never assisted in the delivery of a baby, and have never done CPR?  sure.  but they probably aren't the greatest when it comes to their ALS skills on actual calls.


Sasha said:


> And I would argue IFT medics and emts are more qualified to deal with nursing home patients emergencies anyway as they are more familiar and comfortable with the chronic disease processes and equipment you will run into at the nursing homes.


you could argue that, but you would be wrong.  

IFT medics might be more qualified to deal with STABLE nursing home patients, but a 911 medic will be the expert in acute medical emergencies.  and this might shock you, but not all old people live in nursing homes, and an old person with diff breathing in a private residence should be treated the same as an old person in a SNF.  

Not only that, but nursing homes call 911 services too.  Sometimes for BS, but we go for cardiac arrests, diff breathing and chest pains all the time.  maybe not by you, but by places that realize the patient needs an ambulance NOW, not in 30 minutes one the truck gets there.

Plus, even in the big cities, a paramedic will see more serious medical calls than major trauma.  every day.  You ask any 911 medic, they will tell you.



Sasha said:


> "Oh you're here! We were just going to call you guys to take bed 17 here's the paperwork let's get him moved over."
> "uhm... First we have to get rid of the patient currently on the stretcher...."
> "Oh... You can put him in bed 17 as soon as you take that guy."


yep, that's a problem.  it's cause an idiot nurse





Tigger said:


> Also I would imagine that most major cities have mutual aid contracts with the private companies in the city.


I think you would be wrong.  it is a city's responsibility to handle it's call volume, using city resources.  if the city is constantly taking rollover 911 calls, than it gives the city no incentive to properly staff appropriately to handle the call volume (why properly pay my own people to do the job when i can just dish the overflow to a private that pays it's people peanuts).  Look at cities in NJ (Trenton, Newark, Paterson, Woodbridge, etc), NYC (they don't call anyone outside of the FDNY system, which includes the voluntary hospitals), Philly, DC, PG County MD, none of them use a private system to pick up the slack.  Are there cities that do this?  maybe, but I am not aware of any in the midatlantic or northeast states.


Sasha said:


> Almost every private will take roll over 911 calls if they have a unit available since they stand a better chance of making money by taking the call then just having the truck parked. Our contract is no obligation, if we don't have a unit available we don't get penalized, if we do we make money (sometimes).


maybe by you, but by me, the privates are all about making money, and that's why they do IFTs, because it's guaranteed money, and guaranteed pay for services.  911 isn't a guaranteed money, so many places don't want to get involved in it.


----------



## DesertMedic66 (Jan 18, 2012)

It all depends on how your IFT service is set up. I'm doing IFT right now (for the past 10 months) and I haven't learned anything that I wasn't taught in EMT school except that the sound of deep suction on trach patients makes me gag. Vents? Nope, never used one we just bag them to where ever they are going. Lab values? Nope, doesn't concern me in transports. Their WBC may be elevated but that's not going to change how I treat the patient. Progression of diseases? Nope, the only thing I know is that everyone dies. Most of how a disease progresses is long term issues not the 2mins-2hours I'm with a patient. 

I don't mean to offend anyone. This is just my personal experience on IFTs. The only good thing about IFTs for me is it got me knowing the area and hospitals better and got better at taking vital signs. 911 is personally where I believe learning new and more things comes into the picture. But that's just me.


----------



## Sasha (Jan 18, 2012)

firefite said:


> It all depends on how your IFT service is set up. I'm doing IFT right now (for the past 10 months) and I haven't learned anything that I wasn't taught in EMT school except that the sound of deep suction on trach patients makes me gag. Vents? Nope, never used one we just bag them to where ever they are going. Lab values? Nope, doesn't concern me in transports. Their WBC may be elevated but that's not going to change how I treat the patient. Progression of diseases? Nope, the only thing I know is that everyone dies. Most of how a disease progresses is long term issues not the 2mins-2hours I'm with a patient.
> 
> I don't mean to offend anyone. This is just my personal experience on IFTs. The only good thing about IFTs for me is it got me knowing the area and hospitals better and got better at taking vital signs. 911 is personally where I believe learning new and more things comes into the picture. But that's just me.



Then you are seriously wasting your experience there. 

I love IFT. I learn something new every single day there.


----------



## DesertMedic66 (Jan 18, 2012)

Sasha said:


> Then you are seriously wasting your experience there.
> 
> I love IFT. I learn something new every single day there.



Yeah tell me about it. But I'm soon to get moved up to 911 ALS full time. I keep my skills up by picking up a ton of overtime 911 ALS shifts and being a skills instructor.


----------



## Fish (Jan 18, 2012)

Sasha said:


> I am not talking about inner workings I am talking about equipment and precautions the patients will be on. I would say I am more comfortable around vents, trachs, medication pumps, pleurX drains, fistulas etc then the average 911 medic. I am also more familiar with stuff like the effects of dialysis and what to expect from patients with certain chronic illnesses. I am also probably more familiar with lab values than the average 911 medic.
> 
> So yes, I would say that I am better suited to deal with nursing home patient emergencies than a 911 medic.
> 
> I have freely admitted most of my experience is in IFT.



This Leads me to believe you know or are surrounded by low grade Paramedics, because still I disagree(everything you mentioned I know, and so do the 911 service Medics I know) I would argue only someone who has received training and Cetification in Critcal Care knows those things better than an Average 911 Medic. Doctors offices, nursing homes, Reverse Code STEMI/Stroke/Trauma/Sepsis patients from ERs are calls we frequently run even as a 911 Service.


----------



## Joe (Jan 19, 2012)

DrParasite said:


> I know some paramedics that will intubate 4 people a month.  how many intubations did you do last year?  how many needle decompression?  2 is a lot of a 911 provider, have you ever done one?  how many children have you assisted in the delivery of?  how many times last year did you do CPR?  any CPR saves?
> 
> .



and how many of these have you done??


----------



## katgrl2003 (Jan 19, 2012)

DrParasite said:


> how many times last year did you do CPR?  any CPR saves?



In one month at an IFT service, I had 3 codes, with 1 save, which is more than I have had at my 911 job.


----------



## socalmedic (Jan 19, 2012)

JPINFV said:


> Ever been to Presbyterian Intercommunity Hospital (PIH) in Whittier? 3 hours.



I am going to say that St. Frances in Lynwood is worse. when they closed King Drew (killer king) wait times where regularly 1-2 hours with 3-4 other ambulances. longest wait I had was there, 12 hours and 15 minutes, we did shift change at the hospital... they where there another 2 hours after I went home. other LA area hospitals Centinella/freeman 4 hours, gardena memorial 3 hours.


----------



## DrParasite (Jan 19, 2012)

Joe said:


> and how many of these have you done??


I'm a lowly basic, so they don't let me intubate.  Same with needle decompressions, if I were to do that, my clinical coordinator would want a word with me.  

delivered 4.5 kids, and I say 4.5, because we helped deliver 4 kids in the field, and on the last one, we were smart enough to move fast enough that she delivered no more than 30 seconds after we transferred her to the L&D bed.  Usually we work quick enough to make sure they deliver on scene or in the hospital, with the latter being the preferred method.

As for me doing CPR, before I transferred to the dispatch side of the job full time, I was probably averaging between 6 and 12 times a year. in my career, I think I have 3 saves, 1 of which was a straight ACLS save (praise be the paramedics).  Most old people just don't make it, no matter what you do.

There is one guy who I work with, who in 7 years here, has delivered something like 23 babies as an EMT.  

Kat, if you have done CPR 3 times in a month, and saved 1, I say congrats.  Most IFT people I know have done CPR, but rarely have any saves.


----------



## usalsfyre (Jan 19, 2012)

It's highly dependent on the service and location what kind of calls you will see in a 911 vs IFT setting. My last job was a 911/IFT provider. In the areas we only did IFT you were likely to only do the discharge/dialysis derby. There's also significant logistical challenges that you often don't run into in IFT. My current job is  IFT only. I see more sick patients a shift than I did doing 911, and I don't count CCT in that number, only "urgent" calls from a facility. I end up performing advanced interventions on about 90% of the calls I run. 

The same goes for providers. I wouldn't trust the majority of local big-city FD "paramedics" to treat my worst enemies dying dog. I've seen too much of the back-end of their handiwork. Meanwhile, there's medics who have only done IFT I would trust with just about anything.

Getting into a p!ssing match over what type of medic is stupid and counterproductive. Everyone needs to understand each job has unique challenges.


----------



## Veneficus (Jan 19, 2012)

usalsfyre said:


> It's highly dependent on the service and location what kind of calls you will see in a 911 vs IFT setting. My last job was a 911/IFT provider. In the areas we only did IFT you were likely to only do the discharge/dialysis derby. There's also significant logistical challenges that you often don't run into in IFT. My current job is  IFT only. I see more sick patients a shift than I did doing 911, and I don't count CCT in that number, only "urgent" calls from a facility. I end up performing advanced interventions on about 90% of the calls I run.
> 
> The same goes for providers. I wouldn't trust the majority of local big-city FD "paramedics" to treat my worst enemies dying dog. I've seen too much of the back-end of their handiwork. Meanwhile, there's medics who have only done IFT I would trust with just about anything.
> 
> Getting into a p!ssing match over what type of medic is stupid and counterproductive. Everyone needs to understand each job has unique challenges.



Right on point.

If I could just add something?

A paramedic in the US has always been a healthcare bandaid. First it was for emergency response, later for IFT, still later for things like industrial/wilderness medicine. It seems everytime there is need of a provider, the paramedic gets thrust into that role.

Very good for employment opportunities but unfortunately does nothing to denote the quality/scope you can expect.

From my own observations, US paramedics are generally like European Physicians. There are great ones and rather questionable ones, but there is no mean or median. Specialty or environment has no bearing at all.


----------



## Tigger (Jan 19, 2012)

DrParasite said:


> I think you would be wrong.  it is a city's responsibility to handle it's call volume, using city resources.  if the city is constantly taking rollover 911 calls, than it gives the city no incentive to properly staff appropriately to handle the call volume (why properly pay my own people to do the job when i can just dish the overflow to a private that pays it's people peanuts).  Look at cities in NJ (Trenton, Newark, Paterson, Woodbridge, etc), NYC (they don't call anyone outside of the FDNY system, which includes the voluntary hospitals), Philly, DC, PG County MD, none of them use a private system to pick up the slack.  Are there cities that do this?  maybe, but I am not aware of any in the midatlantic or northeast states.


Well let's see I work in such a system in the city of Boston. So I would say it exists. It's a very similar system to NYC from what I gather, we don't have hospital based EMS here we have private companies. If FDNY runs out of ambulances or has an extended eta they give the call to a voluntary provider right? That's what's done in Boston too.


----------



## JPINFV (Jan 19, 2012)

Tigger said:


> Well let's see I work in such a system in the city of Boston. So I would say it exists. It's a very similar system to NYC from what I gather, we don't have hospital based EMS here we have private companies. If FDNY runs out of ambulances or has an extended eta they give the call to a voluntary provider right? That's what's done in Boston too.




Yep, furthermore, I'd argue that giving NYC's system a pass is disingenuous. Either the 911 provider can provide the service needed, or they can't. Why is it OK when the primary 911 provider in NYC goes outside of FDNY, but not elsewhere?

More importantly, what sort of disservice is a primary 911 provider doing to their citizens when they say, "Out sandbox. Only we can play here, even if we can't provide enough ambulances to cover the call volume."


----------



## Veneficus (Jan 19, 2012)

JPINFV said:


> Yep, furthermore, I'd argue that giving NYC's system a pass is disingenuous. Either the 911 provider can provide the service needed, or they can't. Why is it OK when the primary 911 provider in NYC goes outside of FDNY, but not elsewhere?
> 
> More importantly, what sort of disservice is a primary 911 provider doing to their citizens when they say, "Out sandbox. Only we can play here, even if we can't provide enough ambulances to cover the call volume."



Have you ever seen the movie "gangs of New York" ?

thought that was fiction did you?


----------



## JPINFV (Jan 19, 2012)

Veneficus said:


> Have you ever seen the movie "gangs of New York" ?
> 
> thought that was fiction did you?




No... I just assumed that NYC had advanced since then.


----------



## Veneficus (Jan 19, 2012)

JPINFV said:


> No... I just assumed that NYC had advanced since then.



How long have you been involved in medicine?

Surely long enough to know if you give humans the benefit of the doubt, they will fall well short everytime?

:sad:

People who think they are right or the best have no reason to change.


----------



## mycrofft (Jan 19, 2012)

Hey, OP, still there?


----------



## Tigger (Jan 19, 2012)

JPINFV said:


> Yep, furthermore, I'd argue that giving NYC's system a pass is disingenuous. Either the 911 provider can provide the service needed, or they can't. Why is it OK when the primary 911 provider in NYC goes outside of FDNY, but not elsewhere?
> 
> More importantly, what sort of disservice is a primary 911 provider doing to their citizens when they say, "Out sandbox. Only we can play here, even if we can't provide enough ambulances to cover the call volume."



Couldn't agree more. If a city doesn't have someone doing backup, then what happens? If every truck is tied up on a call turnarounds are going to be slow since the hospitals are also likely to be busy (hey back on thread topic!). 

So then what, do people just wait and wait despite the fact that there are in fact available ambulances capable of providing the same service as the municipality? That seems like more than just a disservice, it seems stupid. Say what you will about private EMS and about how they know nothing about "working the streets," I'd rather have a crappy crew take me to the hospital than wait at home for the 911 super ambulance to come whisk me away.

No service can cover 100% of its call volume and still stay within acceptable response times 100% of the time. An overflow plan needs to be in place, which doesn't necessarily need to include private EMS, but it in many cases it will be the cheapest for the municipality.


----------



## Joe (Jan 19, 2012)

mycrofft said:


> Hey, OP, still there?



Yea still here. Just got a bag of popcorn. I enjoy the discussion. Hahaha. That pic that was posted with all the ambulances in line is what it looks like here on a weekend. I will get a pic tomorrow.  Usually we don't hit true level zero. If we do another private company that usually does ift is called and they cover. They seem to like it.


----------



## DrParasite (Jan 20, 2012)

Tigger said:


> Well let's see I work in such a system in the city of Boston. So I would say it exists. It's a very similar system to NYC from what I gather, we don't have hospital based EMS here we have private companies. If FDNY runs out of ambulances or has an extended eta they give the call to a voluntary provider right? That's what's done in Boston too.


Boston may do that, I don't know.  I always thought Boston EMS handled all EMS in Boston, I never knew they handled overflow.

and you are wrong about FDNY.  completely wrong.  FDNY covers parts of the city, the voluntary ambulances cover other parts.  it's not a case of if FDNY is tied up, they call for help.  Plus, both FDNY and the voluntary ambulances use the same medical command and have the same protocols, and only certain companies are permitted to participate in the FDNY system.  there are quite a few IFT companies in NYC that don't do 911, don't get dispatched to 911 jobs, and will never be part of the EMS system (outside of an MCI situation like 9/11 when every available ambulance will be called).

and FDNY is far from a high quality well run and well managed EMS system.  very far from it.


----------



## JPINFV (Jan 20, 2012)

I'm starting to realize that while the protocols and scope might suck, the system design and system policies for So. Cal. tend to be much better than a lot of other places. I can't imagine a system saying, "Sorry, but you're going to have to wait simply because we don't want to ask for help from one of the many ambulance services in the local area by developing backup contracts and mutual aid." Heck, even many of the fire departments have gone to a common dispatch center where the closest units are sent, even if it's technically the next city over. Granted, it's one continuous suburb our here instead of distinct cities, but still...


----------



## DrParasite (Jan 20, 2012)

JPINFV said:


> I'm starting to realize that while the protocols and scope might suck, the system design and system policies for So. Cal. tend to be much better than a lot of other places.


judging from some of the horror stories I have heard on here, and the reason for the limited protocol and scope, I would probably disagree. 





JPINFV said:


> I can't imagine a system saying, "Sorry, but you're going to have to wait simply because we don't want to ask for help from one of the many ambulance services in the local area by developing backup contracts and mutual aid."


I can, and I can also see the reasons not being what you are thinking.  Aside from the whole "staff enough units to handle the routine call volume" argument that i have been making for years.

If only 1 department runs EMS, than you have control over the system.  you know everyone has the same training level, same protocols,and same equipment.  you know everyone passed the same competancy tests to be on the ambulance.  an agency knows everyone has valid certificates, were trained in house the same way (regarding city operations and navigating the city, etc).  Once you start involving agencies where you DON'T have control over what equipment they are bringing in, or what training they have, the host agency and citizen can expect one level of service, and get something vastly different.  heck, can the private companies even communicate directly with dispatch, or do they need to go through the IFT dispatcher or call 911?

If we are calling any local ambulance service, you don't know who you are getting.  Can you imagine sending Jack and Jill, two EMTs who typically do dialysis runs, and send them into a double shooting?


JPINFV said:


> Heck, even many of the fire departments have gone to a common dispatch center where the closest units are sent, even if it's technically the next city over. Granted, it's one continuous suburb our here instead of distinct cities, but still...


and you don't see them calling private fire trucks when the 1st due areas are tied up right?  ever wonder why?  and there are career FDs that will call other stations in their department from further away before they call their neighbor department for a fire.  happens all the time.


----------



## JPINFV (Jan 20, 2012)

DrParasite said:


> judging from some of the horror stories I have heard on here, and the reason for the limited protocol and scope, I would probably disagree.


To clarify, there's a difference between medical protocols ("treat this by A, B, and C") and system policies (e.g. licensed emergency departments must be capable of treating peds (OC does, LA doesn't), DNR policy, requiring a workable mutual aid policy, etc). 



> I can, and I can also see the reasons not being what you are thinking.  Aside from the whole "staff enough units to handle the routine call volume" argument that i have been making for years.
> 
> If only 1 department runs EMS, than you have control over the system.  you know everyone has the same training level, same protocols,and same equipment.  you know everyone passed the same competancy tests to be on the ambulance.  an agency knows everyone has valid certificates, were trained in house the same way (regarding city operations and navigating the city, etc).  Once you start involving agencies where you DON'T have control over what equipment they are bringing in, or what training they have, the host agency and citizen can expect one level of service, and get something vastly different.  heck, can the private companies even communicate directly with dispatch, or do they need to go through the IFT dispatcher or call 911?


Everyone in urban California systems have the same protocols and the same minimum training level. If you're working at an IFT company in LA, you have the same basic protocol as if you're working at the 911 services. There are a few variations between companies, but none that can be said as being uniquely present at the 911 services. 

You aren't going to see non-EMTs or paramedics responding to medical emergencies because of a lack of people. As far as valid certification, if they're responding on an ambulance, then they are supposed to be licensed by the state as an EMT or paramedic. The fact that some services might skirt the rules regarding this isn't restricted from occurring at fire departments. For example, it wasn't just the private services involved in the MA CE scandal a few years back. 

Furthermore, if city X is contracting with service 1 to provide primary ambulance service and service 2 for backup service, then the contracts for both can specify what ever is deemed mutually agreeable, hence giving control to the city over what systems responds to emergencies in their territory. 



> If we are calling any local ambulance service, you don't know who you are getting.  Can you imagine sending Jack and Jill, two EMTs who typically do dialysis runs, and send them into a double shooting?


Since many services out here run both primary 911 and IFT, then Jack and Jill may very well be sent anyways by the primary 911 system. It definitely can't be worse than the low volume volly systems where you can have the same "OMG, what do I do" in experience reaction. Additionally, and for better or worse, out here many of the IFT EMTs are better than the 911 EMTs at handling medical calls because we aren't reliant on the fire medic umbilical cord to make decisions. 

Personally, would I feel comfortable running a double shooting? Probably. Would I feel comfortable running a multicar TC? At this point no. Let me run a few as a primary unit, though, and I imagine I'd get it down pretty quickly. On the other hand, let me throw the average 911 EMT who's reliant on the fire medic into a nursing home with a strange DNR situation or the pulmonary edema patient who's been sitting in distress for a half an hour before anyone was even called and watch them try to make a coherent decision on whether to transport or call for paramedics and I'm willing to bet they aren't nearly as smooth as I was in those calls after I got a minimal amount of experience. 

Of course, if all the ambulance crew does is freak out and transport, it's better than having the patient sit on scene because no one is available. At least the patient will, relatively quickly out here, reach the ED where an appropriate level of care can finally be established. I'm not a huge fan of the proverbial "diesel bolus," but it's better than nothing. Nothing is what the overloaded EMS system who refuses to ask for help is offering them. 



> and you don't see them calling private fire trucks when the 1st due areas are tied up right?  ever wonder why?  and there are career FDs that will call other stations in their department from further away before they call their neighbor department for a fire.  happens all the time.


If you want to make all 911 EMS municipal, then that's a separate argument than this. Private, non-industrial fire departments are rare, and in the places that have them I hope to God that the municipal services won't think twice about enlisting their help when they need them. 

Municipal services who would rather risk their citizen's lives than call for the fire department next door is insane, stupid, and dangerous. Granted, the urban situation in So. Cal. is somewhat unique compared to other areas. There are 8 cities in this map screen (Tustin, Santa Ana, Garden Grove, Huntington Beach, Costa Mesa, Westminister, Irvine, Fountain Valley) which makes up the north half of the county I grew up in. The cities range from geographically small (60k people, 9 sq miles) to several hundred thousand people. Try to draw the political boundaries. 

I use this to show that often the only way to tell you left one city and entered another is a little sign saying, "Welcome to ____." There's no reason not to pool resources. There's no reason for the city of 60k to have an air/light unit, USAR team, technical rescue team, etc when mutual aid can easily cover for these units. Similarly, if a neighboring city needs additional fire units for a structure fire, the closest unit will be sent regardless of agency. This isn't because the home agency is out of units, but because it's the height of lunacy to ignore the unit 2 miles away and call for the one 6 miles away simply because of a geographical border.

Of course maybe So. Cal. realizes that it's about the citizens and not agency pride. I happy I've never been in an area so politically malignant that they would put their pride over the health and safety of their citizens. Sure, we have our fun out here between "Drop Me in the Pacific," the "Care Bears," "Another Moron Responds," and "The Lynch Squad," but I'll be damned if I don't access the resources I need for my patient because those resources may come in a different colored ambulance and wearing a different color uniform.


----------



## Tigger (Jan 20, 2012)

DrParasite said:


> Boston may do that, I don't know.  I always thought Boston EMS handled all EMS in Boston, I never knew they handled overflow.
> 
> and you are wrong about FDNY.  completely wrong.  FDNY covers parts of the city, the voluntary ambulances cover other parts.  it's not a case of if FDNY is tied up, they call for help.  Plus, both FDNY and the voluntary ambulances use the same medical command and have the same protocols, and only certain companies are permitted to participate in the FDNY system.  there are quite a few IFT companies in NYC that don't do 911, don't get dispatched to 911 jobs, and will never be part of the EMS system (outside of an MCI situation like 9/11 when every available ambulance will be called).
> 
> and FDNY is far from a high quality well run and well managed EMS system.  very far from it.



I assure you that this is how the Boston system works. I am not conjecturing, I work in it. If that's how the FDNY system works then I agree with your assessment of how well run the system is. That seems absurd that FDNY refuses to even make an effort to cover parts of the city. It's not like people living in areas served by the hospitals don't pay taxes or something right?



DrParasite said:


> judging from some of the horror stories I have heard on here, and the reason for the limited protocol and scope, I would probably disagree. I can, and I can also see the reasons not being what you are thinking.  Aside from the whole "staff enough units to handle the routine call volume" argument that i have been making for years.


I imagine the same horror stories exist in all 50 states, CA just seems to have a disproportionately loud (and negative) voice, especially on this site.



> If only 1 department runs EMS, than you have control over the system.  you know everyone has the same training level, same protocols,and same equipment.  you know everyone passed the same competancy tests to be on the ambulance.  an agency knows everyone has valid certificates, were trained in house the same way (regarding city operations and navigating the city, etc).  Once you start involving agencies where you DON'T have control over what equipment they are bringing in, or what training they have, the host agency and citizen can expect one level of service, and get something vastly different.  heck, can the private companies even communicate directly with dispatch, or do they need to go through the IFT dispatcher or call 911?


I'm not sure I understand, the state (at least here) mandates that everyone pass the same minimum training standard and that all ambulances carry the same minimum equipment. On paper, there is no difference in getting a private BLS ambulance and a city BLS ambulance. 

Here in Boston we can communicate directly with Boston EMS if need be, all of our radios have Boston Ambulance Mutual Aid (BAMA) channel on them, and our dispatch has a dedicated BAMA radio. Generally though we have no need to talk to Boston EMS dispatch. If all the city trucks are busy Boston EMS requests an ambulance over the BAMA channel, and the private dispatcher will dispatch his unit to the call and notify Boston EMS dispatch. This is done for both ALS and BLS calls. At that point, it's now a private ambulance call and if additional help is needed (lift assist or ALS), it usually comes from the company that took the call. If the company has no medics available, their dispatcher can request Boston EMS ALS. 



> If we are calling any local ambulance service, you don't know who you are getting.  Can you imagine sending Jack and Jill, two EMTs who typically do dialysis runs, and send them into a double shooting?
> and you don't see them calling private fire trucks when the 1st due areas are tied up right?  ever wonder why?  and there are career FDs that will call other stations in their department from further away before they call their neighbor department for a fire.  happens all the time.


You don't see fire departments requesting private fire departments for mutual aid because they don't exist in a significant quantity. The privatized fire service is tiny compared to private EMS. 

At the company I work at I do mostly non-emergent stuff. It's not my favorite but I appreciate a paycheck every now and again. And though a generous 15% of my runs are "emergencies," that doesn't mean I can't handle myself, and most of my coworkers are in the same boat. Our uniforms and trucks might not be as cool as Boston EMS's and we sure don't carry handcuffs, but at the end of the day being an EMT is just not that difficult of a job. Everyone's scope is so limited that if I ran on a double shooting I'd be doing the same thing that any "911" EMT does, taking the patient to the hospital without delay. You act like somehow private EMS have no idea how EMS on the streets work, which is absurd. Everyone knows the goal is to get the patient to the hospital, it doesn't take being a grizzled veteran to know that.




JPINFV said:


> Of course, if all the ambulance crew does is freak out and transport, it's better than having the patient sit on scene because no one is available. At least the patient will, relatively quickly out here, reach the ED where an appropriate level of care can finally be established. I'm not a huge fan of the proverbial "diesel bolus," but it's better than nothing. Nothing is what the overloaded EMS system who refuses to ask for help is offering them.



This is the crux my argument. There are not that many ways for a BLS crew to completely screw up a call, but even if they do the patient is still getting to the hospital.


----------



## Bullets (Jan 21, 2012)

JPINFV said:


> I can't imagine a system saying, "Sorry, but you're going to have to wait simply because we don't want to ask for help from one of the many ambulance services in the local area by developing backup contracts and mutual aid."



Because not everyone has the same standard of care or staffing requirements. Woodbridge EMS covers 100k people and runs about 10-12k jobs a year. They dont call mutual aid, they page their volunteers who respond and take one of their 8 bls units. Unless its and MCI, they can handle their town.

You also have to understand that not everyone is the same. NJ doesnt have a required ammount of EMT's on a truck. My home squad was getting mutual aid from an adjacent town, we require 2 EMT's as a township rule, but our mutual aid squad, Unbenkownst to us, would send a truck with a driver and a EMT or a driver and a First Responder, or even just 2 guys who know CPR and nothing else. That ended quickly


Question for those talking about hospitals going on bypass...What happens if you ignore the bypass and bring your patient in anyway? They cant refuse treatment, i would have rolled that CPR in and told them tough, start compressions



Tigger said:


> That seems absurd that FDNY refuses to even make an effort to cover parts of the city. It's not like people living in areas served by the hospitals don't pay taxes or something right?


 You also have to understand the geography of NYC. in parts of brooklyn and queens they are so far from a FDNY post or house that responding a EMS unit is not cost effective or practical for the volume of calls generated in that area. There are still volunteer FD in NYC, some are even officially called VFDNY and cover the Rockaways and Breezy Point out past JFK airport


----------



## JPINFV (Jan 22, 2012)

Bullets said:


> Because not everyone has the same standard of care or staffing requirements. Woodbridge EMS covers 100k people and runs about 10-12k jobs a year. They dont call mutual aid, they page their volunteers who respond and take one of their 8 bls units. Unless its and MCI, they can handle their town.
> 
> You also have to understand that not everyone is the same. NJ doesnt have a required ammount of EMT's on a truck. My home squad was getting mutual aid from an adjacent town, we require 2 EMT's as a township rule, but our mutual aid squad, Unbenkownst to us, would send a truck with a driver and a EMT or a driver and a First Responder, or even just 2 guys who know CPR and nothing else. That ended quickly



1. In the rest of the civilized world that doesn't kowtow to the First Aid [grade?] Council, sending an ambulance to an emergency call without appropriate staffing is unthinkable. In any place of any sort of actual population, sending an ambulance without at least 2 EMTs (or higher) is unthinkable. You aren't, for example, going to find an ambulance in Boston without 2 EMTs. You aren't, for example, going to find an ambulance in Southern California without at least 2 EMTs. Extrapolating the inability of NJ to require appropriate staffing levels to other states is like extrapolating the level of intelligence and ability of the average paramedic in California. 

2. As you said, there's a reason you don't have that mutual aid contract anymore. 



> Question for those talking about hospitals going on bypass...What happens if you ignore the bypass and bring your patient in anyway? They cant refuse treatment, i would have rolled that CPR in and told them tough, start compressions


How many times do you do that before you start facing licensing issues? Sure, the hospital can't refuse care under EMTALA, but that isn't going to stop the state EMS office/authority from yanking your EMS license. So I guess the question is, how much is your job worth?



> You also have to understand the geography of NYC. in parts of brooklyn and queens they are so far from a FDNY post or house that responding a EMS unit is not cost effective or practical for the volume of calls generated in that area. There are still volunteer FD in NYC, some are even officially called VFDNY and cover the Rockaways and Breezy Point out past JFK airport


I hope the people in those areas that FDNY considers "too hard" to provide services for don't pay taxes to support the FDNY.


----------



## Veneficus (Jan 22, 2012)

JPINFV said:


> How many times do you do that before you start facing licensing issues? Sure, the hospital can't refuse care under EMTALA, but that isn't going to stop the state EMS office/authority from yanking your EMS license. So I guess the question is, how much is your job worth?



The question is:

"why are you doing that at all?"

CPR in a truck is not only minimally if effective at all, it is exceedingky dangerous for the benefit of a corpse. 

The hospital divert is a complex issue. Beyond the scope of EMS to influence.

There simply are not enough hospitals to meet America's healthcare needs. Nor enough providers. 

So in commercial interest, it is kept that way by a variety of self serving forces who masquerade as being benevolent that simply are not. 

The people in the hospital I know usually have to fight admin for divert status. They don't do it to skip out on work, they do it because they can no longer provide effective care to those they have. (by that time optimal care fell by the wayside some time ago)

When you ignore the welfare of many patients over excitement genrated over a corpse or on a good day, one unstable patient, you are not demonstating the ability and knowledge of a professional.

If you cannot manage 1 patient in any condition to the next available  resource, then your ability is insufficent.

What if said "nearest" hospital was closed for another reason? Would you go anyway? 

Divert is the hospital term for: We can't help, go somewhere who can. (in the interest of all patients, including yours)

If that is too much for people at your agency, then, your agency sucks. 



JPINFV said:


> I hope the people in those areas that FDNY considers "too hard" to provide services for don't pay taxes to support the FDNY.



The power of state monopoly and propaganda. Amazing isn't it?


----------



## DrParasite (Jan 22, 2012)

JPINFV said:


> How many times do you do that before you start facing licensing issues? Sure, the hospital can't refuse care under EMTALA, but that isn't going to stop the state EMS office/authority from yanking your EMS license. So I guess the question is, how much is your job worth?


I've taken patients to hospitals on divert before.  usually it's because the patient is insisting on going there.  But I have brought a cardiac arrest to the closest hospital, or the closest ALS provider, because they were sick and needed an ER and not a field provider.

Never once did I have to worry about my license being yanked, nor would I ever worry about losing my job for doing it.


----------



## JPINFV (Jan 22, 2012)

Most diversion policies that I've seen have allowed a patient to override the diversion for home hospital requests since, generally, the patient would find their way there when all is said and done anyways. Additionally, there's a difference between an isolated occurance and a pattern. I imagine if EMTs and paramedics started just blatantly ignoring diversion status, then bad things would start to happen.


----------



## Handsome Robb (Jan 23, 2012)

We have certain parameters that allow to ignore them divert or bypass status unless it's divert because of internal hospital disaster.

-Pt choice
-Trauma 
-Cardiac arrest if they arrest en route unless its traumatic in origin.
-Inability to obtain an airway/Airway obstruction.
-Severe shock
-Imminent delivery with abnormal presentation.
-Uncontrolled hemorrhage


----------



## Outbac1 (Jan 23, 2012)

The longest I've waited is 4 - 5 hrs at the big hosp. in the city(2hrs away). At our local hosp. the worst was 1 hr. usually only a few minutes. It all depends on the triage score of the patient and how busy they are. Some of the city medics have spent their entire shifts in line with low priorty pts. Sometimes pts will get handed off to other crews who will look after two or three pts in line. This allows other crews to go back out, get another pt and come back to get in line again.
 Of course when the city gets busy it then pulls crews in from other nearby areas  to cover the shortfall of avalible crews. In our system which covers the whole province any empty unit is an available unit. So it doesn't matter that I am based out of a town 2hrs away. If I have dropped off my transfer pt and don't have one to take back I'm considered an avalible unit. If the city is busy I get held for coverage. This we lovingly refer to as "getting sucked into the vortex". Once in it can be hard to get out. The dispatchers do try to get you out if they can but "Murphy" is always present. 
 Like Sun about 02:45 we were just on the edge of the city on our way home and calls started dropping one after the other. We got sucked in. Ended with us doing a 2 pt MVC on the other side of the city as we were the closest unit. Cleared the hosp at 5am. Shift end was at 6am so got an hr of OT. 
Whoopee livin the dream.


----------



## Tigger (Jan 23, 2012)

Bullets said:


> You also have to understand the geography of NYC. in parts of brooklyn and queens they are so far from a FDNY post or house that responding a EMS unit is not cost effective or practical for the volume of calls generated in that area. There are still volunteer FD in NYC, some are even officially called VFDNY and cover the Rockaways and Breezy Point out past JFK airport



Nonetheless, FDNY is still the primary EMS provider even in areas served by volunteer companies. My understanding of the volunteer EMS outfits is that they are no longer dispatched by FDNY and buff calls. Event though these neighborhoods are far from FDNY units, they are still served by FDNY.

I'm thinking more about neighborhoods served by hospital based EMS. If FDNY is not covering those areas period, those neighborhoods should be getting a tax break (in theory) as the the municipality is failing to provide a service. In this case it has nothing to do with call volume, as clearly there is enough population to justify the existence of a hospital.


----------



## DesertMedic66 (Jan 24, 2012)

Had a new experience today while "holding the wall". 

We got the patient a room. However there were no beds left. So we were inside the room with the patient on our gurney as the doctor walks in and starts doing his assessment on the patient. Then X-ray comes and does the X-ray while the patient is still on the gurney.


----------



## Joe (Jan 24, 2012)

Hahaha that sucks! Atleast they are putting the pt first but still sucks for you guys


----------



## DrParasite (Jan 24, 2012)

JPINFV said:


> Most diversion policies that I've seen have allowed a patient to override the diversion for home hospital requests since, generally, the patient would find their way there when all is said and done anyways. Additionally, there's a difference between an isolated occurance and a pattern. I imagine if EMTs and paramedics started just blatantly ignoring diversion status, then bad things would start to happen.


you would imagine wrong, but that's ok.  diverts are a courtesy that EMS is trying to provide to the hospital; it doesn't HAVE to be followed.  


NVRob said:


> We have certain parameters that allow to ignore them divert or bypass status unless it's divert because of internal hospital disaster.
> 
> -Pt choice
> -Trauma
> ...


although we don't have it written down, those are pretty much the reasons we can go to a hospital on divert (the most common being patient choice).





firefite said:


> Had a new experience today while "holding the wall".
> 
> We got the patient a room. However there were no beds left. So we were inside the room with the patient on our gurney as the doctor walks in and starts doing his assessment on the patient. Then X-ray comes and does the X-ray while the patient is still on the gurney.


We brought in a diabetic once with no ALS avail and a BGL of around 14.  the ER nurse started the IV, pushed d50, and started pushing flush after flush to try to get the patient to wake up while still on our cot.  after the 3rd flush, he said to put the patient in a bed (the patient also accidentally overdosed on their narcotic pain meds).  a little narcan later, and the patient was awake and talking.  I was told later that the ER was not able to do anything while the patient is on our cot, but I wasn't going to argue if it helped out patient and preventing his him going into cardiac arrest from hypoglycemia.

taking the x-ray, on the other hand, would have gotten me to call the charge nurse and get a bed, because that seems a little absurd.


----------



## JPINFV (Jan 25, 2012)

DrParasite said:


> you would imagine wrong, but that's ok.  diverts are a courtesy that EMS is trying to provide to the hospital; it doesn't HAVE to be followed.



The same could be said with everything else in the policy and protocol book, which makes any discussion of policies outright asinine. However, please post policies that says, "Hey guys, this entire thing? Yea, it's just a request. Feel free to ignore it just because, you know, you don't want to drive to another hospital." Hell, a DNR is just a request, why not just ignore every DNR that meets criteria because, hey, it's just a request no one is going to physically stop you. 





> although we don't have it written down, those are pretty much the reasons we can go to a hospital on divert (the most common being patient choice).


Didn't you just say it's just a request? Why even have reasons to begin with. If it's just a request, couldn't you just say, "We came here because we wanted to. You know... save the company gas money and put less miles on the ambulance." 



> I was told later that the ER was not able to do anything while the patient is on our cot, but I wasn't going to argue if it helped out patient and preventing his him going into cardiac arrest from hypoglycemia.



What are you going to do to stop the hospital from treating someone on your gurney anyways? 




> taking the x-ray, on the other hand, would have gotten me to call the charge nurse and get a bed, because that seems a little absurd.



Why draw the line there? So they don't have a bed ready now, everything else gets delayed instead of getting imaging studies and labs cooking?


----------



## Handsome Robb (Jan 25, 2012)

firefite said:


> Had a new experience today while "holding the wall".
> 
> We got the patient a room. However there were no beds left. So we were inside the room with the patient on our gurney as the doctor walks in and starts doing his assessment on the patient. Then X-ray comes and does the X-ray while the patient is still on the gurney.



That's pretty much what happened with our narcan guy I was talking about. We ended up in a room on our cot using the hospital's meds, however my partner and I were still providing care not hospital staff.

"oh there's a crash cart here...hey there's narcan in it!"

After they took over care while we were getting ready to leave. "oh btw that crash cart needs two bristojets of narcan replaced...  " 

Charge nurse "really guys?!?"


----------



## DrParasite (Jan 25, 2012)

JPINFV said:


> Hell, a DNR is just a request, why not just ignore every DNR that meets criteria because, hey, it's just a request no one is going to physically stop you.


hmmm, I always thought that a DNR was a legal document written and signed by the patient and their doctor, enforceable by the courts.  It took a 2nd year med student to tell me that they were just a request and didn't need to be followed because no one is physically going to stop you.





JPINFV said:


> Didn't you just say it's just a request? Why even have reasons to begin with. If it's just a request, couldn't you just say, "We came here because we wanted to. You know... save the company gas money and put less miles on the ambulance."


yes, I did, because it is only a request.  We try to accommodate the hospital's request, but if we can't, oh well, not going to lose sleep over it, nor will I lose any sleep because the ER staff is unhappy that we brought a patient to them while on divert.  And just so you are happy, nor will my supervisors, upper management, or local EMS regulatory agency.

BTW, when a hospital goes on divert, do they close their walk in entrance?  no, they keep accepting patients, they just all need to wait a little longer.  That's why a divert is a request and a courtesy, they can't actively refuse to accept a patient (something about EMTALA and dumping patients if I remember correctly).


JPINFV said:


> What are you going to do to stop the hospital from treating someone on your gurney anyways?


well, I could always say "STOP!!!! do not touch MY patient!!!"  would be extremely over dramatic, and not all that productive, but I COULD do it.  Not that I would, especially for a simple, quick life saving intervention.

But if the hospital wants to put the patient on a 12 lead monitor, starts 2 IVs and start pushing medications, maybe even putting in an advanced airway, I'm gonna say "hold it, lets put him on one of your beds, then you can do whatever you want, and we can get out of your way." and most of the time, it will get done.  and if it doesn't, that's when you get your supervisors to call their supervisors and document everything to follow up to prevent it from happening again.





JPINFV said:


> Why draw the line there? So they don't have a bed ready now, everything else gets delayed instead of getting imaging studies and labs cooking?


I guess it's a differences in the importance your hospitals view EMS.  In NJ anyway, might not be the same out west.

Also, if you permit all the work to be done with the patient on your cot, it means that your time and your equipment is not as valuable as theirs.  meaning, why should they even try to get a bed for you when they can just have you babysit the patient until they get around to it?  yes the work needs to be done, but it needs to tie up a hospital resource, not an EMS resource.

it has nothing to do with EMT, paramedic, IFT, 911, uneducated EMS or EMS that requires a Masters degree.  it has to do with the fact that the ambulance does not belong in the ER in a holding pattern with no end in sight.  911 trucks need to be available to answer 911 calls, IFT trucks need to be available to answer IFT calls.  

But if you accept the fact that you can be put in the holding pattern, than that means you have a very low opinion of yourself/your job and your role in the over all system, and you have accept that the ER's time and resources are more valuable than your own.  

I might not be very educated when compared to some of the doctors, but at least I got enough self worth to know that my time isn't there just to be wasted by others.  shame others in the profession don't have that same amount of self worth.


----------



## Bullets (Jan 25, 2012)

Tigger said:


> Nonetheless, FDNY is still the primary EMS provider even in areas served by volunteer companies. My understanding of the volunteer EMS outfits is that they are no longer dispatched by FDNY and buff calls. Event though these neighborhoods are far from FDNY units, they are still served by FDNY.
> 
> I'm thinking more about neighborhoods served by hospital based EMS. If FDNY is not covering those areas period, those neighborhoods should be getting a tax break (in theory) as the the municipality is failing to provide a service. In this case it has nothing to do with call volume, as clearly there is enough population to justify the existence of a hospital.



Actually those areas out on the barrier, reedy point, breezy point, are served by volunteer EMS agencies, a few are part of the volunteer FD and have provided medical coverage for the area long before FDNY reorganized. Its a system that worked so FDNY kinda left them alone. There is only one bridge out to that area, and you have to go through a gate and past a security guard and all that


----------



## JPINFV (Jan 25, 2012)

DrParasite said:


> hmmm, I always thought that a DNR was a legal document written and signed by the patient and their doctor, enforceable by the courts.  It took a 2nd year med student to tell me that they were just a request and didn't need to be followed because no one is physically going to stop you.



Yet, look at all of the places that will gleefully ignore otherwise valid DNR orders/requests simply because they aren't on the proper colored paper. Opps, sorry, you're a hospice patient with an otherwise valid DNR order written into the chart and going to a hospice facility? Well, you don't have our DNR form, so we're just going to ignore it. So, which is it. Is a DNR a legal order or is it not. If it's a legal order, than all of the systems that limits ambulance crews to just the out-of-hospital forms must be breaking the law somehow.  



> yes, I did, because it is only a request.  We try to accommodate the hospital's request, but if we can't, oh well, not going to lose sleep over it, nor will I lose any sleep because the ER staff is unhappy that we brought a patient to them while on divert.  And just so you are happy, nor will my supervisors, upper management, or local EMS regulatory agency.


Similarly, I doubt the hospital staff is going to lose sleep over forcing the crew who ignored the divert to hold the wall. I imagine it isn't too hard to find patients in the lobby that are sicker than your patient. 

You're also missing the entire point of a pattern of ignoring the divert status. There's a difference between one patient and flat out continually ignoring it. I stand by my statement that a crew or company that shows such a pattern will garner the attention of the hospital staff, which will garner the attention of both the company (especially if the company has a contract for that facility) and the local EMS authority. Why is the policy on divert status any less important than all of the other policies out there governing the EMS system?


> BTW, when a hospital goes on divert, do they close their walk in entrance?  no, they keep accepting patients, they just all need to wait a little longer.  That's why a divert is a request and a courtesy, they can't actively refuse to accept a patient (something about EMTALA and dumping patients if I remember correctly).


Comparing someone who hasn't accessed the emergency medical system to  someone who is currently in the emergency medical system is comparing  apples to oranges. Of course it's ironic to discuss dumping patients in a conversation about trying to justify EMTs dumping patients because they don't want to be a team player. 




> But if the hospital wants to put the patient on a 12 lead monitor, starts 2 IVs and start pushing medications, maybe even putting in an advanced airway, I'm gonna say "hold it, lets put him on one of your beds, then you can do whatever you want, and we can get out of your way." and most of the time, it will get done.  and if it doesn't, that's when you get your supervisors to call their supervisors and document everything to follow up to prevent it from happening again.I guess it's a differences in the importance your hospitals view EMS.  In NJ anyway, might not be the same out west.


If you're coming into a facility on divert, what makes you think that a bed is available to treat your patient? I've never had a patient be treated on my gurney, but I also haven't ignored diversion status either. Besides, what makes you think that the hospital supervisors care what the ambulance supervisor thinks when the ED is already packed with patients and on divert? 

Of course out West (since you want to make this a geographical issue) doesn't have a problem with unlicensed providers working on ambulances. 



> Also, if you permit all the work to be done with the patient on your cot, it means that your time and your equipment is not as valuable as theirs.  meaning, why should they even try to get a bed for you when they can just have you babysit the patient until they get around to it?  yes the work needs to be done, but it needs to tie up a hospital resource, not an EMS resource.
> 
> But if you accept the fact that you can be put in the holding pattern, than that means you have a very low opinion of yourself/your job and your role in the over all system, and you have accept that the ER's time and resources are more valuable than your own.
> 
> I might not be very educated when compared to some of the doctors, but at least I got enough self worth to know that my time isn't there just to be wasted by others.  shame others in the profession don't have that same amount of self worth.


Strange, the same could be said about a crew who thinks that divert  status doesn't apply to them. What makes your patient more important  than all of the other patients in the saturated ED? Your time is more important than the hospital staff's time dealing with numerous other patients because you want to dump your patient on them instead of following your system's policy regarding divert? A policy that was made in consultation with both the system administrators, the hospitals, and the ambulance services? I'd rather have a lower sense of worth than an over-inflated sense of self worth where I think I know more than everyone else involved with the system combined. 

Shame on those who thinks that they're the only people that matter in a system.

I wonder what would happen if EMS providers suddenly had to start regularly treating multiple sick patients for hours at a time instead of one patient for 20 minutes. I'm willing to bet the "I'm the center of the universe" attitude would quickly change.


----------



## Handsome Robb (Jan 25, 2012)

DrParasite said:


> .
> Also, if you permit all the work to be done with the patient on your cot, it means that your time and your equipment is not as valuable as theirs.  meaning, why should they even try to get a bed for you when they can just have you babysit the patient until they get around to it?  yes the work needs to be done, but it needs to tie up a hospital resource, not an EMS resource.
> 
> it has nothing to do with EMT, paramedic, IFT, 911, uneducated EMS or EMS that requires a Masters degree.  it has to do with the fact that the ambulance does not belong in the ER in a holding pattern with no end in sight.  911 trucks need to be available to answer 911 calls, IFT trucks need to be available to answer IFT calls.
> ...



This is a ridiculous statement...we are all on the same team, working towards a common goal, that goal being good patient care.

Healthcare isn't a perfect system anywhere in the world. Sure something may look good on paper but paper isn't the real world.

So if I'm reading what you said above correctly your saying by allowing a nurse to pull labs before we get a room in hope to expedite the patient's stay in the ER and eventually clearing a bed more quickly I have no respect for the value of my equipment or myself? If myself and a nurse push a med before the patient is assigned a room because the system, as a whole, is overloaded I have a poor opinion of myself and my job? That's asinine. 

Sure units need to be available to answer calls in the system but even if they are able to answer those calls what good is it if there's nowhere for us to take those patients to? Just some food for thought.


----------



## DrParasite (Jan 25, 2012)

JPINFV said:


> Yet, look at all of the places that will gleefully ignore otherwise valid DNR orders/requests simply because they aren't on the proper colored paper. Opps, sorry, you're a hospice patient with an otherwise valid DNR order written into the chart and going to a hospice facility? Well, you don't have our DNR form, so we're just going to ignore it. So, which is it. Is a DNR a legal order or is it not. If it's a legal order, than all of the systems that limits ambulance crews to just the out-of-hospital forms must be breaking the law somehow.


I know I am probably in the minority, but if i had a DNR, I would want to make it as accurate as possible.  that means using the state DNR form, for out-of-hospital if the patient will be transported out of hospital, and if hospital and hospice if appropriate.  but thats just me.


JPINFV said:


> Similarly, I doubt the hospital staff is going to lose sleep over forcing the crew who ignored the divert to hold the wall. I imagine it isn't too hard to find patients in the lobby that are sicker than your patient.


probably right, but when I start calling for the hospital administration to come down and explain to my patient why they are waiting, a bed will be found.  and while I haven't had to do that, I know of supervisors who have went to the ER and made that request.  it's called advocating for your patient. 


JPINFV said:


> You're also missing the entire point of a pattern of ignoring the divert status. There's a difference between one patient and flat out continually ignoring it. I stand by my statement that a crew or company that shows such a pattern will garner the attention of the hospital staff, which will garner the attention of both the company (especially if the company has a contract for that facility) and the local EMS authority. Why is the policy on divert status any less important than all of the other policies out there governing the EMS system?


you can stand by your statement, but your statement is still wrong.  maybe an IFT company can get in trouble (since that seems to be where all your experience is), but 911 services don't.

the divert status is a hospital request, it isn't an EMS policy.  I could explain it more, but if you don't understand that concept, than it is a moot point.


JPINFV said:


> Comparing someone who hasn't accessed the emergency medical system to  someone who is currently in the emergency medical system is comparing  apples to oranges. Of course it's ironic to discuss dumping patients in a conversation about trying to justify EMTs dumping patients because they don't want to be a team player.


ahhh, not a team player... yeah, that's me.  the guy who wants to get back out there and pick up the next GSW victime, heart attack, or asthma attack, and take them to the hospital, instead of holding a wall for 1-4 hours.  yep, not a team player  :rofl:


JPINFV said:


> If you're coming into a facility on divert, what makes you think that a bed is available to treat your patient? I've never had a patient be treated on my gurney, but I also haven't ignored diversion status either. Besides, what makes you think that the hospital supervisors care what the ambulance supervisor thinks when the ED is already packed with patients and on divert?


well, when you aren't going to make any noise, they won't care.  if you just wait their quietly, hospital supervisors won't care.  maybe the hospitals I have dealt with are just more EMS friendly than others, or just practice good customer service whether it be from a patient or a fellow healthcare provider.


JPINFV said:


> Of course out West (since you want to make this a geographical issue) doesn't have a problem with unlicensed providers working on ambulances.


ouch, a zinger!!! you know, with a small percentage of FD ambulances or rural ambulances in the sticks do doesn't represent the majority, so your cheap shot doesn't phase me at all,nor does it even apply to me.





JPINFV said:


> Strange, the same could be said about a crew who thinks that divert  status doesn't apply to them. What makes your patient more important  than all of the other patients in the saturated ED? Your time is more important than the hospital staff's time dealing with numerous other patients because you want to dump your patient on them instead of following your system's policy regarding divert? A policy that was made in consultation with both the system administrators, the hospitals, and the ambulance services? I'd rather have a lower sense of worth than an over-inflated sense of self worth where I think I know more than everyone else involved with the system combined.


yes, back this the divert thing.  if you can't understand that it's a courtesy, not a requirement, than I won't waste any more time wit you.  

My patient is more important because I have done my job, and brought them to the ER.  if the staff say put him in triage, he goes into triage.  if the staff say put him in a bed, he goes in a bed.  either way, my job (what I'm paid to do, and what my boss tells me to do) is to pick up sick people and take them to the hospital.  Once they are in the hospital, they are the hospital's problem (and yes, overcrowding sucks, but that's a hospital flow problem, not an EMS problem).


JPINFV said:


> I wonder what would happen if EMS providers suddenly had to start regularly treating multiple sick patients for hours at a time instead of one patient for 20 minutes. I'm willing to bet the "I'm the center of the universe" attitude would quickly change.


 first off, usually those sick patients are focused 100% by a doctor or nurse until they are stabilized.  Then they are consistently monitored by a nurse or by a machine (which is monitored by a nurse) for changes, and if there are  any life threatening changes the patient again gets 1:1 care.

if a nurse is handling too many sick patients at the time time, than the hospital needs to hire more nurses.  I am pretty sure there are nursing standards that say how many patients can be assigned to a nurse.  either way, it's a hospital issue, not an EMS one.


NVRob said:


> This is a ridiculous statement...we are all on the same team, working towards a common goal, that goal being good patient care.


absolutely right, in theory anyway.  we also play different roles, ambulance people pick up the people and drop them off in the ER, while the ER people deal with the people we drop off.  but if the ER is preventing you from leaving the ER, then they are preventing you from providing good patient care to the other people who need your help, which is preventing you from doing your job.  so how is delaying access to the EMS system considered god patient care?  ditto delaying getting a comfy bed for the patient (ambulance cots as a whole generally suck when compared to a hospital bed).  We won't even go into the detrimental effects of having a patient on a backboard for an extended period of time.... So again, if the people on your "team" are preventing you from providing good patient care to others who need your help, and are forcing your patients to remain on a ambulance cot and/or long spine board longer than the need to, are they really striving to provide good patient care? 





NVRob said:


> So if I'm reading what you said above correctly your saying by allowing a nurse to pull labs before we get a room in hope to expedite the patient's stay in the ER and eventually clearing a bed more quickly I have no respect for the value of my equipment or myself? If myself and a nurse push a med before the patient is assigned a room because the system, as a whole, is overloaded I have a poor opinion of myself and my job? That's asinine.


so let me ask you this:  if the nurse can do all that work with the patient on your cot, why should he or she work on getting you a bed at all?  why not just leave the patient on your cot?  the patient gets treated, the hospital gets it's tests done, and it doesn't tie up a hospital bed at all.  there is absolutely no reason for the hospital to get you a bed at all.


NVRob said:


> Sure units need to be available to answer calls in the system but even if they are able to answer those calls what good is it if there's nowhere for us to take those patients to? Just some food for thought.


the patients need to go somewhere, and the system (in its current state) has EMS take them to the ER.  You can like it, you can hate it, you can disagree with it, or you can think it can be done better; but regardless of what anyone thinks, that's the systems we have to deal with.  Are the ER's overworked with non-emergent patients?  absolutely.  But they can't turn them away, despite that they would like to.  They do make them wait, but they do get seen, and if a critical patient walks in the door, they do get to jump the line and get seen.

Maybe I am looking at the issue wrong.  Maybe the issue is in other areas the ER staff just doesn't care.  Maybe EMS needs to build better relationships with the ER management so they will care what people think?   

I can't speak for anyone else, but I have gone out with nurses in a purely social setting.  We have all gone drinking after a long shift, and EMS was invited to their christmas party.  We treat them with respect, and they treat us with respect.  Maybe it's because of this that despite being overworked and understaffed, we still rarely wait more than 20 minutes for a bed (and usually it's because they are actively trying to find a bed for us).  We are friends, we work to help them, and they in turn work to help us.  We understand their roles in the healthcare system, and they understand ours.  maybe that's why we don't have hour+ long waits to turn over a patient.

One last example: I had a run in with an L&D nurse a few years ago.  She completely ignored me, ignored everything I had to say, and then sent me down to the ER with my patient (which didn't bother me all that much except that I didn't know the way through the hospital).  Anyways, I made it to the ER, and the nurse (who only knew me professionally, I doubt she even remembered my name) saw I was visibly frustrated.  After we transferred the patient to a bed, she asked what was bothering me and I told her.  She then brought me to the nursing director of the ER, who asked what was wrong, and I told her.  She then picked up her cell phone, dialed a number, and told me to repeat what I told her.  So I did.  I later learned that the person she called was the director of the L&D department who wasn't happy to hear what I had to say.  The original nurse was reeducated on interacting with other healthcare providers (she didn't think she did anything wrong), which I didn't care about, but the department policies were changed to be more EMS friendly (and more patient friendly, which me very happy).

and the only reason anything was done was because I said something about it, and the ER staff respected EMS (as a general whole, not an individual provider) to listen to a complaint to make the system better for all involved.

btw, that nursing director has since moved on to another position, but I have met the new ER director, have her name, email and phone number, and she knows me, and has my contact information.  and yes, we have communicate issues and they tend to be resolved to everyone's benefit.


----------



## JPINFV (Jan 25, 2012)

DrParasite said:


> I know I am probably in the minority, but if i had a DNR, I would want to make it as accurate as possible.  that means using the state DNR form, for out-of-hospital if the patient will be transported out of hospital, and if hospital and hospice if appropriate.  but thats just me.


So, how many extra DNR forms are you willing to fill out for 15 minute transports when every place else allows for a simple order written in the chart. When EMS requires a special document, maybe EMS is the problem and not everyone else. 




> probably right, but when I start calling for the hospital administration to come down and explain to my patient why they are waiting, a bed will be found.  and while I haven't had to do that, I know of supervisors who have went to the ER and made that request.  it's called advocating for your patient.


I highly doubt that most hospital administrators care just as your supervisors don't care about divert status. 


> you can stand by your statement, but your statement is still wrong.  maybe an IFT company can get in trouble (since that seems to be where all your experience is), but 911 services don't.



Let's stop playing stupid games. Put up your local policy that says that the ambulance crew can decide on their own to ignore divert status. Here's three separate county wide policies on divert status. Notice that there is no option for an ambulance crew to unilaterally ignore divert status regardless of the use of the term "request." When the decision is made at the system and base hospital level, it isn't a "request" for the crew anymore. 

http://www.ochealthinfo.com/docs/medical/ems/P&P/310.96.pdf

Regardless of the use of the term "request," notice that none of the decision making regarding the "request" is done at the ambulance level. The lowest it goes is the base hospital. 

Another county:
http://www.remsa.us/policy/5310.pdf

Again, no option for paramedics to simply ignore trauma diversions "just because." 

Another county:
http://www.sdcounty.ca.gov/hhsa/programs/phs/documents/EMS-PolicyProtocol_Manual_2011.pdf
Pg 39-42

Again, note, all decisions regarding diversion are made at the base hospital level.

Now show me where in your protocols you're allowed to make the decision at the ambulance level to dump patients on an ED. 




> the divert status is a hospital request, it isn't an EMS policy.  I could explain it more, but if you don't understand that concept, than it is a moot point.



It very much is an EMS system policy. See above for three separate policies made at the EMS level regarding divert status. 


> ahhh, not a team player... yeah, that's me.  the guy who wants to get back out there and pick up the next GSW victime, heart attack, or asthma attack, and take them to the hospital, instead of holding a wall for 1-4 hours.  yep, not a team player  :rofl:



So your potential patients are more important than the patient in front of you? There are no other calls. Also, if your call volume is so high, why aren't there more units on the road? Why is the hospital required to bend over backwards because of your service's failure to plan?




> well, when you aren't going to make any noise, they won't care.  if you just wait their quietly, hospital supervisors won't care.  maybe the hospitals I have dealt with are just more EMS friendly than others, or just practice good customer service whether it be from a patient or a fellow healthcare provider.



The hospitals I've ever had a regular problem with I can count on one hand. Let me rephrase that, I can think of 1 hospital that had regular issues. So my question is why are you constantly making noise? Furthermore, you are not the hospital's customer in any sense of the term. 


> ouch, a zinger!!! you know, with a small percentage of FD ambulances or rural ambulances in the sticks do doesn't represent the majority, so your cheap shot doesn't phase me at all,nor does it even apply to me.



Ambulance out in the sticks? What's wrong with a state that can't even get one single office/authority/what-have-you providing umbrella oversight even if there are regions? Why does it not surprise me that a state that can't even require all ambulances to have an EMT on it can't draw up a unified policy regarding diversion?


> yes, back this the divert thing.  if you can't understand that it's a courtesy, not a requirement, than I won't waste any more time wit you.
> 
> My patient is more important because I have done my job, and brought them to the ER.  if the staff say put him in triage, he goes into triage.  if the staff say put him in a bed, he goes in a bed.  either way, my job (what I'm paid to do, and what my boss tells me to do) is to pick up sick people and take them to the hospital.  Once they are in the hospital, they are the hospital's problem (and yes, overcrowding sucks, but that's a hospital flow problem, not an EMS problem).



Since I've already posted links in this post, it's only a courtesy for  states that can't provide reasonable oversight to the EMS system. 

Yep, it doesn't matter if the hospital can't currently take care of the patient. You did your job, even if it is ultimately to the detriment of the patient, and many other patients. After all, the only thing that matters is your ability to be a horizontal taxi service, right? 


> first off, usually those sick patients are focused 100% by a doctor or nurse until they are stabilized.  Then they are consistently monitored by a nurse or by a machine (which is monitored by a nurse) for changes, and if there are  any life threatening changes the patient again gets 1:1 care.



...because the number of sick patients in an ED currently under diversion for saturation can't possibly out number the number of nurses and physicians on duty. That's almost like it being impossible for the number of calls to exceed the number of ambulances currently on duty, right? Of course the solution isn't to bring patients to a non-saturated hospital. That's just crazy talk. 


> if a nurse is handling too many sick patients at the time time, than the hospital needs to hire more nurses.  I am pretty sure there are nursing standards that say how many patients can be assigned to a nurse.  either way, it's a hospital issue, not an EMS one.


...because the hospital hires psychics to determine when exactly their capacities will be overwhelmed. Additionally, adding more nurses and physicians doesn't expand the number of beds in the ED. Capital investments like expanding a building aren't exactly as simple as hiring an extra nurse.


----------



## systemet (Jan 25, 2012)

In a past life, I have reported to work, been driven by a supervisor to the ER, and waited for an entire shift with a succession of different patients until being picked up at the ER (late), and driven back to the station.  My personal best on a single patient is 8 hours.

I have worked in re-direct systems where a guy with multiple torso stab wounds, in sight of the trauma center, gets driven across town to another trauma center, because "they're on redirect".  

I've worked in systems where you park the ambulance on scene, because by the current bizarre incarnations of whatever redirect policy is in place, driving in any direction would be completely counterproductive because the combination of hospitals going on redirect and off-redirect meant you'd just have to turn around again.

--------------------------

There is a series of problems.  I'm not sure how this works out in the US.

(1) Shortage of discharge beds.  If there's no long-term care / nursing home / whatever for the ER patient to go to... where do they go.. nowhere.  They stay in the ER.

(2) Failure of other hospital services to admit 24 hours.  Some of the medical wards just aren't taking new admits at 0300.  And, hey, they're busy, and they deserve a quiet night sometimes.  But the spill over is, the patient stays in the ER.

So now you have....

(3) Lack of ER resources, due to 30-50% of beds being occupied by "emergency admitted inpatients".  These patients are assigned to another service, but occupying a bed in the ER, or a nearby hallway, receiving orders from said services, and generally consuming ER resources doing time-consuming tasks ordered by an MD from another service.

Then you have a problem.

(4) Triage back up.  There's 100 people in the waiting room.  Some of these people are sick.  Some are old people with a convincing story for a possible MI.  Some are kids that needing working up.  Some have serious pathology.  And in comes an ambulance.

(5) Lack of incentive to accept EMS patients.  So a bed opens up.  And the triage RN has been worrying for the last 2 hours about an 80 year old with indigestion.  Maybe they've had time to do a quick 12-lead in a corner somewhere, and seen that there's no STEMI.  But they'd love a troponin, and it's been an hour since the last ECG.  And EMS has a homeless person, intoxicated, and incontinent of feces.  

What choice does the RN make?  Well, the patient in the waiting room is probably sicker, so they go in, right.  And EMS waits, because the incontinent homeless guy can't sit upright in a chair.  And this repeats, all night.  Because everyone else is sick.  And he's intoxicated and incontinent.  And if he was a 30 year old stockbroker, maybe the triage RN might care more.  But maybe not.

But let's say he's intoxicated, but ambulatory.  He could go to chairs, but then he's going to mouth people off, and cause problems.  Sure there's security, but they cause as many problems as they solve.   So he stays with EMS, because at least there, someone will correct his behaviour without having five people jump on him.

Or, let's say, the two patients are the same.  There's a vague cardiac rule-out patient with EMS, and one of the same acuity waiting in chairs.  The RN can free up the ambulance crew, or take the patient in chairs.  Which action is most legally defensible?  Sure, it looks bad if the ambulance waits an hour or two, gets a positive 12-lead, and the patient subsequently dies.  Or enzymes show a NSTEMI a few hours later.  But how bad does it look if the person in chair drops after a 4 hour wait?  At least the ambulance patient is getting periodic repeat 12-leads, and if they develop anginal symptoms, EMS can do initial treatment.

(6) EMS becomes surge nursing support.  The hospital doesn't have enough beds.  No one's getting discharged, plenty of people are getting admitted, but none of them are physically moving upstairs.  The hospital isn't paying the paramedic's wages, they're not answerable to the city taxpayer.  They have no incentive to ensure ambulances are available for local 911 care.  That becomes the city's problem.  That's who the taxpayer is turning to if there's no one to answer 911.  [Even if EMS is part of the healthcare system -- a paramedic is still cheaper than an RN, and how important is the ER in terms of hospital departments?  And then how important is EMS?  Neither are a priority compared to say the pediatric neuro ICU].

/ end rant.

---------------------

As an aside, in a life past, I have also been the transfer medic.  One of two ALS cars on at night for stat transfers / CCT for a million people.  Sitting, waiting in the ER, with a pediatric patient with a leg fx, giving periodic pain control, sitting and listening to the triage RN telling the emergency crew that as soon as patient transfer takes their cardiac to the cathlab, they'll be a bed opening up, not realising that the crew that's going to do that job, is waiting to drop off their low acuity patient before anything else can get done.

------------------------

I'm not sure what my original point was, nor am I completely convinced that this is anything more than pointless whining.  

As I saw it, at least, the problem was that the entire system was chronically underfunded, and the ER's had nowhere to send their patients, and nowhere to put them.  It wasn't that anyone was being lazy.  Just that you can't magically make another long-term care bed appear, free up an emergency bed, clear the triage backlog, prioritise EMS, and generally fix things.


----------



## Veneficus (Jan 25, 2012)

*divert, the forest from the trees*

Once I was stationed at a busy station, on a single unit (of 2 stationed there), 12-14 ALS calls for 12 hours was the average shift, but it could get busier, plus any number of dynamic posting (aka system status management) and complete BS calls.

Just down the street was a small hospital, non trauma center, non cardiac center, 1 surgical suite and a whopping 4 bed ICU. But they did have a 6 bed ED (2 acute beds that actually had monitors) with a waiting room with another 8 chairs. 

Now and again, a sick person would actually walk in the front door. Where they would find 1 doctor, 1 nurse, and one "nursing" tech (aka nursing student).

On a bad night, when only 1 anesthesia intensivist was in the hospital outside of the ED, with an on call surgeon who had 45 minutes to get there, 2 or more sick people would actually wander in. 

Rather than pull the intensivist from the ICU, they would call our station on the non-emergent line to see if there was a unit in station and if so, ask if we could come and help.

I am proud to say we went out of our way to help. 

It didn't earn the very reputable EMS company any money, in fact it cost them money. (the official line not written in policy was: do what you can whenever you can to help)

It definately put extra stress on the other unit at the station and likely extra stress on the units in the area.

So why did we do it?

Because a person, who can also be described as a patient was in need. Because some very capable providers who were part of the continuum of care required extra people in order to provide the best they could to this person in time of need.

It was not, and everywhere today is not, about the hospital; not about EMS.

It is about people we call patients. Not to save lives, but to prolong them, hopefully at some level of quality. Healthcare is a team effort, you can be a valuable player or the weak link. But universally when it is about your needs and not the team's, you are the weak link, even if you don't think so.

Every country I know of has doctors and nurses and hospitals. 

Not every country has modern EMS. (or even EMS at all) So in the grand scheme of things, EMS is the bonus it isn't required.

In the US, what is the purpose of EMS? 

To help the patient out of the hospital as an extension of a physician.

Part of the responsibility of a physician is to direct patients to the best care that can be provided. Sometimes that means overlooking said physician's pride, ego, or financial incentives.

But moreover, most physicians I know want to do what is best for a patient. Many times that means sending them somewhere else or engaging the help of other doctors.

Divert status is a way of a doctor saying "We are so overwhelmed patients coming to us will not receive the best care. Take them somewhere they could receive better or appropriate level care."

The reasons for this "status" are many. But the bottom line is the patient for whatever reason will not receive the best care they could and in fact are entitled to get at that facility at that time.

If a tornado came down and wiped out most of the hospital, would you still taker patients there? If the tornado hit a hospital in a neighboring area would you take patients from your MCI there?

Of course not, because the hospital cannot provide adequete care right?

When a hospital has no more beds, no  more equipment, no more staff, it doesn't matter if the deficit comes from being wiped out by a tornado or from treating too many patients. The resources are simply used. There are no more, and the divert status may allow time to get this "internal" disaster in order.

On a really bad day, any given hospital in the world can be so overwhelmed that it may take days to put itself back in order.

Whether it is a polite request, policy, or order, it is a moot point.

A doctor somewhere, somehow, for some reason has asked you to take patients to better help. As an extension of that physician, you have should make every effort to honor that.

On rare occasion a patient may be so bad, that you absolutely need the doctor's help immediately. That is just a reality of life. But that is the exception, not the rule.

When deciding on those exceptions, Keep in mind the patient may need something the doctor doesn't have. (like an available OR) In those cases, the doctor can do no more than you can. In fact, since he can't drive the patient somewhere else, he can actually do less.

Since there are many barriers to sending a sick patient away from an ED, taking a patient to an overwhelmed ED that cannot help does harm to the patient.

EMS that harms patients is worse than no EMS at all.

Anyone can provide Sh***y care, it does not make a superior provider. It is certainly not something to be proud of.

Providing Sh***y care because of hubris, delusional self importance, self righteousness, or spite is definately not acceptable from any member of the healthcare or public safety community.

I think because of the organizational stressors put on dispatchers they often lose sight of reality. (particularly when response times are concerned.)

It does not good to get sunbstandard help in 8 minutes than needed help in 15.

When there are more people requesting help than resources that can help, while simply dispatching an ambulance removes the blinking light from their screen, it doesn't actually translate to needed help or even help at all. It is at best potentially helpful and at worst the hallucination of help. (perhaps better described as "virtual help", since it exists on computer but not reality)


----------



## DrParasite (Jan 26, 2012)

JPINFV said:


> So, how many extra DNR forms are you willing to fill out for 15 minute transports when every place else allows for a simple order written in the chart. When EMS requires a special document, maybe EMS is the problem and not everyone else.


as many as are needed.  

the hospital needs the order written on the hospital chart, EMS needs it on the EMS form.  and I bet the nursing home needs the DNR written on the proper nursing home documentation.  It's not about EMS requiring a special document, it's about the healthcare agency doing what is required by it's policies.  

if EMS requires a special form (that is standardized statewide), is it that hard for the nurse/hospital rep to fill it out, so the other agency (in this case EMS) can follow their protocols, just as the hospital has to follow theres?


JPINFV said:


> I highly doubt that most hospital administrators care just as your supervisors don't care about divert status.


I guess our administrators just respect us more than your administrators respect you.





JPINFV said:


> Let's stop playing stupid games. Put up your local policy that says that the ambulance crew can decide on their own to ignore divert status.


there is no policy, because there is no need for one.  Diverts are a courtesy, not a law.





JPINFV said:


> Now show me where in your protocols you're allowed to make the decision at the ambulance level to dump patients on an ED.


page 1 of the EMT text book: your job is to pick people up and take them to the ED.  look it up yoruself





JPINFV said:


> Also, if your call volume is so high, why aren't there more units on the road? Why is the hospital required to bend over backwards because of your service's failure to plan?


I agree with you 100% more.  there should be more units on the road, but as you said "...because the [ambulance agencies] hires psychics to determine when exactly their capacities will be overwhelmed."  Not only that, but an ambulance not on a run doesn't make money, nor does an ambulance that chronically transports uninsured or underinsured patients.  and we all need to make money to pay the bills.





JPINFV said:


> The hospitals I've ever had a regular problem with I can count on one hand. Let me rephrase that, I can think of 1 hospital that had regular issues. So my question is why are you constantly making noise? Furthermore, you are not the hospital's customer in any sense of the term.


your right, I'm not a customer, I'm a fellow healthcare provider, and my agency is a fellow healthcare agency.





JPINFV said:


> Ambulance out in the sticks? What's wrong with a state that can't even get one single office/authority/what-have-you providing umbrella oversight even if there are regions? Why does it not surprise me that a state that can't even require all ambulances to have an EMT on it can't draw up a unified policy regarding diversion?


There is no written policy, because none is needed.  we can avoid hospitals on divert, but if the patient requests, the family requests, the patient needs immediate hospital care or any other reason given, the patient can and will be transported to the hospital even if it's on divert.  it's a courtesy, not a law.  and yes, my state's DOH has a few issues, and the NJFAC is a worthless.... never said i agree with anything they say, and I have openly said I wish they were gone.  





JPINFV said:


> Since I've already posted links in this post, it's only a courtesy for  states that can't provide reasonable oversight to the EMS system.


nothing to do with reasonable oversight, but I can see discussing this with you is like teaching a pig to sing.


JPINFV said:


> ...because the hospital hires psychics to determine when exactly their capacities will be overwhelmed. Additionally, adding more nurses and physicians doesn't expand the number of beds in the ED. Capital investments like expanding a building aren't exactly as simple as hiring an extra nurse.


and yet, you expect ambulance companies to do just that..... 

whatever, I'm done trying to teach this pig to sing.



systemet said:


> There is a series of problems.  I'm not sure how this works out in the US.
> 
> (1) Shortage of discharge beds.  If there's no long-term care / nursing home / whatever for the ER patient to go to... where do they go.. nowhere.  They stay in the ER.
> 
> ...


everything you just said applies to the US, and is 100% accurate.

It's a hospital flow problem, and not a problem that should be pushed onto EMS providers.


----------



## JPINFV (Jan 26, 2012)

You say there is no law or policy, yet I just posted three separate links to divert policies. As such, there is nothing else to discuss as you are refusing to recognize anything outside of NJ exists.


----------



## DrParasite (Jan 26, 2012)

Veneficus said:


> Divert status is a way of a doctor saying "We are so overwhelmed patients coming to us will not receive the best care. Take them somewhere they could receive better or appropriate level care."


 yes, and you would be surprised how many times an ER has no beds available but they will refuse to go on divert.  The doctors want them to, the nurses want them to, but hospital administration refuse to.





Veneficus said:


> If a tornado came down and wiped out most of the hospital, would you still taker patients there? If the tornado hit a hospital in a neighboring area would you take patients from your MCI there?


internal disasters like a tornado are a little different.  or a HazMat spill in the ER.  or a power outage hospital wide killing the A/C on a hot summer night.  During an internal disaster, a hospital CAN refuse to accept a patient, and the ER can close it's doors.





Veneficus said:


> When a hospital has no more beds, no  more equipment, no more staff, it doesn't matter if the deficit comes from being wiped out by a tornado or from treating too many patients. The resources are simply used. There are no more, and the divert status may allow time to get this "internal" disaster in order.


I'm sorry, but not enough resources is not an internal disaster.  it's a problem, but not an internal disaster.  





Veneficus said:


> A doctor somewhere, somehow, for some reason has asked you to take patients to better help. As an extension of that physician, you have should make every effort to honor that.
> 
> On rare occasion a patient may be so bad, that you absolutely need the doctor's help immediately. That is just a reality of life. But that is the exception, not the rule.
> 
> ...


I think I might have misspoken, or misunderstood.  I am not advocating going to a hospital that is on divert just because you can.  They are a courtesy, but the hospital is overwhelmed, it generally won't do anyone any good, and the wait time will be longer.

HOWEVER, we do transport to hospitals on divert all the time, for the following reasons:

-Pt choice
-Trauma 
-Cardiac arrest if they arrest en route unless its traumatic in origin.
-Inability to obtain an airway/Airway obstruction.
-Severe shock
-Imminent delivery with abnormal presentation.
-Uncontrolled hemorrhage

by FAR, the most common reason is pt (or family) choice.  In fact, that is often asked of the patient before getting a hospital's divert status.  That means if hospital A is on divert, but the patient wants to go to hospital A, guess where they are going?  Ditto a SNF patient whose charts says take to hospital A.  Despite being on divert, that's where they are going.


Veneficus said:


> I think because of the organizational stressors put on dispatchers they often lose sight of reality. (particularly when response times are concerned.)
> 
> It does not good to get sunbstandard help in 8 minutes than needed help in 15.
> 
> When there are more people requesting help than resources that can help, while simply dispatching an ambulance removes the blinking light from their screen, it doesn't actually translate to needed help or even help at all. It is at best potentially helpful and at worst the hallucination of help. (perhaps better described as "virtual help", since it exists on computer but not reality)


I agree.  the politicians put too much emphasis on response times, citizens put too much emphasis on getting an ambulance there quickly (when in most cases, a few extra minutes won't matter), and dispatchers are forced to hurry crews out of the hospital because they have jobs pending.

But until all EMS units end up 100% government funded, and staffed to the level to handle the routine peak call volume 24/7 (like the city FD's are in most urban cities), it won't change.


----------



## usalsfyre (Jan 26, 2012)

Sticking your fingers in your ears, closing your eyes and screaming "not my problem" at the top of your lungs isn't a good way to garner support to fix things.

If your no different than a patient arriving via the front door (i.e. ignoring divert) than why do you have a specialized entitlement to a bed faster than the patient who walks in the door with a similar complaint? Do you tell you patients not to call to get in quicker? 

Your sending mixed messages.


----------



## usalsfyre (Jan 26, 2012)

DrParasite said:


> But until all EMS units end up 100% government funded, and staffed to the level to handle the routine peak call volume 24/7 (like the city FD's are in most urban cities), it won't change.


What city FDs are you around? I've yet to see a major urban FD that staffed appropriately.


----------



## JPINFV (Jan 26, 2012)

DrParasite said:


> I think I might have misspoken, or misunderstood.  I am not advocating going to a hospital that is on divert just because you can.  They are a courtesy, but the hospital is overwhelmed, it generally won't do anyone any good, and the wait time will be longer.
> 
> HOWEVER, we do transport to hospitals on divert all the time, for the following reasons:
> 
> ...




Courtesy. You keep using that word. I don't think it means what you think it means. It's not a courtesy if there are a limited and set number of reasons why it wouldn't apply. That makes those reasons exemptions, and the presence of exemptions does not automatically make something a courtesy that the provide has the option of simply ignoring.


----------



## DrParasite (Jan 26, 2012)

usalsfyre said:


> If your no different than a patient arriving via the front door (i.e. ignoring divert) than why do you have a specialized entitlement to a bed faster than the patient who walks in the door with a similar complaint? Do you tell you patients not to call to get in quicker?
> 
> Your sending mixed messages.


you are right.  patients should be seen in the same order of need, whether they come by ambulance or POV.  That is how the system is supposed to work.

that means, if you bring in an ambulatory patient, they go to triage and wait in chairs.  if you are sick, you get a bed immediately and get a monitor, etc.  if you are non-ambulatory, you get a bed and wait to be seen.  that's how the system is supposed to be.

But the ambulance should not be tied up.  If the patient has to wait due to no staff, so be it, but it is inappropriate to keep the ambulance there and prevent it from responding to other emergencies because the ER lacks staff or is overwhelmed by patients.  The ambulance should be available to answer the next call, not holding the wall because of a lack of beds.

or maybe I have just been spoiled by NJ's amazing hospital ERs.


usalsfyre said:


> What city FDs are you around? I've yet to see a major urban FD that staffed appropriately.


FDNY, Philly FD, Newark FD, Syracuse FD (back when I was in college), and I could name another dozen or so smaller urban FDs in the NYC metro area.  And almost every FD has more units than their city's EMS department, despite EMS answering 4x as many calls.

The way I judge staffing is how often a department needs to call outside mutual aid to assist with routine calls. Not the 3 alarm fires, not the building collapse with people trapped, I am talking about the majority of the calls.  Most departments don't call M/A for every call, and handle their own calls in their own jurisdiction with their own departmental resources that are dedicated to accomplishing that job.  

Unfortunately, many EMS systems can't say the same.


----------



## Handsome Robb (Jan 27, 2012)

DrParasite said:


> I know I am probably in the minority, but if i had a DNR, I would want to make it as accurate as possible.  that means using the state DNR form, for out-of-hospital if the patient will be transported out of hospital, and if hospital and hospice if appropriate.  but thats just me.
> probably right, but when I start calling for the hospital administration to come down and explain to my patient why they are waiting, a bed will be found.  and while I haven't had to do that, I know of supervisors who have went to the ER and made that request.  it's called advocating for your patient.
> you can stand by your statement, but your statement is still wrong.  maybe an IFT company can get in trouble (since that seems to be where all your experience is), but 911 services don't.
> 
> ...



You are a bigger idiot than I originally thought. 

"once they are in the hospital they are the hospital's problem"? What the hell happened to patient advocacy? While your statement is technically true it shows how :censored::censored::censored::censored:ty your attitude and compassion for your patients truly is. I hope that myself, my family members or my friends have the misfortune of landing themselves in the back of your ambulance.

You're constantly saying "my, me, I". It's not all about you, it's about the patient.


----------



## technocardy (Jan 27, 2012)

The longest I've ever waited with a patient has been maybe 15 minutes. Typically when we walk into the ER we stop at the triage nurses station on the EMS side and give our verbal assessment. Once that is done, we are assigned to a part of the ER (A-E). We get into the respected area we've been assigned with our bed (oh yeah, dispatch will make sure they have a bed ready for us if we don't personally patch through to the hospital). We transfer the pt to the bed then walk over to that ER area nurses station, give another more in-depth report of the pt, give them our paper work and head out. We've never had to sit and wait past the first nurse’s station. If the pt is critical (CTAS 1, or majority of CTAS 2) then they're put right into a trauma/resus room and the second report is given to the team. (That's at the hospital I typically run too). If it's to the trauma centre then it's almost the same deal, however it's a quick stop at the nurses’ station, then roll into the trauma bay where the who fam damily is waiting.

We use too have a thing called "paramedic hallway" which was a special team of paramedics who would hang out in the EMS hallway with a backlog of pts, so if the ER was full, or they weren't serious enough too been seen right away then 2 things could happen. 

The medics who brought the pt in can get right back out onto the streets and
The pt would continue to get focused assessments and treatments until a bed was available

There are 2 sides to every situation. Obviously it can get frustrating to sit in an ER with your colleagues coming and going, bring in and dropping off pts, etc etc. However if a pt is brought in via personal ride, 911, or IFT and they are to be seen quicker than you, then that's the way it is. It sucks, and I'm not saying OP is whining or anything but that is the way it is. Yes the argument exists that for every minute you sit in the ER with a pt, that’s another minute your service and coverage area is a unit short. Can the service bring over an IFT unit that's just sitting in some hall? Cross coverage? I know they're not all ideal solutions to the problem but they are temporary solutions that can provide a band aid fix until you return to the streets. 

There is only so much we can do, the ER staff can do, and our services can do. Let’s face it, the population is getting older and sicker and we just cannot keep up with the demand so problems will exists.

Possible solutions? Well if things aren't running smoothly between EMS and ER staff that might be a good place to start. Sit down with supervisors, ER dept. staff, the doc that signs your protocols and help to make things more streamlined than they currently are. If you see something that's broken or not running at 100% efficiency then heck, let’s do everything we can to get it there. For you, the ER staff, but more importantly the patients.

/soapbox


----------



## the_negro_puppy (Jan 28, 2012)

When hospitals are on divert we are not allowed to go there unless we have a category 1 pateint (cardiac arrest, STEMI, serious trauma, head injury). They will not let us in the door. Sometimes due to miscommunication we go to hospitals on divert, and the patients refuse to be driven elsewhere, get off our stretcher and walk into the waiting room with chest pain and are seen straight away :wacko:h34r:


----------



## SkaMedic (Jan 30, 2012)

While there is no mandated diversion except in the case of an internal disaster, hospitals that request diversion usually do so for good reason. If we are all on the same team, we should act responsibly and professionally doing our best to honor this request. In California, hospitals cannot go on diversion for BLS patient; they must accept all BLS patients.  If I am transporting a BLS patient, I try not to a hospital on diversion because I know I'm going to hold up a wall or my patient is just going to sit in the waiting room (I will tell my patient this and usually agree to go to a different hospital). Additionally, I am just adding to the saturation of the ED on diversion. There is, however, absolute diversion of ALS patients here. If a hospital is on diversion, you CANNOT bring an ALS patient.  If you were to disregard the diversion I guarantee your "self worth" would be the last thing you would have to worry about.

Dr. Parasite: it seems that in New Jersey if a hospital is on diversion it is true that you can still bring those patients who request to go to an ED that is on diversion but you must inform the patient of the hospital's diversion status and advise them that there will be an extended wait time.  If the patient still wants to go to that hospital, you should advise the ER.

Here is a link to the diversion guidelines (true, they are not policies) for New Jersey by New Jersey's hospital association

njha.com/Publications/Pdf/DivertGuidelines2009.pdf


----------



## Amberlamps916 (May 3, 2012)

4 hours at Intercommunity-Citrus Valley hospital in Covina........


----------



## TRSpeed (May 4, 2012)

4.5 hrs Corona Regional


----------



## Anonymous (May 4, 2012)

Addrobo87 said:


> 4 hours at Intercommunity-Citrus Valley hospital in Covina........



tiny little place, usually takes that long to find a place to park the ambulance lol


----------



## Joe (May 4, 2012)

Addrobo87 said:


> 4 hours at Intercommunity-Citrus Valley hospital in Covina........



ive been to citris valley. not one of my favorite places.. luckily i havent been there in a while haha


----------

